A man visiting his daughter in Sydney told his wife he would meet her in 20 minutes. But he would disappear before a grisly discovery.
Warning: Distressing content
When Bernard Gore walked into Westfield Bondi Junction on January 6, 2017, it was like almost any other day.
The Tasmanian retiree loved walking and regularly made the trek to the shopping centre in Sydney's eastern suburbs from his adult daughter's nearby apartment on Ocean St, Woollahra.
"He would generally return after a period of one to three hours," counsel assisting the coroner, Anna Mitchelmore SC, this week told an inquest into his lonely and distressing death.
She said his wife, Angela Gore, knew he liked to journey to Westfield and he'd walk along Wallis St, take the footbridge over Syd Einfield Drive then make his way down Oxford St.
It was about a 15-minute journey.
The 71-year-old, nicknamed Butch, was "generally in good health" at the time of his death, Mitchelmore said.
The couple were visiting their daughter, Melinda, on a three-and-a-half week holiday over Christmas and New Year and planned to return home on January 11.
Their daughters had moved to Sydney in the 1990s and both parents had visited many times.
Gore was taking medication for hypertension and a mild cognitive impairment, being early onset dementia.
That particular summer morning, he got up between 6am and 7am and had toast for breakfast.
It was raining and he watched TV with his wife.
"After the sun came out, Bernard said he wanted to go out," Mitchelmore said.
"He was keen to get moving and she was not quite ready.
"Angela told him that she would be about 20 minutes behind."
But within 20 minutes of leaving the apartment, Gore had disappeared without a trace.
He left the Woollahra address about 12.30pm and had planned to meet his wife outside Woolworths on level three inside Westfield at 1.15pm.
CCTV broadcast to the inquest on Monday revealed he had walked past a meat store on Oxford St at 12.40pm and a real estate agency at 12.42pm.
He walked in an entrance on level four at 12.48pm and turned into a fire escape – through door L407 – at 12.50pm.
Gore was captured on multiple cameras outside and inside the enormous shopping centre, wearing a red and black flannelette jacket and with his white hat atop his head.
One of his daughters cried in court as she watched vision of him turning left into the fire exit.
It wasn't for another three weeks, about 8am on January 27 that year, that Gore's decomposing body was found at the bottom of the stairwell by a maintenance worker.
He was found lying in a "semi-kneeling position", Mitchelmore said.
"It appears that he had been sitting on a chair that was found near his body, and at some stage he had fallen forward and off the chair."
His white hat was found halfway down the fire escape and police also located a handkerchief, dentures, a men's watch, a black comb, a glasses case and a $5 note.
An autopsy was unable to determine the direct cause of death due to the state of Gore's body and the exact date and time of his death also remain unclear.
Data indicated to a forensic entomologist he'd been dead for a minimum of one to two weeks.
HISTORY REPEATING ITSELF
Gore had gone missing before, less than a year before he died.
The retiree had worked primarily as a bread delivery driver and also as a barber.
"He continued to cut the hair of his friends and other people he knew," Ms Mitchelmore said.
He lived in Tasmania with his wife of more than 50 years in the house they bought in the late 1960s to raise their three children – two daughters and a son – before they flew the nest.
From early 2016, Gore's wife noticed that he was "sleeping excessively".
One afternoon in June of that year, the Gores went shopping in the Hobart suburb of Moonah.
They arranged to meet at the car but after waiting for a while, Mrs Gore returned home alone.
She reported her husband missing to police at 6.30pm.
"Bernard was found at about 10pm in CBD of Hobart," Ms Mitchelmore said.
"Angela recalls … she was told when police asked Bernard where she was, he replied that he was waiting for her and that she was at the hospital."
She said a Tasmanian police officer advised Gore's family that he should carry a location tracker or have a mobile phone.
Their son, Mark Gore, bought his father a watch which had a GPS tracking device inside it.
The next month, Mrs Gore took her husband to see a GP "using his sore toe as a pretext as he was not fond of doctors".
Tests indicated he had a moderate cognitive impairment and he was prescribed medication.
"Angela Gore stirred the tablet into Bernard's coffee each day and found that it made a huge difference to him," Ms Mitchelmore said.
By December 2016, his mental score improved and was downgraded from moderate to mild.
FAMILY'S DESPERATE APPEAL
Mrs Gore went to meet her husband outside Woolworths on January 6 but he never showed.
She searched areas they commonly frequented but returned home by 2pm.
The couple "more or less had a routine when they attended Westfield", Ms Mitchelmore said.
They only attended Zone A – the side of the centre in which Gore died – but the pedestrian entry varied among the six entrances not through a shop or a car park.
