The family of a man who went missing from Calvary Hospital and was not found for months were still coming to terms with how sick and vulnerable he had been, an inquest into the man's death heard on Monday.
Tad Kahsai, 61, was being treated for alcohol withdrawal when he walked out of Calvary Hospital on December 30, 2015, and went missing.
It took 29 days for police to begin their search and rescue effort, but it was not until three months after he went missing that students found Mr Kahsai's body in bushland not far from the hospital doors, in a place not checked in the police search.
Hearings at an inquest into Mr Kahsai's death last week scrutinised the decisions made by hospital staff and police after Mr Kahsai was admitted to and then left the hospital.
The court also considered various mistakes and failures in communication between the hospital and police, such as a typographical error in the address of one email from the hospital about Mr Kahsai's absconding that meant police did not receive it, and did not begin investigating the missing person until the next day.
As the inquest hearings came to a close on Monday, Mr Kahsai's family said they had been confronted with just how sick and vulnerable their father had been. They said it had been painful to hear much of the evidence from people who saw him at his worst, "the last days of his life".
In the statement, read to the ACT Coroner's Court by their counsel Brodie Buckland, Mr Kahsai's family also acknowledged a genuine desire on behalf of the hospital and police to "accept there were mistakes, to learn lessons and achieve meaningful change".
But they said Mr Kahsai would still be alive had he not fallen through the cracks now apparent in the institutions tasked with the care and protection of people in need.
"As a community we should have faith and confidence that those most vulnerable, like our father, are going to be properly looked after," his family said.
They suggested, among other matters, that the coroner make recommendations on police training on missing person investigations, education and awareness training for police about alcohol withdrawal and the establishment of a specialised detoxification unit at Calvary Hospital.
Counsel assisting the coroner, Sarah Baker-Goldsmith, said in her submissions that while people had made mistakes, there was no one individual to blame for Mr Kahsai's death.
She said this was a case where each individual decision was open and reasonable to the decision-maker at the time, but the effect of each decision was a "snowballing" to an undesirable outcome.
The mistakes, she said, pointing to the email typo as one example, represented a lost opportunity to intervene.
But it would not be "proper to attribute blame to anyone individual," Ms Baker-Goldsmith said, adding that there were "a number of systems failures."
She suggested the coroner make no adverse findings against the parties or individuals involved.
Counsel for the ACT government and for the police said they mostly adopted counsel assisting's submissions.
Counsel for the AFP, Callan O'Neill, asked the coroner to consider not making any recommendations in relation to the police.
He said the systems that were in place had been tested by human error.
"There is nothing more human than a typo," he told the inquest, but conceded that "the system was too sensitive to a very minor error."
He said the police had made changes since Mr Kahsai's death, including ensuring more experienced staff were involved at an earlier stage of a missing persons investigation. Mr O'Neill said police were "constantly looking for holes" in their new procedures.
Coroner Beth Campbell said she would aim to hand down her findings on May 4.