The body of Bernard & # 39; Butch & # 39; Gore (photo) was found at Westfield Bondi Junction in Sydney in January 2017
A full investigation of one of Sydney's busiest shopping malls by all its employees could have saved the life of a 71-year-old man, an investigation has heard.
Bernard & # 39; Butch & # 39; Gore was found dead at Westfield Bondi Junction in Sydney in January 2017 after not meeting his wife outside of Woolworths, as planned, three weeks earlier.
Although the procedure is to create a & # 39; Code Gray & # 39; to call when there is a missing person in the mall, the call was never made, the NSW Coroners Court in Lidcombe was told Tuesday.
According to the standard operating procedures of the center, which relate to lost or found children and vulnerable persons, the coroner's counsel, Anna Mitchelmore SC said: & # 39; Once a Code Gray has been broadcast, all available employees must participate in a systematic search. & # 39;
Gore was reported missing on January 6 after he hadn't met his wife outside of Woolworths as planned earlier that day.
Forensic analysis indicated that he died at least one or two weeks before his body was found – meaning he died slowly in the stairwell (photo) in the course of more than a week
Gore, known as & # 39; Butch & # 39; for his friends, came from Tasmania and stayed with his daughter on Ocean Street in Woollahra in the weeks before his disappearance
71-year-old Tasman, who had early dementia, had walked from his apartment in Woollahra to Westfield and entered a fire escape house where he was trapped.
He was missing with only $ 30 and his opal card.
The images showed him walking into Westfield at 12.48 pm, to level four and through 12.40 pm through door L407.
Hundreds of thousands of shoppers came and went as Mr. Gore was locked inside and heard their voices echoing down the stairs. More than 20 million people visit the center every year and spend $ 1.1 billion.
His body was discovered on January 27 by a maintenance officer.
Mr. Gore was found in a & # 39; semi-kneeling position & # 39; in the stairwell. He seemed to have fallen from a chair in the stairwell.
Forensic analysis indicated that he died at least one or two weeks before his body was found – meaning that he died slowly for more than a week.
Police are seen outside the fire escape house at Bondi Junction where the body of Bernard & # 39; Butch & # 39; Gore was discovered
A security guard working the night Mr Gore went missing told the investigation on Tuesday that he had spoken with Mr Gore's daughter Melinda outside of Woolworths between 9:30 PM and 10:00 PM.
When searching for Mr Gore, guards and police only assessed CCTV from certain pedestrian entrances to the center and to the Woolworths area, believing that he had never arrived.
CCTV cameras did enter Mr. Gore Westfield as he walked through the mall and at the ill-fated moment he was silent and entered the fire stairwell.
But those & # 39; s videos have not been investigated by authorities.
The guard confirmed to lawyer Kelvin Andrews, acting for the Gore family at the investigation, that neither himself nor the other wandering guard who cared for the area had not checked the fire escapes that night, The Mercury reported.
& # 39; He was a strong and resilient man & # 39 ;, said the son of Bernard Gore (photo)
He said that the fire escapes of the court are checked monthly and every emergency exit is checked once a month.
He said the police had not asked where the security of the mall had been checked while searching for Mr. Gore.
The court was told that if Code Gray is mentioned, they would control those areas.
& # 39; That would always come from the center management if it was escalated so high. & # 39;
The guard also told the court that there was no reason for the chair to have been in the stairwell, and it was against regulation because fire escapes are always & # 39; a free passage & # 39; had to be.
His supervisor told that Code Gray would not have been called unless the missing person had been confirmed on the spot.
He had considered calling Code Gray after talking to the police on January 7 at 1:00 AM.
Detectives are huddled here outside the fire escape where Mr. Gore's body was found, and blocked the door as they investigated
He told the court afterwards that a Code Gray or a full search should have been called.
# I think it would have helped with the problem.
& # 39; But at the time I did not feel it was appropriate with the information I had. & # 39;
The investigation heard how the door where Mr. Gore entered through the stairwell could not be opened from the inside, and although there was an exit through a staircase and along a corridor, he did not find it.
The police searched the mall three days after the pensioner was reported missing, but did not enter the stairwell.
Officers are expected to prove that they believed the stairwells were being searched by security, while an expert was expected to say that Mr. Gore could have survived only three days without water.
Detective senior agent Andrew Agostino, who investigated Mr. Gore's death, told the investigation that a & # 39; full search & # 39; of the Westfield – including the stairwells – should have been done by the police.
Mr Agostino said that the NSW police should not have relied on Westfield information, but rather eliminated the mall itself before searching for other areas.
& # 39; The way the investigation was conducted was probably not the best way to manage an investigation if we know someone's high risk & # 39 ;, he said to the NSW Coroners Court on Monday.
The counsel for Anna Mitchelmore SC told the investigation that Mr. Gore waited for the sun to rise before he walked to the mall the day he went missing.
His wife wanted to walk with him, but was not ready and he wanted to get moving.
Mrs. Mitchelmore said before he was diagnosed with cognitive impairment, Mr. Gore was once lost in Hobart and as a result his son had bought him a watch with a GPS tracker.
But the watch was broken and he didn't wear it.
Instead, his wife and daughter had given him a card with his daughter's address on it.
The investigation is still ongoing.
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