An inquest into the death of a 71-year-old man discovered in the stairwell of a Sydney shopping centre about 20 days after he went missing has found he died of misadventure and there were “shortcomings and inadequacies” in the search effort.
Bernard Gore likely died inside the fire stairwell at Westfield Bondi Junction between 6 and 9 January 2017, the NSW deputy state coroner, Derek Lee, concluded on Friday.
An autopsy found no evidence of traumatic injury or direct third party involvement, raising the possibility he could have died from natural causes.
But while Gore was suffering from some pre-existing medical conditions, the “psychological, environmental and physiological stressors” experienced as a result of being stuck inside the stairwell were “possible significant contributors to his death”, the coroner said.
Those factors, along with “identified shortcomings and inadequacies associated with the efforts to locate Bernard,” led Lee to conclude the man’s death was not entirely due to natural causes but rather a result of misadventure.
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Gore had lived in the same house in Tasmania with his wife, Angela, since 1968. The couple, who celebrated their 50th wedding anniversary in 2016, frequently travelled to Sydney to visit their children.
The former bread delivery driver and barber loved walking and did so every day for up to three hours while he was in Sydney on holiday.
Before their most recent Christmas trip in 2017, Gore was reported missing in Hobart one evening but was later found high-spirited although vague regarding his whereabouts.
He was later given medication for hypertension and the early stages of dementia which was observed to improve his cognitive abilities.
Gore and his wife were staying with their daughter in Woollahra in 2017 and would often eat lunch at Bondi Junction. On 6 January, Gore left 20 minutes before his wife and they planned to meet after 1pm.
After he failed to show up, his wife searched all his favourite spots, before returning home and contacting police. That evening their daughter visited Westfield and provided two security officers with information.
While video footage was being checked, the two security officers searched the mall area including the lifts, escalators, toilets, dock areas and garbage rooms – but not the fire stairs or fire corridors.
A walk-through of the fire stairs area on 9 January was the only police search conducted in the 21 days Gore was missing.
Several missed opportunities arose from early assumptions by police that Gore had never arrived at the Westfield, partly informed by security details and their ill-informed handover notes, the inquest found.
Lee has made several recommendations to NSW police including updating standard operating procedure concerning missing persons. The coroner suggested the owner-operator of the shopping centre – Scentre Group – should update its policy checklist for finding vulnerable people.