Inquest into the disappearance of CD
Deceased
CD
Demographics
36y, male
Date of death
2019-06-17
Finding date
2022-09-16
Cause of death
Cannot be determined
AI-generated summary
CD, aged 36, disappeared on 17 June 2019 after exhibiting significant mental health deterioration, recent suicidal ideation, paranoia, alcohol abuse, and relationship breakdown. The coroner found sufficient evidence that CD is deceased (on balance of probabilities) but could not determine cause or manner of death. Critical clinical lessons: early risk assessment in missing persons with mental health crises is essential; the initial 24-72 hours are crucial; high-risk cases require immediate detective allocation and resource intensity; and triangulation of mobile phones should be considered routinely for at-risk individuals. The coroner found significant deficiencies in the police investigation including failure to conduct timely risk assessment, inadequate canvassing of the area, failure to request triangulation despite clear risk factors, and lack of continuity in investigation. The coroner also highlighted legislative barriers (s 287 Telecommunications Act) that may impede rapid location of vulnerable missing persons.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Mental health deterioration including depressive symptoms, anxiety, and paranoia
- Recent suicidal ideation and threats of self-harm
- Alcohol intoxication and substance abuse
- Relationship breakdown and separation from wife and son
- Recent criminal charges and apprehended domestic violence order
- Inadequate police risk assessment and investigation response
- Failure to request triangulation of mobile phone when clinically indicated
- Lack of continuity and intensity in initial police investigation
- Poor family communication and lack of family liaison officer support
Coroner's recommendations
- Commissioner of NSW Police Force to review Missing Persons Standard Operating Procedures 2022 to clarify that the first 24-72 hours of missing person investigation are most critical, particularly for high-risk categories, and that continuity and intensity during this period are important
- For high-risk missing person investigations, consideration should be given to immediate allocation to a designated Detective (rather than General Duties officers) with capacity to provide continuity and expertise for the critical 24-72 hour period
- In relation to triangulation procedure: (i) requests should be made by Duty Officer or Supervisor (except in remote areas); (ii) if a request is declined, there should be a review procedure allowing escalation by Duty Officer or Supervisor with clear specification of that procedure
- In the Missing Persons Checklist, add reference to canvassing the area/last place the missing person was seen for witnesses (e.g. street neighbours)
- Minister for Communications (Commonwealth) be provided with findings and evidence of Chief Inspector Charlesworth, together with findings from Inquest into death of Thomas James Hunt, regarding interpretation and operation of s 287 Telecommunications Act 1997, with a view to considering urgent reform including: (a) removal of the qualifier 'imminent' threat (consistent with Australian Law Reform Commission Report 108 (2010), Recommendation 72-7); (b) change of requirement of 'belief' to 'suspicion'
- Commissioner of NSW Police Force to: (a) be provided with transcript of evidence of CI Charlesworth in this inquest; (b) give consideration to obtaining urgent advice providing authoritative guidance to NSW Police Force as to the construction of s 287 Telecommunications Act 1997 (from appropriate senior counsel or Crown Solicitor's Office), in light of the remedial purpose of that provision and noting evidence that the decision whether to triangulate can be a matter of life and death
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —