Significant mistakes by police searching for a man who drowned while evading officers could be avoided with better training on Indigenous Australian history.
Gordon Copeland, 22, died in the early hours of July 10, 2021, presumed drowned after he fell or waded into the flooded Gwydir River in the northern NSW town of Moree.
In findings delivered on Tuesday, Coroner Teresa O'Sullivan said there was a communication breakdown between police which led to the search being called off prematurely.
"(This) led to the fraught discussions between police and family that night and in the early hours of the next morning, adding to their pain and anxiety," she wrote.
"It has had a corrosive impact on the relationship between some Aboriginal families in Moree and the (NSW police force) that will take a long time to heal."
Just before his death, Mr Copeland was a passenger in a black Toyota Corolla driven by friends Jabour Clark and Kowhai Roberts.
Police spotted the car and, suspecting it was stolen, followed it to the Gwydir River where it became bogged down before the three occupants got out and fled on foot around 2.30am.
While Mr Clark and Ms Roberts slipped off unnoticed, Mr Copeland was spotted by police crouching by a shrub in the darkness.
The Gomeroi man turned and ran, jumping a wire fence before falling down a slippery embankment towards the water. Police heard a groan of pain as he hit the bank, before he entered the fast-flowing river.
The search lasted for 13 minutes with police unsure of how many people were in the car. Officers left, assuming whoever was in the vehicle had escaped.
Officers again spotted Mr Copeland struggling amongst debris in the river around 4am but could not retrieve him from the water and eventually lost sight of him as he was carried downstream.
Reported missing by family members on July 11, his body was found submerged and stuck under a tree on October 7 about 450 metres from where he first entered the river.
Ms O'Sullivan found police officers who conducted the initial search were inexperienced, engaged in "group think" and failed to appreciate the gravity of the situation.
"There is no doubt that, in hindsight, the police should have done more critical thinking and they should have been much more focused on the safety of the person that had fled," she said.
She also found mistakes were made in later discussions with family members.
"It is completely inappropriate that the Copeland family did not get more urgent help and more respect when they went to the police station to report Gordon missing in these circumstances," she wrote.
A meeting with Detective Senior Constable Bradley Beddoes with family members was described as "dismissive" and "frustrating, hurtful and heartbreaking".
"DSC Beddoes did not show them the empathy and understanding that they deserved and he didn't spend enough time really listening to them about their concerns for Gordon," Ms O'Sullivan said.
Her recommendations include that NSW Police undergo training about the history of Indigenous Australians that is "as comprehensive as possible" regarding colonisation and its impact.
The coroner suggested training be undertaken on trauma-informed communication with families around missing loved ones and that current training on critical decision-making in situations like searches be reviewed.
The New England Police District was also urged to review its current resources, training programs and debriefing procedures.
While her findings would not bring closure or comfort to Mr Copeland's family, Ms O'Sullivan hoped the situation surrounding his death would become clearer.
"I have no doubt that the police involved have been deeply affected by Gordon's death," she wrote.
"I hope that the lessons learnt here will inspire more efforts to listen deeply to First Nations families and to resolve to learn from the mistakes that happen when we don't."
