It's likely Kawhia man Trevor Smith died before police picked up his missing person report and launched a search and rescue operation.
The report sat idle in a police officer's in-tray for nearly 24 hours after his worried family reported him wandering off from Waikato Hospital on March 16.
Smith's family went back to Hamilton Central Police Station the next day for an update and it wasn't until then an official search was launched.
Coroner Gordon Matenga found that Smith had probably already suffered a heart attack and collapsed down a bank of the Waikato River, by the time police acted on the missing person report.
The circumstances around the police bungle came out in an inquest into the death of Trevor Percy Smith, 70, at the Hamilton Coroner's Court on Friday.
Police told Coroner Gordon Matenga that the officer involved had been given training and procedures have been changed to ensure the issue did not occur again.
Smith, who had dementia, went missing from the hospital at 4.45pm, after visiting a family member.
Hamilton police Sergeant Phil Bell told the inquest that Smith's extended family alerted police at 7pm, the same evening.
Bell explained that when a person with mental health issues - dementia or serious medical conditions - is reported missing, police are to immediately action a search.
"The custody sergeant [forwarded] the file to the constable delegated the responsibility of monitoring the missing person reports. He did this by placing the report in a tray provided for that purpose.
"The delegated constable of missing persons was not at work on Monday the 17th of March, and the tray was not cleared," Bell said.
Bernard Hutchison a close friend to the Smith family, and involved in the search, questioned the police delay and asked whether new protocols had been put in place.
"The police report . . . mentioned the officer was away and the system fell down for a day. I want to know what protocols have been put in place to stop that from happening again. We lost a very valuable day," Hutchison said.
Bell said the file should have been urgently reviewed as Smith had dementia - one of the red flag factors.
"The flag should go up and search and rescue should be called. It should never, if it's going to be an urgent case - go to that tray," Bell said.
Hutchison told the inquest the delay was "disappointing" and asked if anything else could be learned from the incident.
Bell said the sergeant involved had received further training and a new "flow chart" had been created to ensure the issue did not happen again.
"There's a couple of ways it should have been picked up, but it didn't," Bell said.
The family wanted to ensure lessons were learned from the incident so other families would not go through the same pain, Hutchison said.
A criminal investigation was launched on March 17 at 6pm and search and rescue teams dispatched to work alongside the family, which had already formed whanau search parties.
The extensive search covered the hospital and surrounding areas, as well as door-knocking.
Police obtained CCTV footage which showed Smith near Clarence Street Pak 'n Save. His body was eventually found by four teenagers on the edge of a steep bank of the Waikato River, opposite Riverlea, three weeks later on April 6.
Coroner Gordon Matenga, who visited the site where Smith was found, said Smith had died of a heart attack on March 17, 2014.
Before closing, Coroner Matenga praised the actions and support of Smith's whanau.
- Waikato Times