Kumanjayi Johnson, a 45-year-old Arrente man, died at Mount Gillen, Alice Springs, in early December 2022 after walking away from his supported accommodation at Ironwood.
Coroner Chrissy McConnel, releasing her report on Friday, found Mr Johnson died in a gully from environmental exposure and dehydration.
Mr Johnson had multiple health issues including severe mental impairment, diabetes, epilepsy, hypertension and depression, and was in shared supported accommodation in the care of the Public Guardian.
The coroner identified mistakes made by carer agency Lifestyle Solutions and overstretched Northern Territory police after Mr Johnson walked off heading for Mount Gillen on December 3, 2022.
The overall issue was lack of communication about risk and urgency, she found.
Her report said a computer-aided dispatch was not re-categorised as a missing person which would have given it level one priority and may have triggered a risk assessment.
This miscommunication was exacerbated by the failure of Lifestyle Solutions staff to follow the missing persons procedure and provide a missing persons checklist to police.Â
Ms McConnel said police at the time were responding to "unusually high levels of domestic violence jobs" and had limited officers available to respond.
The resulting delay in obtaining a missing persons report and a lack of search and rescue training for frontline officers completing search urgency assessments meant there were "failures on both sides", she found.
Once the search got underway it was well executed, Ms McConnel found.
Mr Johnson's body was found six days after he went missing.
The coroner noted Mr Johnson's cultural needs were not well understood by the office of the Public Guardian and Lifestyle Solutions, including regular engagement with families.
Mr Johnson had been agitated and at times aggressive in the lead-up to his disappearance.
The office of the Public Guardian had since implemented all the recommendations of an internal review, Ms McConnel noted.
She recommended Lifestyle Solutions improved cultural safety in its workforce in consultation with Aboriginal organisations, staff and family members of clients.
Lifestyle Solutions should also review and strengthen their missing persons procedure to include specific guidance on providing information to police.
It should also review training and guidelines on reporting missing persons and develop triple-zero call guidelines and training for all staff working in supported independent living facilities, the coroner said.
She recommended NT Police review operations to ensure the integrity of missing person classifications.
Police should also review the organisations in the community that needed to provide risk assessments to police for missing persons and other incidents to inform call-taking, dispatch and response, Ms McConnel said.
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