Warning: Distressing content

The missing person procedure at a Westfield shopping centre required all staff to sweep almost every corner of the building if the person hadn't been found in 10 minutes, an inquest has heard.

But no "Code Grey" was ever called on January 6, 2017 and Bernard Gore remained lost in a stairwell for three weeks until his decomposing body was found.

A week-long inquest is being held in the NSW Coroners Court in Lidcombe into the 71-year-old man's disappearance and death, examining the adequacy of the review of CCTV and searches by police and security, among other issues.


"Once a Code Grey has been broadcast, all available staff should join a systematic search," counsel assisting the coroner, Anna Mitchelmore SC, said today.

She cited a customer assistance document within the centre's Standard Operating Procedures that dealt with lost or found children and vulnerable people.

Bernard Gore was 71. Photo / Supplied
Bernard Gore was 71. Photo / Supplied

Gore was aged 65 years or over and had a mental, developmental, or physical disability, being his diagnosed mild cognitive impairment — the two criteria for being classified a "vulnerable" person.

"It (Code Grey) involves a sweep of the mall," Ms Mitchelmore said.

"That includes various items: back of house corridors, any unlocked room or recess accessible from the mall or back of house, there are various other areas.

"If the person is not found within 10 minutes of the start of the search, all staff will join the search. The duty manager ... will assume control and staff will notify police."

Gore was on a three-and-a-half week holiday with his wife, Angela, to visit their daughter in Woollahra, in Sydney's east, from December 2016.

He left to walk to the Westfield at about 12.30pm on January 6, 2017 and was never seen by his family again.


He had planned to meet his wife outside Woolworths on level three at 1.15pm.

CCTV broadcast to the inquest on Monday revealed he had walked in an entrance on level four at 12.48pm and turned through a fire escape door at 12.50pm.

A security guard rostered on the night shift, from 6pm to 6am, spoke to Gore's daughter Melinda outside Woolworths between 9.30pm and 10pm. Police had already been notified by family.

He gave evidence today that she had told him her father was missing and provided a description of the elderly man.

"He didn't like dark places, loud noises," the guard recalled.

Bernard Gore's body was discovered three weeks after he was reported missing. Photo / Supplied
Bernard Gore's body was discovered three weeks after he was reported missing. Photo / Supplied

"There was a piano outside David Jones at Christmas time that he liked listening to ... but that was gone (by January).

"And he had early stages of dementia."

He said searching the carparks, tenancies and locking entrances and exits during closing procedures as a "rover" was part of his ordinary duties, but checking fire stairs and corridors was not.

Barrister Kelvin Andrews, acting for the Gore family at the inquest, asked: "The fire stairs are accessible from the mall, aren't they?"

"Yes, they are," the guard replied.

He was one of two rovers in the Woolworths and Zone A part of Westfield and confirmed neither of them checked the stairwells that evening.

"The fire stairs are checked monthly," he told the court.

"Every fire exit is checked once a month."

Police never asked about the searches the shopping centre security staff had carried out, he said.

The court previously heard there are some 10 to 14 kilometres of fire stairs and corridors at Westfield Bondi Junction.

When asked by Ms Mitchelmore if any practice or procedure dealt with checking them, he said: "That would always come from centre management if it was escalated that high."

"In case of a report of a Code Grey. If it was confirmed the missing person was onsite or had been onsite."

Inside the stairwell at Westfield Bondi Junction where Bernard Gore's body was found. Photo / Supplied
Inside the stairwell at Westfield Bondi Junction where Bernard Gore's body was found. Photo / Supplied

He said he had reviewed some CCTV for a few hours, including from a revolving door entrance on level three, after receiving the missing person report.

But it was at double-speed, working backwards in time and also "in between" his regular duties that night.

When asked if he knew which cameras his supervisor had been looking at on another computer terminal, he said: "I don't recall, sorry."

The inquest on Monday heard Gore was found in a "semi-kneeling position" and appeared to have at some stage fallen off a chair in the stairwell, Ms Mitchelmore said.

Under further questioning from Andrews today, the guard said fire stairs should always be "a clear passageway".

Andrews asked: "There's absolutely no reason for a chair to be in a fire stairwell, is there?"

"No," the guard replied.

The man's supervisor today gave evidence that he would not initiate a "Code Grey" unless a missing person had been confirmed onsite, which was something he'd only considered doing after speaking to a police officer around 1am on January 7.

Flowers for Bernard Gore outside the old Woollahra Post Office. Photo / News Corp
Flowers for Bernard Gore outside the old Woollahra Post Office. Photo / News Corp

Neither he nor the rover looking at CCTV footage spotted Gore in their reviews.

Barrister Michelle England, representing the NSW Commissioner of Police and other officers, asked the security supervisor: "Knowing now, with the benefit of hindsight, that Gore was found in the stairwell in awful circumstances, do you agree that a Code Grey should have been called?"

"I do agree in hindsight that a Code Grey or a full centre search should've or could've been called," the man replied.

"It would've helped with the issue, I believe.

"But at the time, I didn't feel it appropriate with the information that I had."

The inquest is expected to hear authorities formed the view early in their investigation that Gore never made it to Westfield and completed land searches of areas like Centennial Park instead.

A forensic entomologist is expected to say an analysis of data indicated Gore "died a minimum of one to two weeks before his body was found".

It's anticipated an expert will give evidence of survivability without water being a maximum of three days, and what he considers to be the most likely cause of Gore's death - one of many unanswered questions.

The inquest continues.