The New South Wales coroner has delivered damning findings after an inquest into the disappearance and death of a woman on the state's North Coast.
Carley Metcalfe was last seen at a Lismore bus shelter on November 3, 2017.
The following day her belongings, including a wallet containing bank cards and a Medicare card, were found scattered on the railway platform at Mullumbimby.
On Friday, an inquest heard it was likely that Ms Metcalfe was alive for days or weeks before her body was found in the Brunswick River on November 29 that year.
Decomposition made it impossible to determine the cause of death.
'Grossly inadequate'
Ms Metcalfe's parents went to Byron Bay police on November 5 to raise concerns about their daughter, but it was noted as a mental health event rather than a missing person case.
Three days later they approached police in Lismore, where a missing person report was taken, but the case was not allocated until November 14.
In handing down her findings in Byron Bay, Teresa O'Sullivan described the initial police investigation as "grossly inadequate".
"There was little evidence before me of properly documented investigative steps taken during this period," she said.
"Counsel assisting described this phase of the investigation as 'grossly inadequate' and I agree.
"In making this finding I note my disappointment that no steps were taken by the [NSW Police] Commissioner to formally apologise or explain to Carley's family what went wrong."
NSW Police created a Missing Persons Registry in 2019.
Its manager, Detective Inspector Glen Browne, told the inquest new standard operating procedures meant every police area command and police district now had an officer trained in missing persons investigations.
'Missed opportunity'
In the days leading up to her disappearance, Carley Metcalfe had been sleeping outside the Lismore courthouse, and had been taken to Lismore Base Hospital by ambulance in a confused and disoriented state.
Ms Metcalfe was deemed not suitable for admission to the mental health unit, having been misdiagnosed as suffering from acute intoxication.
She ended up spending several hours in the hospital's emergency department before leaving of her own accord the following morning.
The court heard there had been heated conversations between staff in different departments about how she should be treated.
"Ms Metcalfe's needs became secondary to a demarcation dispute between medical staff at the Lismore Base Hospital," Ms O'Sullivan said.
"The care Carley received at Lismore Base Hospital was a missed opportunity to … change the course of an increasingly downward trajectory.
'Key new tools'
Ms O'Sullivan made a series of recommendations about how similar cases should be handled in the future, including changing the definition of a missing person case to make it clear that no particular form of words need be used by an informant.
She also highlighted the importance of collecting CCTV images.
Ms O'Sullivan also recommended the Northern NSW Local Health District introduce instant saliva-based testing for the detection of illicit drug use by mental health clinicians and assess the need for a psychiatric emergency care centre at the Lismore Base Hospital.
NSW Police said the recommendations were being reviewed.
In a statement to the ABC police said since the establishment of the Missing Person's Registry in July 2019 there had been a full revision of operating procedures, including an emphasis on exploiting technological advances.
"One of the key new tools now available to police when looking for missing people – and vulnerable missing persons in particular – is geo-targeted messaging, which enables NSW Police to send texts messages to mobile phone users within specific area, appealing for assistance," the statement said.
"Standard operating procedures have undergone a complete review and update, based on lessons learned after revising past investigations.
"More than 70 police officers – at the rank of Detective Sergeant – have now been trained as dedicated Missing Persons Coordinators … this means every police area command and police district across the state will have a detective trained in these specialist missing persons investigation skills on the team."
The ABC has approached the Northern NSW Local Health District for comment.
