When Bernard Gore left his daughter’s home in Woollahra in Sydney’s south-east for a stroll to Westfield’s Bondi Junction last month, his intention was to do an hour’s shopping before meeting up again with his wife and daughter.

Instead, the 71-year-old who suffered from dementia passed away after becoming lost in the stairwell, his body not being discovered until three weeks later.

Sadly, this is not the only case in which problems have occurred in stairwells. In 2014, for example, Irish resident Donnie O’Sullivan almost died after becoming lost in a Bondi Junction stairwell after leaving the Tea Gardens Hotel in the early hours of a Sunday morning and being found by chance days later by the manager of a cleaning company.

All this raises questions about what can be learned and how practices can improve going forward.

Joe Manton, a director and accredited access consultant at the Institute of Access Training Australia (IATA) says it is important to appreciate that anyone can become trapped in a stairwell. This could include not only someone of visual or cognitive impairment but also children, workers or even someone who is hiding with the intention of accessing the building after hours. Equally important to understand, she says, is that the number of people (and thus building users) who have impairments such as dementia will increase in line with the number of older people in Australia as our population ages.

Manton says obvious considerations to be aware of in enclosed places such as stairwells include cameras, visual observation to detect anyone who could be lost or stuck, alarm buttons to enable those who do become stuck to reach out to those on the other side and handrails on the stairs themselves.

Wayfinding, Manton says, should go beyond signs with words and should incorporate features such as symbols, arrows and colour coding in order to assist those who have difficulty reading, understanding English or who have challenges with intellectual cognition. Finally, human interventions such as having security personnel conduct regular sweeps of these areas are recommended.

Apart from stairwells, Manton says other areas of the building also warrant due consideration, including elevators, isolated toilet blocks, car parks and access between car parking areas and building entrances.

In order for those of limited vision to arrive at the right floor, for example, elevators should incorporate braille. Glass doors, as well, should have appropriate signage in order to mark that they are in fact doors and thus help to prevent people from walking into them. Signage which is not written in simple language, too, can be problematic: some visitors to hospital emergency departments, for example, would easily understand any sign reading ‘come here first’ but might struggle with one that simply reads ‘triage.’

Manton says it is important for companies to take a holistic approach which takes into account the range of those who may use the premises.

“We would be saying to organisations that they need to think about the controls they have in place based on the expected usability and users of the facility,” she said.

Others agree that lessons can be learned. Writing on LinkedIn after the Westfield case, UK-based emergency management, evacuation and fire safety expert professor Ed Galea said there are a number of areas where lessons can be learned.

First, he said, the fire escape has non-returnable doors, meaning that anybody who entered the stairwell was unable to exit except for via the ground floor or on a car park located on top of the roof. Whilst these are common in large public buildings for reasons of security, Galea said they were problematic in this case for anyone who became trapped. Had a child strayed into the stairs, Galea said, they would have no means by which to get out.

Emergency stairs should also be monitored with CTV cameras, Galea said, whilst having emergency phones linked to both the security control  room and the fire brigade would be ideal. At the very least, Galea says each level of the stairwell should be clearly signed with indications about not only the current floor number but also the direction and distance to the nearest exit point.

Indeed, looking at some of the images which have been seen in the media, it does appear that improvements could be made in the Westfield case.

First, the floor, walls, stairs door and handrails were all coloured grey. This means there is little by way of colour contrast to aid anybody of either limited vision or intellectual cognitive impairment to navigate their way around the stairwell. Exit signs shown in these images were red, which does not provide a great deal of luminous contrast when set against the grey background.

There is also no colour contrast on the nosing of the stairs, which would have assisted to reduce the likelihood of trips and falls. Greater contrast in colour between the door and walls would assist those with visual or cognitive impairment to locate the door once they reached the bottom of the stairs.

According to News Ltd, 20-year-old Sunday Telegraph reporter Sarah Keoghan tested the shopping mall’s stairwell exits and found them confusing and exhausting, with only two exit points on the roof at the basement and no phones or help points at any level.

It should be noted that tighter requirements are in place for buildings which are constructed today. To enable easier distinction between the doors and the walls, for example, the doors or at least the frame of the doors have needed to contrast with the frame since 2011. Each door now needs to be notated by illuminated sign at the top of each door, whilst tactile or braille signs also need to be provided. These must note both the direction to the exit and the level of the particular floor in question.

Going forward, Manton says National Construction Code requirements have their place but should be seen as a baseline minimum rather than a prescriptive way of delivering the best possible outcome. With no two situations being the same, she recommends risk assessment of each building and the adoption of a holistic approach to deliver better outcomes with regard to access, safety and usability for everyone.

Finally, she says it is important to avoid blame and instead focus on how things can be done better going forward.

“We (IATA) see situations like this as opportunities for improvement rather than an opportunity to find out who’s to blame,” Manton said.

“It’s not a blame game, it’s more about learning from our experience and saying ‘ok, what do we do differently next time, what can we learn from that process and how can we move forward so that that risk is significantly reduced or eliminated.’

“If you take that positive approach moving forward, people will be willing to engage, think and be creative. If you take an approach of ‘we need to find someone to blame’ then people tend to be quite negative and defensive.”