As Bernard Gore's wife of 50 years waited to meet him in a Sydney shopping centre, she had no idea her husband was trapped nearby in a fire stairwell where he would later die.
Angela Gore, surrounded by her children, cried silently as an inquest heard how her husband's body was found kneeling forward - as if he'd fallen off a nearby chair - in the stairwell at Westfield Bondi Junction in early 2017.
Three weeks had passed since he disappeared.
Ms Gore and her daughter, Melinda, reported him missing on January 6 after he failed to meet his wife outside Woolworths as planned earlier that day.
The 71-year-old Tasmanian, who had early-onset dementia, had walked to the Westfield from his daughter's Woollahra apartment and entered a fire stairwell where he became trapped.
His body was discovered by a maintenance worker on January 27.
When searching for Mr Gore, security officers and police only reviewed CCTV from certain pedestrian entrances to the centre, and for the area surrounding Woolworths, which led them to believe he never arrived.
CCTV cameras did capture Mr Gore entering Westfield, walking through the shopping centre and the fateful moment he paused and turned into the fire stairwell. But those videos weren't examined by authorities.
An inquest into Mr Gore's death heard the door through which Mr Gore entered the stairwell couldn't be opened from the inside and, while there was an exit down some stairs and along a corridor, he didn't find it.
Police searched the shopping mall three days after the retiree was reported missing but didn't enter the stairwell.
Officers are expected to give evidence they believed the stairwells were searched by security, while an expert is expected to say Mr Gore could only have survived three days without water.
Detective Senior Constable Andrew Agostino, who investigated Mr Gore's death, told the inquest a "full search" of the Westfield - including the stairwells - should have been done by police.
Mr Agostino said NSW Police shouldn't have relied on Westfield's information but rather eliminated the shopping centre themselves before moving on to search other areas.
"The manner of the investigation, in how it was conducted, probably wasn't the best way to manage an investigation when we know someone's high risk," he told the NSW Coroners Court on Monday.
A security guard on duty on the night Mr Gore's daughter Melinda reported him missing to Westfield also gave evidence to the inquest.
The guard admitted he spoke to Ms Gore for less than five minutes and took notes on a timesheet he subsequently misplaced.
The guard participated in a search of the shopping centre that evening which did not include the fire stairwells - which he said were checked monthly.
Counsel assisting Anna Mitchelmore SC told the inquest Mr Gore waited for the sun to come up before he walked to the shopping centre on the day he went missing.
His wife wanted to walk with him but wasn't ready and he was keen to get moving.
Ms Mitchelmore said before he'd been diagnosed with cognitive impairment, Mr Gore had become lost once in Hobart and, as a result, his son had bought him a watch with a GPS tracker.
But the watch had broken and he wasn't wearing it.
Instead, his wife and daughter had given him a card to carry with his daughter's address on it. The inquest continues.
Australian Associated Press