A Tasmanian retiree visiting Sydney, Bernard Gore had planned to have lunch with his wife but instead died after making a wrong turn inside a Sydney shopping centre nearly four years ago.
Mr Gore walked into Westfield Bondi Junction on January 6, 2017 and was never seen alive again.
While visiting Sydney, the 71-year-old left his daughter’s apartment in Woollahra to travel to the bustling shopping centre and meet his wife.
Mr Gore, who was taking medication for hypertension and early onset dementia, was captured on CCTV walking through a fire exit door.
His body was not found for three weeks.
Today NSW Deputy State Coroner Derek Lee handed down his inquest findings, saying the failure to find Mr Gore sooner was due to “shortcomings and inadequacies” in efforts to locate him.
He described the police search as “a walk-through, rendering it largely ineffective in confirming whether Bernard had arrived at Westfield and was still there”.
The inquest heard there was no physical search of the fire stairs by police or security on any of the 22 days that Mr Gore was missing.
No “Code Grey” search, requiring all staff to sweep almost every corner of the building if a child or vulnerable person was not found within 10 minutes, was ever initiated by security.
“Bernard died inside a fire stairwell within Westfield Bondi Junction in circumstances where he was not initially found and, for reasons which are not well understood, did not, or was unable to, exit the fire stairwell,” the Coroner said.
He said it was “more probable than not” that Mr Gore died between about January 6 and January 9 but the available evidence does not allow for a finding as to his cause of death.
A maintenance worker investigating a report of a bad smell in the area found the father-of-three on January 27, “lying in a semi-kneeling position on the ground with no signs of life”.
“It appeared that Bernard had been sitting on a chair that was found near his body, and that at some point he had fallen forward and off the chair,” the inquest findings state.
The coroner found Mr Gore’s manner of death was the result of misadventure.
“The perimortem psychological, environmental and physiological stressors that Bernard would have experienced as a result of being within the stairwell were possible significant contributors to his death,” he said.
“When these matters are taken into account, together with certain identified shortcomings and inadequacies associated with the efforts to locate Bernard, it cannot be said that Bernard’s death was entirely due to natural causes.
“Therefore, it is more appropriate to conclude that the manner of Bernard’s death was as a result of misadventure.”
Mr Lee said the distress Bernard must have felt in that stairwell, and the “uncertainty and anguish” felt by his family in the weeks that followed was “unimaginable”.
“It is hoped that the shortcomings that have been identified as part of the coronial process, the lessons that have been learned by individuals and organisations involved in the attempt to locate Bernard, and the recommendations that have been made following this inquest will mitigate the possibility of another family having to endure such a traumatic event,” he said.
He made six recommendations – three to the NSW Commissioner of Police and three to the chief executive of Scentre Group, which owns and operates Westfield centres in Australia.
These include an update to the NSW Police Missing Persons standard operating procedure to identify and emphasise “the purpose and importance of canvassing for, and gathering, CCTV footage in the context of a missing person investigation; the timing of when, and extent to which, such CCTV footage is to be reviewed; and the need for comprehensive and accurate communication between police and community partners who are requested to engaged in the provision and review of such CCTV footage”.
He also recommended specific training and education be given to police officers relating to the availability of land searches and relevant co-ordinators for searches of commercial premises.
The coroner recommended Scentre Group amend its ‘Lost and Found Children or Vulnerable People Policy’ to clarify the order in which fire stairs and corridors should be searched in response to a Code Grey.
The coroner acknowledged the toll the inquest proceedings – which began more than a year ago and were hampered by the COVID-19 pandemic – would have had on Mr Gore’s family.
“There cannot be any doubt that Bernard is greatly missed by his family, loved ones, and friends, and that his untimely loss has caused them immeasurable grief and distress,” he said.
“It is particularly devastating to know that Bernard died so unexpectedly, and in circumstances where January 6, 2017 appeared to be a day no different than any other that Bernard and Angela had experienced during their trip to Sydney.”
