CULTURAL WARNING: Indigenous readers are advised this article contains the name of a people who has died. 

A coronial inquest has found police in Bourke should have done more in the 2019 search for missing man Dion Moore.

A family member had reported the 29-year-old missing on Saturday morning January 6.

 Mr Moore and his nephew had been driving from Dubbo to Bourke the day before when their vehicle ran out of petrol, leaving it on the side of the highway and separating.

The nephew headed towards Bourke, Mr Moore to a remote property bordering the road.

Mr Moore was found dead on January 7.

Deputy State Coroner Harriet Grahame found that his death occurred on January 5 or 6 and was linked to drug toxicity, dehydration and heat.

In her findings, read at Bourke Local Court on August 6, 2024, Magistrate Grahame said Mr Moore had been described as a "happy-go-lucky boy, always up for a good time, a laugh and a joke."

"Dion’s mother, Jennifer told the court that Dion was adored by his brothers and sisters, nieces and nephews and all of their extended family," Magistrate Grahame said.

"Jennifer told the court that Dion was the third of her children to die too young and the traumatic circumstances of his death meant that family were never able to hold him or say goodbye. Her pain was palpable in the court room."

Magistrate Grahame said police had made a "number of poor decisions" after the missing persons report.

She accepted police had made a "continuous response" to locate Mr Moore, including attempting to locate to witnesses, a drone search and consulting search and rescue experts.

However, she said police should have begun a coordinated land search a day earlier as advised by one of the experts.

 She also found police also partially based the decision not to begin a search on "erroneous" information that Mr Moore had "bush survival skills."

"This assumption was apparently based on a past attempt by Dion to evade police in January 2018. Police in Bourke took into account erroneous information that Dion had spent three days in the bush on this occasion.

"Police in Bourke took into account erroneous information that Dion had spent three days in the bush on this occasion. In reality, Dion had only spent 20 hours in the bush and was treated for dehydration in hospital after being found.

"This should have been clear from NSWPF’s own records," she said.

Magistrate Grahame also found "no evidence" that police encouraged assistance from landowners of the property Mr Moore was found on.

"(They) knew the property where Dion might have been better than anyone. They also had vehicles available to search and in the course of their work needed to move around the property frequently.

"In my view they should have been encouraged to assist a fellow citizen who may have been in serious trouble on their land at the earliest opportunity."

Command and culture changes recommended

Magistrate Grahame made two recommendations to the NSW Police Force Commissioner.

One was "additional cultural awareness training" for police in the Bourke, with the facts of the inquest considered as a case study.

The other was a shift change in who makes the calls on search and rescue operations.

NSW Police have specialists trained in search and rescue, although under its command structure it is the 'Duty Officer' attached to a police command who has overall authority on responses to situations.

That includes whether and when to begin search operations.

In Mr Moore's case, the court found the officer in charge decided against a larger-scale search involving SES personnel, despite advice from a specialist.

"Some of the factors recorded as C/Insp Weyland’s reasons for not accepting the advice of Sgt Hood to escalate the search on the morning of January 6, 2019 included factors that were either irrelevant or given too much weight.

"For example it is difficult to know what weight was given to the recorded fact that Dion was 'a violent criminal', that he had 'bush skills' and that he had people willing 'to harbour him'. These factors may have been weighed differently by an officer whose sole focus was on LANDSAR (land search and rescue) criteria.

"In the context of missing persons who may also be wanted by police or are attempting to evade police, families and communities may also feel more comfortable to provide information if the response to a missing person report is managed by an accredited SAR (search and rescue) Officer rather than by local officers tasked also with criminal investigations."

A NSW Police spokesperson said the force will consider the report recommendations.

"The NSW Police Force notes the findings of the State Coroner in relation to the death of Dion Moore in January 2019.

"A comprehensive review of the findings will be undertaken and all recommendations that are directed to police will be considered."