The death of a teen who fell through a skylight has prompted calls for tighter safety measures at a Bay of Plenty school.
Te Hawiki Hona Kiri Te Amo (Hawiki) was fatally injured when he fell from the roof of the library building at Ōpōtiki College on October 13 last year.
The 16-year-old from Christchurch was visiting his father when he and his cousin Hoani Abraham decided to go to the school grounds and climb on the buildings.
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The boys were kicking the skylight when it broke.
They fell 8m to the floor below - Hawiki landed first and Hoani landed on Hawiki's back.
Hawiki had a traumatic head injury that was later deemed non-survivable.
He was transported to Waikato Hospital via helicopter and he died at 11pm the next day.
Hoani broke his leg, suffered bruising and loss of memory and was transported by
ambulance for treatment at Whakatāne Hospital Emergency Department.
Coroner Gordon Matenga's findings were released today after a hearing on Monday.
He recommended Ōpōtiki College either removed the skylight in the roof or complied with Ministry of Education guidance for roofing materials.
Matenga also ordered that his findings be distributed to all New Zealand state-funded schools.
Coroner Matenga wrote he was surprised a metal grille had not been installed over the skylight at the college after Hawiki's death.
"While I accept that installation of ministry-compliant skylights may not have been possible because of the lack of structural support, and the availability of funding at the time, funding is now available. Ōpōtiki College Board of Trustees chose to utilise their capital funding allocation to complete other works."
He also wrote that the board "worked with the ministry's property personnel to make their decision".
"The ministry was a part of the decision [not to install a metal grille] and appears to have been in direct conflict with the ministry's own guidance."
In the finding, Secretary for Education Iona Holsted was quoted saying the ministry's guidance document for school roofing materials was updated after 8-year-old boy Justin Reid died in 2017.
He fell through a section of polycarbonate roofing over a walkway between two classrooms at a primary school in Palmerston North.
"Our guidance maintains that, 'if non-trafficable roofing sheets are to be used, these must be laid over safety netting or mesh that is strong enough to hold the weight of an adult'."
Holsted said: "Schools receive property funding every five years and are required to use this money on priority areas. Making roofing safe is a priority area and I expect this to lead to the replacement of potentially unsafe historic roofing material."
Hawiki's mother, Esther Corlett, said there was a fire escape stairway that led towards the school roof, allowing easy access.
She told Coroner Matenga of her own experience as a child climbing the roof of Ōpōtiki College.
In the finding, principal Susan Impey was quoted saying the school was considering putting in external fencing.
She said the school's gym was also being re-roofed and the pitch was being changed, which would "minimise the possibility of access by climbing".
She said Ōpōtiki College took health and safety very seriously and was "always looking for ways to improve the safety of the school site".
When approached for comment about Coroner Matenga's findings, Impey told the Rotorua Daily Post the cousins' fall "was a tragic and traumatic accident".
"Although Kiri Te Amo was not a student at the college, we were very saddened by the accident and the loss of a young life.
"The school will work with the Ministry of Education in relation to the Coroner's recommendations regarding building materials for all skylights in the school."