On the morning of Friday, January 6, 2017, Bernard Gore travelled to the Bondi Junction Westfield mall in Sydney, Australia.
He was on a trip to visit his daughter, Melina, and told his family he planned to walk to the mall before meeting his wife of 50 years, Angela Gore, for lunch about an hour later.
But he never made it to lunch.
Mrs Gore soon became concerned and searched the mall for her missing husband. She filed a missing person’s report with local authorities later that evening.
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It would be three weeks before he was found.
Tragically, Mr Gore was found dead inside a fire escape stairwell at the shopping mall on January 27, 2017. His body was discovered 21 days after he was reported missing.
It is thought that he'd accidentally entered the stairwell, described as a 'labyrinth' of self-locking doors and confusing exits, through a fire door, and couldn't find his way out.
A sales assistant at Westfield's Chanel store had spotted Bernard, who suffered from dementia, looking confused on the morning of his disappearance.
"He was completely lost and confused," she told Australia’s Daily Telegraph. "He came in asking for help, he was frail and confused and was pacing up and down outside the store and eventually came inside.
"He said he couldn’t find the carpark or people he was supposed to be meeting. I asked if he needed help and he shook his head and wandered off.
"We were so worried my colleague called security and one of the guards told us they could check CCTV footage to locate him.
"The thought that he had been in the stairwell for three weeks makes me feel so sad. Why has it taken so long to find the body?"
An inquest into why it took such a long time for Mr Gore to be found uncovered a number of shortcomings, including 'inadequate search procedures and ineffective communication'.
The stairwell where his body was found was not searched initially, and investigators found that the review of CCTV footage was not comprehensive.
New South Wales Deputy State Coroner Derek Lee has issued a series of recommendations to improve searches for missing people in New South Wales.
"The distress that Bernard must have felt after 12.50pm on 6 January 2017, and the uncertainty and anguish that his family must have felt in the hours, days, and weeks that followed is unimaginable," said Mr Lee in his findings, per ABC news.
The suggestions include improvements to how New South Wales police deal with a missing person report, an emphasis on the importance of gathering CCTV footage, training and education in relation to searching urban areas, and emphasising the importance of checking fire stairs and corridors among other points.
Mr Lee added: "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."
Gregory Robinson