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Bernard Gore walked into Westfield Bondi Junction on January 6, 2017 and was never seen alive again.

The 71-year-old Tasmanian retiree left his daughter’s apartment in Woollahra, in Sydney’s eastern suburbs, about 12.30pm and had planned to meet his wife outside Woolworths.

His journey to the centre, in a white hat and red and black flannelette jacket, and the fateful moment he opened door L407 to a fire stairwell at 12.50pm was all captured on CCTV.

But his body was not found for three weeks.

This was due to “shortcomings and inadequacies” with efforts to locate him, NSW Deputy State Coroner Derek Lee said as he handed down his inquest findings on Friday.

He said the police search “can more accurately be described as a walk-through, rendering it largely ineffective in confirming whether Bernard had arrived at Westfield and was still there”.

There was no physical search of the fire stairs by police or security on any of the 22 days.

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.

The court heard the push-button exit door at the bottom of the stairwell was not opened in the three-week period, as no alarm was activated.

“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.

RELATED: Why shopping centre stairwells were never searched

‘A RESULT OF MISADVENTURE’

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 findings state.

The inquest into Mr Gore’s death heard there are some 10 to 14 kilometres of fire stairs and corridors at the shopping centre that security guards were required to check once a month, however the frequency of checks has since been increased.

They were also meant to be kept clear and there was no reason for a chair to be left inside.

Mr Gore was taking medication for hypertension and a mild cognitive impairment, being early onset dementia, at the time of his death.

The coroner found his 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.”

RELATED: Guard defends search for man in Westfield

RECOMMENDATIONS TO POLICE, SCENTRE GROUP

Mr Lee said the distress Bernard must have felt in that stairwell, and the “uncertainty and anguish” felt by his family in the hours, days and 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”.

Additionally, he recommended specific training and education for police officers relating to the availability of land searches and relevant co-ordinators for searches of urban areas and 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, and a review of security staff training on checks to fire stairs and fire corridors to ensure such tasks are effectively communicated and properly understood.

RELATED: Missing persons investigations overhauled since Bondi death

FAMILY’S DEVASTATING LOSS

Mr Gore’s wife, Angela, and his adult children were in court to hear the findings on Friday and embraced each other outside.

The coroner acknowledged the toll the inquest proceedings, which began in November 2019, would have had on them, independent to it being almost four years since the 71-year-old died.

“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.”

In a statement provided to news.com.au on Friday, the Gore family said: “Bernard was a loving father, husband, and great friend.”

“It has been devastating to lose him under these circumstances,” they said.

“We hope that the Coroner’s recommendations will be followed, and that this will prevent something like this happening to another family.

“We would like to thank the Coroner’s court for their dedication and sensitivity through this process, and would ask for privacy for our family at this time.”

sarah.mcphee@news.com.au

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