A coroner has identified wrong rescue gear, the wearing of waders and possible impairment by a lifejacket as being contributing factors in the death of a Greytown whitebaiter swept out to sea at Lake Ferry last August.
Retired market gardener Leslie Wan Wong, 71, died after being hit by a series of 3m high waves that knocked him over and dragged him across the sandbar as he was scooping for bait at the mouth of Lake Onoke in knee deep water.
Coroner Christopher Devonport has found Mr Wong drowned despite commendable attempts by David Buick, Trevor Shirkey and others to rescue him.
"It is unfortunate that the only life saving equipment available to Mr Wong's rescuers was in retrospect inappropriate, and in which they were not trained," Mr Devonport said.
At the inquest into Mr Wong's death it was revealed Mr Buick and Mr Shirkey had been sitting in the Lake Ferry Hotel and saw Mr Wong drop his net then try to pick it up.
He was hit by three waves and washed out to sea.
As police were being alert by hotel management the two men ran down to the beach and tried to help Mr Wong.
Mr Buick firstly threw a log into the water which Mr Wong grabbed but the wind blew both him and the log further out to sea.
He then stripped, put on a lifejacket and holding a rope tried to swim out to Mr Wong while Mr Shirkey held the other end of the rope on the beach.
A reel/winch was brought to the scene and the reel's rope was attached to the rope being ferried out to Mr Wong.
Mr Buick reached Mr Wong after about five minutes and the pair were dragged back towards the beach.
In evidence Mr Buick said Mr Wong was slipping down in his lifejacket, his face getting covered in water.
Eventually the two men were brought ashore and rescuers, including police Constable Nicholas Atherley, checked for vital signs and started CPR.
A defibrillator was brought down from the hotel, a rescue helicopter was summoned and the police launch Lady Elizabeth arrived on the scene from Wellington with its crew taking over CPR on Mr Wong which was unsuccessful in saving him.
The coroner, who had consulted lifesaving expert Brian Velvin, said he recommended the reel should not be used as a surf lifesaving device at Lake Ferry "as that device should be properly maintained and only used by trained teams of lifesavers". He said a jetski or an inflatable rescue boat "may be more appropriate" for Lake Ferry and similar areas but that is dependent upon availability, trained operators and sea conditions.
Evidence had been given the Lake Ferry reel had probably never been used before in a rescue and its original swimmer's harness was missing.
It had also been fitted with a different rope from the special type it had previously had.
The coroner said Mr Wong was wearing waders but did not have a knife for cutting them free if the need arose and they were not able to be readily unclipped.
It was possible his lifejacket may have hindered easy removal of the waders.
"It is also possible the waders created a dragging impediment while Mr Wong was being hauled to the beach and that this contributed to him being submerged," he said.