An inquest into the death of a 71-year-old man, who was found in a Sydney shopping centre stairwell 21 days after he went missing, has found several missed opportunities.
Bernard Gore likely died inside the fire stairwell within Westfield Bondi Junction between January 6 and 9 in 2017, Deputy State Coroner Derek Lee concluded.
The reasons for which Mr Gore did not, or was unable to, exit the stairwell are not well understood, he said.
An autopsy later found no evidence of traumatic injury or direct third party involvement, raising the possibility that he died from natural causes.
And while he was suffering from some pre-existing medical conditions, the "psychological, environmental and physiological stressors" experienced as a result of being stuck inside the stairwell were "possible significant contributors to his death".
These matters along with "identified shortcomings and inadequacies associated with the efforts to locate Bernard," led to the conclusion his death was not entirely due to natural causes, but a result of misadventure.
Mr Gore had lived in the same house in Tasmania with his wife Angela since 1968. The couple who celebrated their 50th wedding anniversary in 2016 frequently travelled to Sydney to visit their children.
The former bread delivery driver and barber loved walking and did so every day for up to three hours while he was in Sydney on holiday.
Before their most recent Christmas trip in 2017, Mr Gore was reported missing in Hobart one evening but was later found high-spirited but vague regarding his whereabouts.
He was later given medication for hypertension and early stages of dementia which was observed to improve his cognitive abilities.
The couple were staying with their daughter in Woollahra in 2017 and would often eat lunch at Bondi Junction.
On January 6 Mr Gore left 20 minutes ahead of his wife and planned on meeting up together after 1pm.
After he failed to show his wife searched all his favourite spots before returning home and contacting police.
That evening their daughter visited Westfield and provided two security officers with information.
While video footage was being checked the two officers searched the mall area including the lifts, escalators, toilets, dock areas and garbage rooms - but not the fire stairs or fire corridors.
A walk-through of the fire stairs area on January 9 was the only police search conducted in the 21 days Mr Gore was missing.
Several missed opportunities arose from early assumptions by police that he had never arrived at Westfield, partially informed by security details and their ill-informed handover notes, the inquest found.
Mr Lee has made several recommendations to the NSW police including updating their standard operation in terms of missing persons, and to the owner-operator of Westfield - Scentre Group - including updating a policy checklist for finding vulnerable people.