Councils have been urged to check, secure and fix dangerous manholes by the coroner who conducted the inquest into the death of a West Auckland toddler.
The police have already changed the way search and rescue teams operate as a result of the investigation into the death of Aisling Symes, 2, who disappeared in October 2009 in Massey.
Her body was found in a drain seven days later, despite it having been checked several times.
In a report issued today after an inquest in June, coroner Garry Evans ruled that Aisling was "tipped" down a manhole when she stepped on its displaced cover after heavy rain. She fell about 1.6m and was swept 36m down the pipe.
In his report, Mr Evans recommended that all territorial local authorities take immediate steps to secure manhole covers or fit safety grilles to manholes that could flood or had known problems.
His other recommendations included:
* Fitting main stormwater networks with sensors to enable a rapid response to displaced manhole covers.
*Creating a "robust system" of identifying and ranking public safety risks with all manholes
*Developing a public health and safety risk profile of all existing manholes.
The report also quoted pathologist Dr Simon Stables, who said Aisling probably drowned, but might have survived the initial fall.
"It is not possible to tell from the autopsy findings how long Aisling might have been alive in the pipe ... possibly only for a few minutes.
"Even if Aisling had been seen to fall into the pipe and the pipe had been relatively full of water, it is still possible that she might have died if there had been difficulty extracting her."
The section of the drain in which Aisling's body was found had been blocked several times, and 11 complaints had been made to the old Waitakere City Council about the manhole cover being lifted and displaced by backed-up water.
The inquest was told New Zealand has no safety standards relating to displaced manhole covers, and the only way to ensure covers were replaced was through a complaints register process.
The coroner's report noted that Brian Kouvelis, a civil engineer and stormwater and drainage specialist, had said "aspects of Aisling's tragic accident and subsequent investigation have highlighted the lack of any specific requirements or construction standards in relation to manhole lid security and public safety issues in respect of displacement of manhole lids".
Mr Kouvelis had acknowledged that fitting safety devices to all manholes would be challenging and costly.
Police have changed the way search and rescue teams are run after flaws were highlighted in the initial investigation into the Aisling's disappearance.