"It was manslaughter or at least involuntary manslaughter."
Those are the words of the late grieving husband of a woman killed by a fallen tree in Rotorua's city centre.
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 it he said he wanted to write his submission because he wasn't sure if he would still be alive when the coroner's inquest was held.
That inquest took place today in the Rotorua Coroner's Court before Coroner Wallace Bain.
Trish Butterworth, 56, died after a 23m-tall Spencer's oak tree split in two during a storm and fell on the corner of Arawa and Amohia Sts, crushing her car.
The tree, which was more than 150 years old, was the responsibility of the Rotorua Lakes Council.
Police investigated and concluded no criminal charges would be laid.
The inquest, before coroner Wallace Bain, heard from 11 witnesses. A framed photograph of Trish Butterworth sat besid Bain during the inquest.
The inquest heard reports had been done about the tree in 2002 and 2017 and an independent arborist had warned the council about dangers of the tree a few months before the tragedy.
Keith Butterworth wrote his affidavit while in respite care after suffering an illness he said came on after the stress and grief of losing the "love of his life".
In reading the affidavit to the court, counsel for the Butterworth family James McDougall said Keith Butterworth wrote his submission before being made aware of the significant changes the Rotorua Lakes Council had since put in place to improve its tree management systems.
Coroner Bain also acknowledged many of the issues Keith Butterworth had with the council had since been addressed with the council's full review and changes to the way it now monitored trees.
The affidavit 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 the council had been told the tree was rotten and an independent arborist Tom Rika told the council the tree needed to become down.
"I can't accept that this was just a freak accident. They did not do their job and there were plenty of warning signs."
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."
Council operations group manager Henry Weston said during evidence it was clear from a report done after Trish Butterworth's death the council's systems were not as good as they should have been at the time of Mrs Butterworth's death.
He said the council was too reliant on responding to immediate concerns and they needed to get more "on the front foot".
He also acknowledged there was a lack of good written records.
The inquest heard a report done on the tree in 2002 identified there was fungal decay in the trunk.
However, despite a recommendation for a more thorough investigation, which would have picked up the extent of the decay, it instead chose to address more immediate concerns.
Weston said the council had reviewed its procedures and as a result had improved its systems.
Council open space operations adviser Mark Paget said the council was responsible for about 12,000 trees in the district. So far 6000 had been inspected and the rest would be finished by December 2019.
The council had also employed a "highly qualified arborist" to oversee the work carried out by the council's company, Infracore, and the council was working with Niwa to develop an alert system when severe weather was due
so it could monitor high-risk trees quicker during a
storm.
Independent arborist Tom Rika said during evidence he told the council in August 2017 he thought the tree was dangerous.
He said he could tell just by looking at it that the tree wasn't safe.
He encouraged the council in future to not only ensure their processes were in place but they had the right people to make the right calls when needed.
"I am a father, I am a husband and if there is any risk of anyone at all (being hurt) I would err on the side of caution."
He said that advice could have been given at the time to "avoid this whole fiasco".
"There are already a number of trees around town I have spotted that are potentially really dangerous and I don't know if they are on the books or not."
Phil Sale from Arborcare, who did a risk assessment test and subsequent report on the tree in February 2017 at the request of the council, said he was not aware the tree was rotten and there were no visual signs of decay.
A sound test involving hitting a mallet around the outside of the tree failed to show any signs of decay.
He said it would have been helpful to have been given a copy of the 2002 report which indicated there was fungal decay in the trunk.
Sale said this was the only tree he had seen that was so decayed on the inside but had no signs of decay on the outside.
Detective Sergeant Herby Ngawhika told the inquest he had conducted a thorough investigation for police and concluded there was no criminal responsibility and prosecution was not needed.
Coroner Bain said he would reserve his decision. He also asked Dowthwaite to follow up with police Keith Butterworth's claims he wasn't kept informed during the police investigation.
"I am a bit concerned when I heard that ... That is frankly not good enough if that is right because I thought the police inquiry had been very thorough."
Defence counsel says Mark Hohua died after falling on to concrete steps while fleeing.