The Government needs to do more to address the high number of quad bike deaths, a coroner has warned.
The call comes after the investigation into the death of 56-year-old Neville Ian Anderson who was found under a quad bike on a farm in the Clutha District in September 2014.
Coroner Brigitte Windley concluded Anderson died because his chest was crushed when the quad bike rolled on top of him and he could not breathe.
Anderson was told to drop off a trailer and follow a prescribed route to check the paddocks for new lambs or mothers in difficulty but when he was last seen he was not on the route he was told to follow.
When he failed to drop off the trailer and did not return by 5.30pm, his boss tried to call him and a search began.
Anderson was found pinned under the overturned quad bike about 6.30pm.
Windley concluded that despite Anderson's experience, he failed to appreciate the lack of stability the incline, the turn he was making at the time of the crash and the trailer would cause.
It was "imperative" further work be done by the Government to address New Zealand's unacceptably high number of quad bike deaths and serious injuries, Windley said.
"Despite the public attention quad bike deaths have received, and the ongoing work done by government agencies such as WorkSafe and ACC, with input and support from industry organisations, quad bike deaths were reported to have reached a record high in 2016," she said in her finding.
Despite a quad bike safety campaign started by the Ministry of Business, Innovation and Employment in 2010 there were 14 quad bike deaths by October 2016 although not all were at workplaces.
Worksafe said about 850 people were injured riding quad bikes on farms every year and five people died. There had already been three deaths in 2017, Windley said.
Quad bikes were involved in about 28 per cent of all farm deaths.
"Clearly quad bikes present a persistent cause for concern and there is still work to be done to prevent future deaths and serious harm," the coroner said.
The circumstances of Anderson's death were "by no means unique," Windley said.
Rider education resulting in changes to the use of quad bikes would remain vital in reducing deaths and injuries, she said.
"While there is on-going work by government agencies such as Worksafe and ACC to raise awareness of quad bike safety through education, on the basis of this recent research it would seem timely for New Zealand agencies with a mandate to set, implement and enforce quad bike standard and safety to revisit the position of mandating ROP devices."
She recommended agencies consider whether there was a case for roll-over protection devices be mandatory for all quad bikes; a rebate or subsidy programme for rider training, the purchase of toll-over protection devices and the purchase of alternative vehicles; and a national five-star safety rating system for quad bikes.
"It is imperative that we examine proposals that may improve quad bike safety and reduce quad bike trauma and death," Coroner Windley said.