Savanah May Halcrow should have celebrated her first birthday at a North Canterbury playground in January last year.
Instead, she died on the day she turned 1 after falling from a playground fort as her mother prepared the area for the toddler's upcoming party.
A Coroner has used the case to remind parents of the importance of watching young ones vigilantly as they play.
On January 14 last year Savanah was at the Glenmark Playcentre in Waipara with her mother Sandra Laurie.
Savanah's first birthday party was to be held on the coming Saturday and Laurie had gone to the playcentre to prepare for it.
The playcentre is a parent-run cooperative meaning parents, care givers and whānau of those who attend are directly responsible for all the requirements of running the centre including maintenance and repairs on site.
About 10.30am Laurie took Savanah into the playcentre and arranged furniture for the party.
She then started to mow the lawns, leaving Savanah in the playground.
The playground had a fort consisting of three square-sized areas with interconnecting bridges.
One bridge was enclosed by a concrete tunnel.
The other bridge was described as a hanging swing bridge - with wooden slats and galvanised steel chains and a dip in the middle.
Bark chip was in place under the entire fort.
In her findings, Coroner Sue Johnson explained how Savanah suffered her fatal injuries.
About midday, as Laurie finished mowing the lawns, she saw Savanah climbing a rope ladder on to the fort.
Savanah had not climbed this ladder before, so Laurie checked she could manage, but the toddler climbed it unassisted.
She then walked onto the hanging swing bridge holding on to the guard rails.
Laurie saw her daughter do this "a few times" and saw her play on other parts of the fort.
She left Savanah standing on the hanging swing bridge while she returned the lawnmower to a shed.
"She told police that they were 'only momentarily' out of her sight," said Coroner Johnson.
"While she was in the process of putting away the mower, Sandra heard Savanah crying and turned to see her sitting in the bark below the middle of the hanging swing bridge.
"She went to pick her up and Savanah started shaking, becoming floppy and unresponsive.
"Carrying Savanah, Sandra ran out on to the road and tried to wave down a car, but when it did not stop, she ran across the road to a house."
The woman at the house was a trained nurse. She immediately recognised the seriousness of Savanah's condition.
She drove Laurie and the child to the Amberley Medical Centre.
A doctor at the centre assessed Savanah and arranged for urgent transfer to the emergency department at Christchurch Hospital.
The local rescue helicopter was not available to another incident so Savanah was taken by ambulance.
At 1.54pm she arrived at hospital and was assessed as having a traumatic brain injury.
A CT scan later confirmed she had a brain bleed and swelling and rising pressure in her skull.
She underwent emergency surgery and the next day as her condition did not improve, Savanah was transferred by helicopter to Starship Children's Hospital in Auckland.
"Over the next four days, her intracranial pressure remained high and was not responding to medical treatment," Coroner Johnson explained.
"On 18 January Savanah was taken off sedation for a formal neurological examination.
"This showed no evidence of a return to consciousness, and Savanah's pupils were fixed and dilated."
An MRI indicated Savanah had a severe traumatic brain injury which had left her with profound and permanent brain damage.
"After discussion between Savanah's doctors, a decision was made to focus care on her comfort and she was extubated at 4.20pm," said Coroner Johnson.
She died later that evening at 10.26pm on her first birthday from blunt force trauma to the head.
A police investigation examined the playground and fort. Police also examined the bark flooring of the play area and found it "very cushioned and spongy at the time" as it was quite wet from recent heavy rain.
The Ministry of Education carried out a licencing assessment of the playcentre which revealed the bark under the play area was "not safe and suitable for its intended use".
The assessment said that the bark did not meet the required depth or cover and appeared to have compacted over time.
"The hanging swing bridge including the set up with the horizontal guard rails was assessed as not safe and not suitable for its intended use," said Coroner Johnson.
The playcentre's licence was suspended until conditions were complied with.
Laurie and Savanah's father James Halcrow wrote to Coroner Johnson asking for a recommendation that the ground beneath all play equipment should provide enough protection so that a child landed safely if they fell.
Coroner Johnson did not consider this necessary, saying education centres could only do so much to protect children and parents were ultimately responsible for monitoring toddlers.
"Around one-third of falls among children involve playground equipment and 50 per cent of those falls take place at school, she said.
"In New Zealand there is a surface standard and requirements that it is complied with."
She added that even when regulations were complied with, it did not mean a child would always land safely.
"There are other factors in a fall that are unrelated to the surface, such as the position of a child is in when they land and how far they fall.
"In this case the bark might not have provided the required impact absorbing protection to cushion Savanah's fall. But Savanah's fall would have been more likely not to have occurred in the first place if her mother had been watching her children.
"Sandra said she was away only momentarily. Sadly, it takes far less than a moment for a child to fall from playground equipment."
Coroner Johnson ruled that while Laurie should have been watching the child, no one was responsible for Savanah's death.
"Savanah's death was a heart rending and absolutely tragic event for her family," she said.
"Sandra has written to me saying that she now lives with her daughter's death every day of her life and will do so forever."