The couple would visit the food court on level five and eat Chinese, go to Woolworths to pick up groceries, and Gore would get an ice cream from McDonald's before the walk home, Ms Mitchelmore said.
"In view of his cognitive impairment, Bernard may have become confused en route," she said.
As it got dark, the family became "increasingly worried".
Close to eight hours had passed when Gore's daughter, Melinda, called police at 7.59pm to report her father missing.
Two officers arrived at the apartment at 8.18pm and were given a photograph and description.
At about 9pm, Melinda went to Westfield and spoke to a manager.
By 10pm, she had also spoken to two security guards rostered on as "rovers" in the area.
Both men testified at the inquest this week about what happened after they were notified.
"He didn't like dark places, loud noises," one guard recalled the daughter had said.
"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."
Gore's son, Mark Gore, joined Sydney police in an appeal for information on January 11.
"My father would not want to be a bother to anyone if he was lost, and I think it's unlikely he'd approach a stranger for help," he said.
"I hope someone will notice him alone and ask if he needed help.
"He'd probably say he was fine, but people need to contact police if they think it is him."
Superintendent Brad Hodder said, to his knowledge, Gore had "not had any sustenance".
"The gentleman has turned up here on a regular basis over the last couple of days," he said.
Police renewed their appeal for information on January 21.
"In all likelihood he's probably still in the Sydney area, whereabouts we don't know unfortunately," Inspector Craig Hewlett said.
"Obviously the concerns are escalating as time goes on with both Gore's age, his health and also the heat we've had in Sydney.
"He's not considered dangerous at all and if people do think they've seen him don't be scared to approach him and contact police straight away."
WHERE DID THEY SEARCH FOR GORE?
The inquest heard there are between 10 and 14 kilometres of fire stairs and fire corridors in Westfield Bondi Junction.
Not all of the entrances from Oxford St, which dissects the two zones, are on the same level.
One security guard gave evidence it took him six hours to walk the length of the shopping centre's fire corridor system.
The barrister representing the NSW Commissioner of Police, Michelle England, described it as being "somewhat of a maze" with "a great many sets of fire doors".
Another guard 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, asked: "The fire stairs are accessible from the mall, aren't they?"
"Yes, they are," the guard replied.
He conceded there was no reason for a chair to be found there as they should be kept clear.
Their examination of CCTV in the early hours and days after Gore's disappearance failed to identify the missing man.
Despite it's labyrinthine construction, the stairwells were never fully searched by authorities.
Police and security instead formed the view early on in their investigation, between about January 7 and 12, that Gore had never made it to the Westfield, Ms Mitchelmore said.
A guard who was a security supervisor at the time of Gore's disappearance denied he was asked by officers to search the stairwells.
"Absolutely," he said when asked if he would have searched any area asked of him by police.
He said a search of "basically the whole mall" was carried out including the toilets, rest rooms, lift lobbies and back of house corridors.
The guard denied he'd failed to comply with company policy which stated that any "unlocked recesses" accessible through the centre should be searched.
The inquest heard that the doors to the fire stairs were not alarmed and security was only notified if someone exited them onto the street.
The alarm was never activated on the push-button door onto the street from the stairs in question in the three weeks from when Gore disappeared and was found, the court heard.
The man who took over as security supervisor later on January 7 told Ms Mitchelmore the circumstances of Gore's disappearance did not present a normal Code Grey situation.
Code Grey is the centre's policy to deal with lost or found children and vulnerable people.
"In the past, (they) originated with the person being present inside the centre, confirmed as being lost within our vicinity," he told the inquest.
"Furthermore, we did not receive any information confirming that he had arrived to the centre which made it unusual compared to previous instances."
A detective who took charge of the case in 2018 described the management of the investigation as "poor".
Detective Senior Constable Andrew Agostino said he had never seen a high-risk level missing person investigation remain in the hands of general duties officers "for such a period of time".
"I found that there was a lot of miscommunication between police and Westfield in relation to CCTV," he told the inquest.
"What they've canvassed, what they've done, what searches they've done.
"Even in relation to what Woolworths was nominated – there was talk about Woolworths at Bondi Beach. There was a lot of information that was probably not accurate or correct."
He said the Woollahra address and shopping centre in question should have been fully searched and eliminated completely before areas like nearby Centennial Park were looked at.
Ms Mitchelmore asked: "Police should take their own course irrespective of whatever the policy might be of, for example, the particular shopping centre?"
"Yes," the detective replied.
Scentre Group – the company that owns and operates Westfield centres in Australia and NZ, SecureCorp, NSW Police and the Gore family were all legally represented at the inquest.
Deputy State Coroner Derek Lee will deliver his findings and recommendations at a later date.