Ray Speechley had only been in the South Coast aged care centre for two nights, but he suffered from dementia, was distressed and looking for his beloved wife Jan.
Just before nightfall, the 77-year-old found a ladder, climbed the perimeter fence of the secure wing he was in, and walked off quickly towards the Princes Highway.
He was never seen again.
That moment in Dalmeny happened on July 7, 2016, and his wife of 57 years, Jan Speechley, said this week the guilt and anger have never left her.
"I just feel there were so many mistakes made," she said in relation to his disappearance and subsequent police investigations.
July 29 this year should have been Ray's 87th birthday, but instead of celebrating together, she sat alone at the kitchen table of her Cordeaux Heights home.
She still wonders how it all went so very wrong for her and Ray.
Ray grew up in Warrawong and he met Narooma-born Jan at a dance in her home town a few days after Christmas in 1957.
"Can I walk you home?" he asked her that night.
Jan said it was a "a good mile and a bit from the dance hall and then he turned up the next day".
They married on September 27, 1958, moved into a house in Windang and had two children, Michael and Nicole.
They were happy, Jan said. He worked as a boilermaker in BlueScope and loved to spear fish, play rugby league and, as he got older, they played lawn bowls together.
Ray had a cheeky sense of humour and was easy to get along with.
"He was a character, he had a very dry sense of humour and it just came out of nowhere," she said.
It was Ray's idea to move to Narooma.
After his diagnosis with acute myeloid leukaemia, he developed dementia.
As it worsened, and following a hospital visit, he was admitted to a secure wing at Illawarra Retirement Trust Retirement Village at Dalmeny.
When Jan received that call 10 years ago that her husband had disappeared, she headed straight to the aged care centre.
On the way, she passed a red Honda sedan on the opposite side of the road, with a man standing outside the passenger side of the vehicle. He was bending down to talk to the driver.
"You could see the skid marks where the car pulled up, you know, heavy marks where they'd braked," Jan said.
She quickly turned her car around to speak to the driver of the Honda to find out if they had seen Ray, but by the time she got back the red car was pulling out.
While she jumped out of her car and tried to wave them down, the driver waved at her and kept driving.
"There were two people in that car when it drove off," she said.
To this day she believes Ray got in that car, she has no idea why
"I have to think that. And I didn't get to get the number plate," she said as her voice choked with tears.
"I'm so precise about everything, but I missed that. The most crucial thing and I didn't do it and I'll never forgive myself."
Police never found out who was driving that red car.
It was mid-winter when Ray disappeared, it was cold and there was light rain, and while police conducted line searches, Ray was never found.
A survivalist expert, Dr Paul Luckin, told a coroner's inquest in 2019 that "Mr Speechley likely did not survive past the evening of July 9, 2016" due to exposure and health factors.
The coroner also heard that the IRT staff member who witnessed Ray's escape did not follow him for fear she would injure herself jumping down from the fence. Also, she had no way of letting other staff know, and as a registered nurse was required to remain on the premises.
NSW Deputy State coroner Elaine Truscott determined that Ray Speechley "became lost in bushland after scaling the fences of the Illawarra Retirement Trust facility in Dalmeny wanting to return home to be with his wife Jan".
She also handed down four recommendations to police, including greater use of the dog unit in searches; and a cadaver dog search for Mr Speechley's remains.
She also recommended a policy of "maintaining all land search operations for missing persons for three days beyond the maximum survival period"; and better consultation between police in NSW and the ACT in emergencies.
In the immediate aftermath of Ray's disappearance, Jan did not cope well.
"I was a mess after Ray disappeared, I used to stand at the window all night looking out hoping he'd come home," she said.
"But I knew, you know, within a month I knew that he was never going to come home."
As the months wore on after Ray disappeared she could not bear to walk the same streets and drive the same roads they had taken together, so she moved back to the Illawarra.
These days, the grief and anger are still there and she lives with hope that one day she will have answers.
"It never changes because it never goes away and it never will," she said.
If you have information about any missing person, call Crime Stoppers on 1800 333 000.
