GORE Bernard - Findings
Deceased
Bernard Gore
Demographics
male
Date of death
2017-01
Finding date
2020-12-18
Cause of death
The available evidence does not allow for any finding to be made as to the cause of Bernard's death; possible contributing causes included cardiac arrhythmia, electrolyte derangement from dehydration, or stroke, but none could be definitively established
AI-generated summary
Bernard Gore, a man with Alzheimer's dementia, entered a fire stairwell at Westfield Bondi Junction shopping center in Sydney on 6 January 2017 and became trapped. He likely died within 24-48 hours from cardiac complications exacerbated by dehydration and stress, but was not found for 21 days. The coroner determined the manner of death was misadventure, not natural causes, due to multiple procedural failures in the search response. Key failures included: Security failed to initiate Code Grey procedures; Police and Security reviewed CCTV of wrong entrances and failed to conduct physical searches of fire stairs and corridors; inadequate communication between agencies prevented understanding of search scope; and Land Search and Rescue coordinators were not engaged. The coroner made six recommendations to improve missing persons procedures, CCTV protocols, inter-agency communication, staff training, and search procedures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Alzheimer's disease/early-onset dementia preventing self-rescue and exit
- Pre-existing hypertensive cardiovascular disease and coronary artery disease
- Dehydration and food/water deprivation in stairwell
- Psychological, environmental and physiological stressors from confinement
- Failure to initiate Code Grey missing persons procedure
- CCTV review of wrong entrance (Zara entrance not reviewed)
- No physical search of fire stairs and corridors
- Inadequate documentation and communication of CCTV review scope
- Missing information about Bernard's usual entry point
- Inadequate risk assessment and delay in assigning investigator
- Failure to engage Land Search and Rescue coordinator
- Inadequate planning and insufficient search resources
- Inadequate questioning about missing person's likely route/entry
- Security staff lack of understanding about fire stairwell checking procedures
- Poor inter-agency communication between Police and Security
Coroner's recommendations
- Clarify NSW Missing Persons SOPs to require police officers to refer to Missing Persons Checklist when taking missing person reports; consider including reference in Section 9.1
- Update NSW Missing Persons SOPs to identify and emphasise: purpose and importance of canvassing for CCTV footage; timing and extent of CCTV review; and need for comprehensive communication between Police and community partners regarding CCTV
- Provide specific training and education to NSW police officers on availability of land searches and engagement of Land Search and Rescue coordinators for searches of urban areas and commercial premises
- Amend Scentre Group Lost and Found Policy to include in checklist questions about how missing person attended centre and entry point; make checklist available to security staff; provide induction training
- Amend Scentre Group Lost and Found Policy to clarify the order in which fire stairs and fire corridors should be searched in response to Code Grey
- Review training for Scentre Group security staff on checking fire stairs and corridors to ensure tasks are effectively communicated and understood; implement measures to review documentation and identify follow-up needs
Further listening
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