Missing persons procedures probed after Lismore man Rohan Lloyd found dead
An inquest into the death of a Northern Rivers man has found critical failures in his medical care and the NSW Police Force’s search response, leading to recommendations to amend procedures for missing persons.
An inquest into the death of Rohan Lloyd has found critical failures in his medical care and the NSW Police Force’s search response, leading to recommendations to amend procedures for missing persons.
Lloyd’s body was found in Whiteman Creek, 21 km northwest of Grafton, near Copmanhurst, in September 2020 after an extensive search.
Deputy State Coroner Derek Lee determined Lloyd died between August 14-18, 2020, from presumed heavy metal poisoning and freshwater drowning.
Lloyd, diagnosed with schizophrenia at 21, was believed to be experiencing a psychotic episode when he became lost in bushland.
The Coroner’s findings, released in September, highlighted a missed diagnosis and inadequate police risk assessment as key factors delaying the search.
According to the findings, Lloyd’s psychiatrist reclassified his schizophrenia as anxiety or autism, leading to the cessation of antipsychotic medication.
Expert forensic psychiatrist Dr Kerri Eagle testified the decision lacked clinical basis and increased Lloyd’s risk of psychotic relapse.
Dr Eagle told the inquest that any decision to “reverse” Rohan’s schizophrenia diagnosis “would appear to be unsupported by his documented clinical history of psychotic relapses” and “would arguably not be a decision made by a reasonably competent psychiatrist in the circumstances”.
He had been off medication for a year before his disappearance.
On August 15, 2020, Lloyd’s mother reported him missing to Sutherland Police Station, detailing his severe mental health condition.
Despite this, NSW Police classified him as “medium risk”.
The Coroner found sufficient evidence to designate Lloyd as high risk under the 2020 Missing Persons Standard Operating Procedures.
Errors in interpreting Lloyd’s mobile phone data, including a triple-0 call and a delay in identifying his last known location near Copmanhurst caused family and friends to search the wrong area for day, the inquest heard.
His car was located on September 3, 2020, but the subsequent land search and rescue effort was criticised for prematurely ending on September 6.
Barefoot footprints found upstream from his car were not adequately investigated, and the search radius fell short of the standard 4.7 km boundary for individuals with psychological illness, the inquest also heard.
Civilian volunteers ultimately found Lloyd’s body 1.84 km upstream on September 12, 2020.
The inquest also exposed communication breakdowns between Richmond and Coffs/Clarence Police Districts, causing delays and leaving Lloyd’s family without updates for months.
Magistrate Lee extended condolences to Lloyd’s family, acknowledging their profound loss and grief.
Mr Lee recommended the Acting Commissioner of NSW police amend its Missing Persons, Unidentified Bodies and Human Remains Standard Operating Procedures to explicitly include “severe mental health condition” as a factor for classifying a missing person as “vulnerable” or “particularly vulnerable,” ensuring consistent and clearer risk assessments across the state.
The Coroner sought this amendment to ensure “consistency and clarity” in how vulnerable persons, particularly those with severe mental health conditions, are identified within the procedures, aiming to improve risk assessments and prevent future tragedies.
