Police officers made a litany of failings in their investigation into a missing man who was at high risk of suicide, a court has heard.
The failings were highlighted during the third day of an inquest into the death of 29-year-old Jonathan Magee, who died after he was hit by a train after walking out of the emergency department at Belfast City Hospital in the early hours of January 29, 2011.
Mr Magee had been waiting in A&E for a psychiatric assessment after he cut his wrists, when he walked out of the hospital.
Police Ombudsman investigator Fergus Jamison, who interviewed the police officers involved in the case, described how a number of officers did not follow proper procedures in the hours after Mr Magee's disappearance.
One of the blunders examined during the inquest was the failure of police to commence a missing person report for seven hours after his disappearance, despite Mr Magee being identified as high risk by hospital staff.
Mr Jamison told the hearing at Laganside Courts that as Mr Magee's medical background had been well documented - including the fact he had tried to take his own life - he should have been classed as a high risk missing person from the outset.
It also emerged that:
Mr Jamison said: "We believe that valuable time and focus was lost and that added an unnecessary delay and a focus could have been made to explore other avenues.
"Without that risk assessment it leaves the police vulnerable."
Inspector John McIntyre told the court that he checked the logged details of the case when he started his shift some eight hours after Mr Magee went missing.
He explained that the case had been opened, closed, then reopened a number of times in the hours preceding the deceased man's disappearance.
He said by the time he arrived at work at 9am it was still not being treated as a missing person case.
The top-ranking officer also described the former process of conducting a missing person report as a "shambles".
He expressed concern at the length of time it was taking to go and search Mr Magee's home after his requests to do so.
Sergeant Stephen Patty, who had been a supervisor on the day of Mr Magee's death, admitted that he had received no training for his temporary post and was effectively not trained to deal with a missing person case.
The inquest continues today.