On the morning of 6 January, 2017, Bernard Gore went to the Bondi Junction Westfield shopping centre in Sydney while on a trip to visit his daughter Melina.
Bernard told his family that he planned to walk to the shopping centre and do a spot of shopping before meeting his wife Angela for lunch about an hour later. But he never showed up.
Angela - who'd been married to the 71-year-old for 50 years - soon became concerned and searched the shopping centre for her missing husband.
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Later that evening, she filed a missing person's report with local authorities in Australia.
Three weeks later, on 27 January, Mr Gore was found dead in a stairwell at the mall.
It is thought that he'd accidentally entered the stairwell - which was a 'labyrinth' of self locking doors and confusing exits - through a fire door and couldn't find his way out.
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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 the 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.
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"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 so long for Mr Gore to be located found a number of shortcomings, including 'inadequate search procedures and ineffective communication'.
The stairwell his body was found in was not initially searched, and investigators found that the review of CCTV footage was not comprehensive.
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New South Wales Deputy State Coroner Derek Lee said that members of security staff had different understandings about what CCTV had been reviewed by other members.
"No physical search of the fire stairs at Westfield was ever conducted by either security or police in the period between 6 and 27 January 2017," he continued.
"This is because no code grey was ever initiated. Even if one had been initiated, it would have required a duty manager to exercise discretion to extend such a search to include fire stairs and fire corridors."
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He made a series of recommendations to improve the searches for missing persons in NSW, and hopes they will 'mitigate the possibility of another family having to endure such a traumatic event.'
Topics: World News, Australia
Bec Oakes