Carmelo Fino had already been wandering in the streets for 15 hours before authorities began to search for him outside the care home, the inquiry into his disappearance shows.

Times of Malta saw the final report of the inquiry, which underlines how staff at the home only realised the man was missing five hours after he had left the hospital and then spent an entire morning looking for him inside the premises and in the home’s grounds because night shift officials had given false statements about when they had seen him last.

Fino, an 83-year-old dementia patient, disappeared from St Vincent de Paul residence on June 28. He was caught on CCTV footage walking out of the open gates of the building at 2.47am. Despite search efforts, he remains missing to this day and many fear he could be dead.

On July 1, Active Ageing Minister Jo Etienne Abela asked retired judge Geoffrey Valenzia to conduct an independent inquiry into the case.

The inquiry found there were four staff members in Fino’s ward that night – one nurse (Rhys Xuereb) and three carers. The inquiry found that Fino left his bed before 2.45am but none of the staff realised he was walking out of the ward.

It is unclear whether he took the lift or the stairs. He probably took the stairs because he could not communicate or take care of himself independently. He could only say the words “number one” and was unlikely to be able to operate a lift on his own.

He somehow found himself at the front gates of the building at 2.45am, and still, nobody realised he was walking out and nobody tried to stop him.

There were at least two security staff who were meant to man the gate and an official in charge of them, but the inquiry said they were nowhere to be seen.

CCTV footage showed Fino walking down the front entrance towards the main gate and then walking towards the guard room. Then, momentarily, he seemed like he was going to return to where he came from but changed his mind, turned around, and walked out of the gate, which was open.

By 3am, Fino was out wandering in the streets wearing a shirt and shorts.

Hospital regulations oblige night security staff to close the main gate between 11pm and 7am. The gate must only be opened when ambulances, food catering and other services come in during the night and must be closed immediately after they leave.

CCTV footage showed that night, the gate was left open for most of the night, “if not for the whole night”.

“When Fino walked out, or even before he walked out, no ambulance or vehicle had entered the premises,” the judge said.

“An ambulance was seen entering at 12.30am. The gate was open and remained open. The ambulance left at 12.55am and there were no staff at the gate.”

When interviewed, the official in charge of the security detail said it was a ‘normal’ night and she spent it in a nearby office doing paperwork, like she usually does. She said by the time she left the office at 6.30am, nobody informed her of a missing person.

“Evidence shows that the gate was left open against the regulations. Fino was able to walk out freely and consequently, he remains missing to this day,” the judge said.

“The officer in charge of security staff is not there to stay in her office all night. For her, that night was “normal”, when in fact, it wasn’t normal at all. She was responsible to see that the security staff assigned to her do their job.”

By 8am – more than five hours after Fino’s disappearance – nobody had realised the man was missing.

The night shift staff left and were replaced by the morning staff, who were not given a handover.

At around 8am, the morning staff realised that Fino was not in his bed when they were doing a ward round to wash the patients.

They called the night shift staff, who told them they had last seen Fino in his bed at 5.45am.

“I saw Carmelo sleeping in his bed until 5.30am, when I last checked the patients,” Rhys Xuereb told his nursing manager in an e-mail later that day.

One carer said Fino was given coffee without sugar at that time.

The night shift staff either knew Fino was missing and said nothing, or else, out of negligence, did not even realise that a patient had been missing since 2.45am- Judge Geoffrey Valenzia

“He was in bed, awake and not sleeping. He did not have the bed side raised up around his bed. I was with other care workers at that time doing the nappy changes and giving coffee,” the carer told his superiors, despite CCTV footage showing Fino walking out of the hospital at least three hours before.

Xuereb later asked to withdraw his statement through the nurses’ union, claiming he was put under pressure. Judge Valenzia said that for this reason, he did not interview Xuereb during the investigation.

The hospital CEO told the judge there was no staff shortage that night, but the MUMN is insisting that leaving one nurse on duty with an entire ward constitutes a nurse shortage.

As per hospital regulations, the night shift staff are obliged to check on residents and walk through all rooms at 11pm, 1am and 3am, and the walk must be documented.

The inquiry found the situation was exacerbated when all efforts to find Fino began to revolve around a lie – that Fino was still in bed at 5.45am.

They looked at CCTV footage from that time onwards, and when they did not see Fino leaving the premises, they figured he must still be wandering around the hospital.

Consequently, staff spent almost all morning searching for Fino inside the hospital premises. At 11.45am, they went to the Luqa police station to file a report for a missing person.

This means that by the time police were alerted to Fino’s disappearance, the elderly man had already been wandering the streets for nine hours.

It was not until the afternoon, that another patient in his ward told staff and the authorities that Fino could not have had tea or coffee at 5.45am, because he was already out of his bed at 3am.

This prompted the police and hospital authorities to start looking at CCTV footage from 11pm.

The footage showed Fino leaving the hospital at 2.47am, and another CCTV footage near the Luqa LIDL showed him walking past at 3.17am. That was Fino’s last sighting.

The footage was inspected at 6.30pm that evening and so the search for Fino in the streets began more than 15 hours after he had disappeared.

“The night shift staff either knew Fino was missing and said nothing, or else, out of negligence, did not even realise that a patient had been missing since 2:45am,” the judge said.

He said the staff misled management, and consequently misled the search for Fino, because the most crucial hours of the search were concentrated on the inside of the facility.

“Consequently, a lot a precious time was wasted and the result could have been different,” the judge concluded.

St Vincent de Paul has open wards and closed wards. Open wards allow the residents to walk freely in and out of them, while closed wards are reserved for cognitively impaired residents and severe wanderers with dementia.

Closed wards are locked all day and can only be opened by nurses and carers.

Doctors told the inquiry that despite being a dementia patient, Fino was put in an open ward because he never showed signs that he might wander off. He never left the ward, was physically able and never had suicidal tendencies.

Despite not being able to communicate and despite needing prompting to change clothes, he never showed troubling signs, would not wake up at night and never indicated that he might head for the exits.

Among other things, Judge Valenzia recommended the introduction of a dignified tracking device, more clearly defined criteria on the procedures that decide in which ward residents are put, stricter surveillance on people entering and exiting the premises, as well as greater vetting on prospective employees.