Death by ‘misadventure’: Rules of the investigation into the man found dead on the stairs of the shopping center after disappearing for 3 weeks

Australian retiree Bernard Gore entered Westfield Bondi Junction on January 6, 2017 and was never seen alive again.

The 71-year-old retiree from Tasmania left his daughter’s apartment in Woollahra, in Sydney’s eastern suburbs, around 12:30 p.m. and was scheduled to meet his wife outside Woolworths.

His trip downtown, in a white hat and a red and black flannel jacket, and the fateful moment when he opened door L407 to a fire escape at 12.50pm, was captured by CCTV.

But his body was not found for three weeks.

This was due to “shortcomings and inadequacies” in efforts to locate him, said New South Wales Deputy State Coroner Derek Lee, releasing the findings of his investigation today.

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

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

Security personnel did not initiate any “Code Gray” search, which required all personnel to sweep nearly every corner of the building if a child or vulnerable person was not found within 10 minutes.

The court heard that the push-button exit door at the bottom of the staircase was not opened within the three-week period, as no alarms were activated.

“Bernard died inside a fire escape at Westfield Bondi Junction in circumstances in which he was not initially found and, for reasons that are not well understood, did not or was unable to exit the fire escape,” the coroner said.

He said it was “more likely than not” that Gore died between January 6 and 9, but the available evidence does not allow a finding as to the cause of death.

‘Result of a misadventure’

A maintenance worker investigating a report of foul odor in the area found the father of three on January 27, “in a semi-kneeling position on the ground with no signs of life.”

“It appeared that Bernard had been sitting in a chair that was found close to his body, and that at some point he had fallen forward and out of the chair,” the findings state.

The investigation into Gore’s death heard that there are between 10 and 14 km of stairs and fire walkways in the mall that security guards are required to check once a month. Since then, the frequency of checks has been increased.

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

Gore was taking medication for hypertension and early-onset dementia at the time of his death.

The coroner discovered that his way of dying was the result of an accident.

“The perimortem psychological, environmental and physiological stressors that Bernard would have experienced as a result of being inside the ladder were possible major contributors to his death,” he said.

“When these issues are taken into account, along with certain identified deficiencies and inadequacies associated with efforts to locate Bernard, it cannot be said that Bernard’s death was due entirely to natural causes.

“Therefore, it is more appropriate to conclude that Bernard’s death was due to an accident.”

Recommendations to Police, Scentre Group

Lee said the anguish Bernard must have felt in that stairwell, and the “uncertainty and anguish” his family felt in the hours, days and weeks that followed, was “unimaginable.”

“The deficiencies that have been identified as part of the coronary process, the lessons learned by the individuals and organizations involved in trying to locate Bernard, and the recommendations that have been made after this investigation are expected to mitigate the possibility of another family he had to endure such a traumatic event, “he said.

It made six recommendations: three to the New South Wales Police Commissioner and three to the CEO of the Scentre Group, which owns and operates the Westfield centers in Australia.

These include an update to the NSW Police Standard Operating Procedure on Missing Persons to identify and emphasize “the purpose and importance of searching and collecting CCTV images in the context of a missing person investigation; the timing and the degree to which such CCTV images must be reviewed; and the need for full and accurate communication between the police and community partners who are required to participate in the provision and review of such CCTV images.

In addition, it recommended specific training and education for police officers regarding the availability of land records and relevant coordinators for records of urban areas and business premises.

The coroner recommended to Scentre Group to amend its ‘Lost and Found Children or Vulnerable Persons Policy’ to clarify the order in which stairways and fire corridors must be searched in response to a gray code, and a review of training from security personnel on fire escape and fire corridor controls to ensure these tasks are effectively communicated and properly understood.

The devastating loss of family

Gore’s wife, Angela, and their adult children were in court today to hear the findings and hugged outside.

The coroner recognized the price that the investigation process would have caused them, which began in November 2019, regardless of the fact that almost four years have passed since the death of the 71-year-old man.

“There can be no doubt that Bernard is greatly missed by his family, loved ones and friends, and that his untimely loss has caused them immeasurable pain and anguish,” he said.

“It is particularly devastating to learn that Bernard died so unexpectedly, and in circumstances where January 6, 2017 seemed to be a day not unlike any other that Bernard and Angela had experienced during their trip to Sydney.”

In a statement provided to news.com.au today, 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 are followed and that this prevents something like this from happening to another family.”

“We would like to thank the forensic court for their dedication and sensitivity throughout this process, and we would ask for privacy for our family at this time.”