Coronial
NSWcommunity

Inquest into the suspected death of Youliang Lin

Deceased

Youliang Lin

Demographics

84y, male

Coroner

Decision ofJudge Lee

Date of death

2017-09-15

Finding date

2026-04-10

Cause of death

The available evidence does not allow for any finding to be made as to the cause of Mr Lin's death. Possibilities include natural progression of underlying medical conditions (particularly worsening dementia with increased confusion and agitation), exposure to environmental elements, dehydration, lack of sustenance, traumatic injury from a fall, or a combination of these factors.

AI-generated summary

An 84-year-old man with Alzheimer's dementia and a history of wandering left his home on 15 September 2017 and was never found alive. The coroner determined he is deceased, likely died within days of going missing in bushland near Eric Mobbs and Ted Horwood reserves. Cause of death cannot be determined without remains. The coronial inquiry identified several systemic police response issues: delayed CCTV canvassing (should have begun immediately on 15 September), delayed engagement of a Land Search and Rescue Coordinator (not deployed until 19 September despite 'very high risk' assessment), lack of designated family liaison officer creating ad hoc communication, and failure to consult the family before ceasing the search. Clinical relevance: geriatrician assessment identified the patient as at-risk for wandering with poor insight and worsening dementia; family required 24-hour supervision. Early information synthesis about sighting reports could have accelerated search commencement by approximately 24 hours.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

geriatric medicinegeneral practice

Error types

delaycommunicationsystem

Clinical conditions

Alzheimer's dementiahypertensionrenal impairmentpostural hypotensionbehavioural and psychological symptoms of dementia

Contributing factors

  • Alzheimer's dementia of moderate severity with behavioural and psychological symptoms
  • Recurrent wandering behaviour with poor insight and disorientation
  • History of dizzy spells possibly linked to hypertension
  • Significant impairment in renal function
  • Postural hypotension
  • Advanced age (84 years)
  • Left home without food, water, protection from elements, or means to purchase these items
  • Did not speak English
  • Wandered into dense bushland area
  • Delayed commencement of coordinated land search (4 days after reporting missing)
  • Delayed engagement of Land Search and Rescue Coordinator
  • No immediate CCTV canvassing to establish last known position
  • Lack of effective command and control structure in police response
  • Incomplete canvassing of entry and exit points to reserves

Coroner's recommendations

  1. Conduct a further land search operation of the bushland within and contiguously extending from Bidjigal Reserve in the immediate vicinity of Eric Mobbs Reserve and Ted Horwood Reserve with the aim of locating Mr Lin's remains, in consultation with the family
  2. Review the Victoria Police Family Liaison Officer Practice Guide and consider amending the Missing Persons, Unidentified Bodies & Human Remains Standard Operating Procedures to provide for the availability of a Family Liaison Officer (FLO) in missing person investigations, including the functional role in facilitating communication with missing person's relatives and addressing the needs of relatives from cultural and linguistically diverse backgrounds
  3. Review the Victoria Police Spontaneous Volunteer Practice Guide and consider amending the Missing Persons, Unidentified Bodies & Human Remains Standard Operating Procedures to provide for the availability of a Spontaneous Volunteers Manager (SVM) in missing person investigations, including the functional role in safely and effectively managing spontaneous community volunteers to ensure efficiency and search effort cohesion
  4. Amend the Missing Persons, Unidentified Bodies & Human Remains Standard Operating Procedures to provide that the family of a missing person must be given at least 24 hours' notice before the search is suspended or terminated, unless such notification is likely to jeopardise the investigation or disclose confidential information
Full text
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