He recommended that police, no matter how they were notified of a missing person, create a dispatch job for the case and that they are prompted to follow up the matter if they receive no further information.
The hospital had warned that Mr Kahsai was delirious, not competent and was a risk to himself when he left treatment four days following his admission on December 26, 2015 with alcohol withdrawal symptoms.
A wardsman spoke to Mr Kahsai after he exited Calvary Hospital but did not learn it was missing him until later, prompting First Constable Callaghan to recommend it colour code its patient wrist bands to indicate their risk of absconding.
Mr Kahsai's three children and a long-time friend sat in court as First Constable Callaghan explained that a police officer decided the missing person report's delay mitigated the need for a 24-hour response time, and dispatched officers to the missing man's Reid home on December 31 believing he would have returned there.
The officers working on the investigation also went on leave throughout January 2016, and during that month police did not act on the case for periods totalling at least 13 days.
First Constable Callaghan said that without a handover of a case, a "meaningful" investigation ceased.
Misinformation from a neighbour, who wrongly told police that Mr Kahsai had been home, also slowed efforts to find him.
Police searching his home also didn't find his phone in clothes inside the unit until February, and an earlier discovery may have prompted them to consider search and rescue sooner, First Constable Callaghan told the court.
He said an officer conducting the early investigation reported he called the hospital to clarify information about Mr Kahsai and was told, contrary to its medical report, he had been "competent and capable".
The officer rated the risk to Mr Kahsai as "high" on an assessment but an acting sergeant did not confirm the rating, a decision influenced partly by the misinformation police had received from the man's neighbour and the report they said had come from a hospital staff member that he had been "capable", the court heard.
First Constable Callaghan said this decision marked a point at which Mr Kahsai's chances of being found alive were reduced, and recommended it be mandatory that any report about a missing patient be made by the treating doctor only so that information about the person remained consistent.
Had this been the case, and if police had created a dispatch job upon receiving a phone call, police would have sought advice that would have led to a quicker emergency response, increasing Mr Kahsai's chances of survival, he said.
On January 28, or 29 days after he went missing, police deployed a search and rescue team throughout a 1.23km radius of the hospital, however by this time they did not expect to find him alive and their surveys of terrain beyond this area were focused only on shelter.
Police suspended the search after four days and on April 2, 2016 two Canberra Institute of Technology students conducting environmental monitoring found Mr Kahsai's body in bushland 1.9km from the hospital and near Bruce Stadium.
A brief prepared for the court described Mr Kahsai, who moved to Canberra from Eritrea to study in the 1970s, as having "an infectious sense of life", "a broad political awareness", and "enormous potential".
He was "fun loving", charismatic, popular yet "someone to be taken seriously", however his health deteriorated as he developed a dependence on alcohol.
In the year leading to his disappearance he had drawn police attention multiple times for incidents relating to alcohol use.
Magistrate Beth Campbell said the inquest was not intended to be an "exercise in blame" but a search for "useful recommendations". The case continues and will hear from at least 17 witnesses until its expected finish on Friday.
Tahadesse Kahsai inquest hears search for missing man impacted by email typo
April 10, 2018
A missing persons report on a man who was "delirious and confused" when he left Canberra's Calvary Hospital was delayed because of a typo in an email address, a coronial inquest into the man's death has heard.
At the beginning of the inquest into the death of 61-year-old Tahadesse Kahsai, the court was told his family wants answers about how he was allowed to leave the hospital and subsequent search efforts.
Mr Kahsai was admitted to Calvary suffering from alcohol withdrawal on December 26, 2015, and walked out four days later, never to be seen alive again.
The ACT Coroners Court heard the inquest would focus on the circumstances around Mr Kahsai's departure from the hospital, the process of notifying police he was missing and the appropriateness of the searches carried out.
The court was told on the morning Mr Kahsai walked out of the hospital one nurse observed he was delirious and confused.
The court heard a wardsman had a brief conversation with Mr Kahsai outside the hospital but did not have any immediate concerns for him.
Later that morning another staff member called police to file a missing persons report but was advised a form needed to be lodged via email.
A typo in the email address meant the form was never received by police.
The court heard the error was only realised the following day when inquiries were made about the status of the search, and the delay in reporting meant police assumed Mr Kahsai was no longer in the vicinity of the hospital.
A patrol was sent to his home and police spoke to a neighbour who advised he thought Mr Kahsai had returned home the night before.
Police searched the home but there was no sign of Mr Kahsai.
Coronial investigator Senior Constable Matthew Callaghan told the court he had made seven findings including:
- An initial phone call from staff to police advising Mr Kahsai was missing was not recorded on the police database
- Police waited for a missing persons report to be emailed but an error in the address meant it never arrived
- Misinformation from a neighbour impacted the search area
- Calvary Hospital provided inconsistent information about Mr Kahsai's condition
Body found less than 2km from hospital
The court was told the police officer leading the investigation was not on duty for a period of nine days after Mr Kahsai went missing, resulting in a lack of progress.
The court heard it was not until nearly a month later a search of bushland around the hospital was conducted but that failed to locate Mr Kahsai.
Search crews focused on areas that would provide shelter and not open areas.
Mr Kahsai's body was eventually found 1.9 kilometres in a straight line from the hospital by two students conducting environmental monitoring in the area on April 2, 2016.
Senior Constable Callaghan made recommendations for the coroner to consider including:
- Police create a case file no matter how the notification is received
- Police record attempts of handover on the case file
- Missing patient reports be completed by a treating doctor
- Introducing different-coloured ID bands indicating a patient's risk of absconding
The lawyer representing Mr Kahsai's family told the court they were not seeking vengeance but wanted answers about what happened and assurances it would not happen again.
Seventeen witnesses are listed to give evidence over the next four days.
Topics: courts-and-trials, law-crime-and-justice, canberra-2600, act, australiaEmail typo impacted search for missing man later found dead