A rotting tree trunk and strong winds were behind the fall of a tree which crushed a woman in Rotorua early last year - an incident the coroner has called "a tragic accident".
Now the district council has been asked to implement a new policy and hire a new staff member to prevent anything similar ever happening again.
Coroner Wallace Bain has just released his findings into the death of Trish Kathleen Butterworth on January 5, 2018 following an inquest earlier this year.
Butterworth, 56, was killed when a 23m-tall historic oak tree split in two during a storm and fell on the corner of Arawa and Amohia Sts, crushing her car.
The winds were howling at up to 90km/h and caused damage to trees which could have been the worst in the district for 15 years, according to submissions during the inquiry.
The fallen tree, known as Spencer's Oak, was planted in 1863 and been in Rotorua Lakes Council ownership since 1991.
In its lifetime steel cables and rods had been used to brace some of the tree's limbs and concrete had been inserted into its trunk to fill a cavity. It was also cut back many times.
The tree was assessed by arborists in 2002, 2007 and 2017. The latter did not reveal any critical areas of concern.
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Butterworth grew up and was buried in Te Puke, where her mother still lived at the time of her daughter's death.
After her death police investigated and concluded that no criminal charges would be laid.
The inquest was heard in August this year and included submissions from 11 witnesses including people from the council and Butterworth's family.
Since the incident, the council has reviewed its tree management practices and developed a tree management strategy and tree management plan. It has introduced a requirement for the annual inspection of 3000 trees, the appointment of an arborist to supervise operations and the development of an alert system in respect of high-risk weather events.
The council has also identified other improvement areas including auditing, risk analysis and the need for good records.
In the findings Coroner Bain said the family felt management of the tree was "inadequate" and if better processes had been followed and identified the tragedy would not have happened.
However, he said, the family was supportive of what steps the council had taken and "takes comfort from those changes and improvements".
"Their view was that inadequate investigations into the condition, health and likelihood collapse of the tree was the primary cause. Had those been carried out then the result may have been different," Bain wrote.
"The family acknowledges, as does this court, that the council has undertaken a thorough review and is improving its processes."
Coroner Bain commended the council for its approach to meet the Butterworth family and consider criticisms as well as adopt practices aimed at preventing similar accidents in the future.
"This is a tragic accident"
He made several recommendations for the future but acknowledged the council was already complying with most of them.
The coroner recommended the council adopt a policy setting out how it manages the maintenance, management, and risk of trees. He said that policy should have an overriding concern with the management of public health and safety risks, rather than the amenity or historical value of trees.
He recommended the policy be annually audited and respond to and investigate complaints and concerns about public trees and identify dangerous trees.
If a tree is identified as being immediately dangerous, that danger should be removed either through access prevention, tree maintenance or removal.
He recommended the council maintain a publicly accessible tree register that identifies assessments and maintenance carried out, expert recommendations made and if they have been implemented.
He also recommended the council employ someone to ensure the policy is complied with and be available to analyse arborists' advice and recommendations, something which has already been done.
Coroner Bain's inquest also looked at whether the extent of the trunk decay should have been discovered in previous inspections and he found it would have if "advanced tree inspection techniques had been used", however the presence of concrete in the cavity affected test results.
The inquest also found a static cable bracing in the tree may have minimised its ability to dampen the windy conditions and contributed to its fall. When a tree has static bracing it has less natural ability to resist wind.
Husband's scathing affidavit revealed at inquest
Keith Butterworth wrote a scathing affidavit about his feelings towards the Rotorua Lakes Council and Rotorua police about the death of his wife, Trish Butterworth, on January 5 last year.
The affidavit was written a month and a half before Keith Butterworth died in June this year.
In the affidavit, he said he felt let down by the council and the police, who he said didn't keep him informed during the investigation.
"I feel like the police have tried to sweep the whole thing under the mat. The police told me the council did nothing wrong but I can't live with that, it's not something you can just explain away.
"I think there should have been charges laid. It was known that this tree was dangerous. No one did anything about it and now it is too late. I just want justice for my wife."
Keith Butterworth said if anything was to happen to him he didn't want to be resuscitated.
"I just don't want to go on without Trish, I just want to be with her."
Keith Butterworth said his family met the council after his wife's death but he couldn't go.
"I hated them so much, I couldn't be around them. I want someone to stand up for the council and acknowledge responsibility and say they have made a huge mistake, that they are very sorry and it won't happen again. That would be closure for me."