Bridget Flack was reported missing on December 1, 2020 but officers failed to recognise her high suicide risk despite concerns from family, Victorian Coroner Ingrid Giles found on Thursday.
That decision delayed efforts to quickly triangulate Ms Flack's phone so officers were unable to pinpoint her exact location, the coroner said in her long-awaited findings.
Bridget Flack was found dead in bushland by community members who organised their own search. (HANDOUT/VICTORIA POLICE)
Police then left the on-the-ground search for Ms Flack to members of the LGBTQI community, who rallied after learning of her disappearance.
Two of those community members found her body in bushland near Kew on December 11, 2020.
"(Victoria Police) failed to consider the safety and wellbeing of the community members searching for Bridget," Ms Giles said in her report.
"Police left a vulnerable community to search for one of their own, in the knowledge that Bridget might be found deceased."
However, she acknowledged "concerning gaps" in the investigation did not cause Ms Flack's death as she likely died by her own hand on November 30.
Ms Giles did not make any adverse findings against the officers involved, instead making three recommendations to Victoria Police.
These include implementing changes to its missing persons risk assessment, first identified in an internal review carried out in 2021.
Bridget Flack's sister Angela Pucci Love says they participated in hope of helping the next family. (Joel Carrett/AAP PHOTOS)
Ms Flack's sister Angela Pucci Love, who gave evidence at the inquest, said she hoped the findings would lead to actual change.
"The only reason we embraced this process was to help the next family," she told reporters outside of court.
"Sadly, it doesn't change our situation.
"But if we know the next person doesn't feel they're not heard or not treated with the respect that they deserve, be it in life or after life, then it makes us feel really proud."
The coroner also investigated the deaths of four other transgender or gender diverse young people, who died by their own and between 2020 and 2021.
A further seven recommendations were made following the inquest into the deaths of Natalie Wilson, Matt Byrne, Heather Pierard and another person known under the pseudonym AS.
These include recommending the federal government restrict the online sale and distribution of a substance used by three of the people to take their own lives.
There were also recommendations to increase access and capacity to gender-affirming treatments in Victoria, and mandating cultural sensitivity training for GPs and psychiatrists.
Ms Giles also made a recommendation to Victoria's State Coroner John Cain to consider the introduction of a LGBTQI awareness training model for all staff at the court.
Transgender Victoria CEO Son Vivienne says none of the coroner's recommendations are impossible. (Joel Carrett/AAP PHOTOS)
Transgender Victoria chief executive Son Vivienne welcomed the coroner's findings, saying many were long overdue.
"None of them are impossible," they told reporters outside of court.
"They just need to be timelined and budgeted for, and we can move ahead."
Anna Bernasochi, from LGBTQI suicide prevention organisation Switchboard Victoria, said Thursday's findings would not mark the end of the advocacy work.
"We're going to be there every step of the way to ensure that government, the police and our institutions are held to account so that we can change this reality for our communities," she said.
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