The search for Hobart man with dementia who died while trapped in a Sydney shopping centre was obstructed by inadequate investigative procedures, a coroner has found.
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Bernard Gore, 71, died inside fire escape stairwell at the Westfield shopping centre in Bondi Junction in January 2017.
Mr Gore and his wife Angela were in Sydney to visit their daughter Melinda over the Christmas holiday period.
On the day he was reported missing, Mr Gore had left his daughter's apartment to meet his wife at the shopping centre.
When he did not turn up, his wife became concerned and searched the shopping centre for him.
His disappearance was reported to police that evening.
New South Wales deputy coroner Derek Lee said evidence presented to the court did not allow for a determination for the exact cause of death or when it occurred, saying it was probably he died between January 6 and January 9.
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"[The] psychological, environment and physiological stressors that Bernard would have experienced as a result of being within the stairwell were possibly significant contributors to his death," he said.
"It cannot be said that Bernard's death was entirely due to natural causes.
"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."
Mr Lee in his findings said the stairwell where Mr Gore's body was located was not originally searched and that the review of CCTV footage was not comprehensive enough.
He said it was the incomplete review of the vision that led police to assume three days after his disappearance that Mr Gore had not arrived at the shopping centre.
Mr Lee said the search for Mr Gore at the shopping centre was hampered by inadequate and ineffective communication between police and security personnel at the shopping centre.
"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 said.
Political reporter for Australian Community Media, based in Hobart.
Political reporter for Australian Community Media, based in Hobart.
