A 6-year-old girl killed by a truck outside her Gisborne home shouldn't have been walking to school without an adult, a coroner has ruled.
Carla Neems was killed by a recycling truck outside her family's Russell St home, as she arrived home from school on her scooter about 3pm on May 2, 2017.
Coroner Tim Scott ruled that Carla should have been accompanied by an adult on her journey home, inquest findings released today say.
Instead, Carla had two older sisters - aged 8 and 10 - and regularly travelled to and from school with them.
However, on the day of her death she walked home with two other young children, and part of the way on her own, the report stated.
"Carla was not accompanied home from school by a responsible older person, preferably an adult and she should have been," Coroner Scott said.
He also referred to the publication Flying Start - Safe Kids dealing with scootering policy guidelines.
"[These guidelines] stipulate that a child in Year 4 and below - Carla was in Year 2 - should not be permitted to ride a scooter unless accompanied by an adult."
In addition, Scott said the police crash investigator had agreed that Carla should have been accompanied by an adult.
"It cannot be stated with certainty that Carla would have been safe had she been accompanied by an adult. It is possible, but unlikely, that she still might have been struck by the truck," he said.
"I do not accept that it was acceptable for Carla to go to and from school in the care of her older siblings - and part of the way home alone.
"The siblings were too young to be vested with that responsibility.
"Sadly the confidence that [her parents] had about Carla's road safety was misplaced and flies in the face of what happened."
Carla's dad: 'She was a confident kid'
Carla's father Dion Neems spoke with the Herald and questioned the Coroner's ruling on her needing adult supervision.
"In the Coroner's mind he believes that all children under the age of 10 should be walked to and from school by an adult. Our concerns there are how do you manage that?
"It's all about mitigating risk, and we live in a quiet street with very low levels of traffic, one crossing on the way to school and she was always walked there by her older siblings.
"That day she was walked home by an older friend, and only walked the last 100m on her own - so we feel as parents that we mitigated that risk well," he said.
"We need not lose sight of the fact she wasn't just 6-years-old, she was three weeks outside her 7th birthday and cognitively there is a big difference between a 6 and 7-year-old.
"She was a confident kid, she was aware of her surroundings, and it wasn't like she was a little flighty kid that would just run across the road."
Education Minister: Schools, communities should decide
Education Minister Chris Hipkins also believed parents should have the right to decide on their children's abilities.
"My sympathies go out to Carla's parents during this difficult time," he said.
"Parents, schools and their local communities are best placed to determine how to keep kids safe on their journey to and from school."
The driver of the Waste Management recycling truck involved in the crash has previously been cleared of any wrongdoing.
Sau Tulua Aliifaalogo, 37, was found not guilty of careless use causing Carla's death, by a judge-alone trial in Gisborne District Court in November last year.
The judge retired for 15 minutes before delivering his decision, which was met with silence by supporters of the Neems and Aliifaalogo families.
In his decision, Scott recommended that Waste Management investigates the retro-fitting of audio proximity alarms to its fleet - as it "would make a similar tragedy highly unlikely".
He also recommended that the company put signage on its trucks to alert people that they stop often.
Neems said these recommendations were "a big win".
"The recommendations are the overarching governance of the whole thing and that is that Waste Management have six months to investigate the retrofitting of sensors and cameras - which would have saved Carla's life in this case, and other people's as well," he said.
However, Neems said the family were disappointed in WorkSafe's investigation and the lack of accountability from Gisborne District Council.
"WorkSafe basically let everybody off - there were no recommendations at all, only considerations, and that's what we were unhappy about.
"We saw this as a huge health and safety risk to our communities and we didn't want it to happen again - and that was our sole purpose, for no other family to go through what we have been through, losing a child in these circumstances," he said.
The Coroner's report also stated there were a number of obvious discrepancies in the WorkSafe inspector's report.
Coroner Scott stated the inspector had received no particular training in investigation or report writing, and had no particular expertise in the subject he was investigating.
He said "there may be room for WorkSafe to address these issues".
WorkSafe head of specialist interventions Simon Humphries offered WorkSafe's sincere condolences to the Neems family.
"We set out in this investigation, as we do with every investigation, to establish circumstances and whether there were any breaches of health and safety legislation by any party involved.
"Despite a lengthy investigation, we could not find any breaches, as we have explained to Mr Neems and to the Coroner investigating his daughter's death," he said.
"We have noted the Coroner's comments about inconsistencies in the investigation report, and particularly his comment that 'any shortcomings in the report, have at the end of the day, had no effect'.
"We will consider his recommendations about inspector selection, training and report writing."
On the Gisborne District Council, Neems said; "We feel that our local district council, as the person conducting a business or undertaking [PCBU] of their contractor, were relieved of all responsibility and we think that is wrong.
"How the Coroner has looked over that, I struggle with and can't understand."
Neems said he was also disappointed that the council didn't attend the formal inquiry.
"It's been a rough ride. It's terrible and has definitely taken its toll."
The council did not wish to make any comments.