Indy Henderson was just three years old when she was crushed by an Anzac memorial in front of her family as they celebrated her grandmother's birthday.
An inquest this morning heard how her heartbroken family rushed to save her on November 26, 2016 at a family birthday party at Black Head Bowling at Hallidays Point on the NSW Mid North Coast.
The tiny girl, from western Sydney suburb of Airds, had been playing with other children near a sandstone monument, when its large headstone suddenly collapsed and fell.
The family had been brought together to celebrate the birthday of Indy's grandmother, Shiralee Walker. Many of them were playing barefoot bowls nearby.
Two witnesses saw the terrifying moment the memorial dislodged from its base and fell backwards as children played and ran around the grass area near the memorial — which was not fenced off and was freely accessible alongside the club's two bowling greens.
One witness told the inquest she saw a young child sitting "astride the headstone, rocking his body forwards and back as though riding a horse".
Another witness said children were playing on the memorial, however a third said she hadn't seen children playing on it that night — but she had seen children playing on it before.
The inquest heard how Walker and Indy's mother, Tamica Harrower, rushed over "in great distress" as Indy's body was pinned underneath the 425kg headstone, with her head and neck visible.
Walker tried to resuscitate her granddaughter using CPR as the young girl lay unconscious and trapped, but she couldn't be saved and was pronounced dead at Manning Base Hospital at 8.13pm that night.
The post mortem report showed Indy died of multiple injuries to her chest and stomach.
In this morning's findings by magistrate Elizabeth Ryan, it was revealed the sandstone headstone — erected in March 1997 — had "not been properly affixed to its base".
The inquest had heard Harrower describe her daughter as a happy little girl who had learned to talk at an early age.
"She loved laughing and having jokes and conversations with people," the coroner's report added.
Harrower told the inquest of her family's grief at the sudden and terrible loss of their baby girl.
"Indy was much loved by her family and they miss her very deeply," the coroner's report added.
Outside Glebe Coroner's court this morning, Indy's mother and grandmother released a statement saying the three-year-old was a "much loved daughter".
"We hope that the coroner's findings and recommendations will see due consideration and save other families suffering a similar tragedy," the statement read.
The coroner recommended that the Department of Planning and Environment consider changing the development standards to ensure memorials and masonry higher than one metre are structurally sound.
As a result of Indy's death, the Mid North Council has inspected all monuments on its land to ensure their stability. A structural engineer with over 40 years' experience told the inquest that a "properly constructed memorial" should not require ongoing maintenance.
"In Gohil's opinion, the headstone collapsed because the manner of its fixing to its stone base was wholly inadequate," the coroner's findings read.
"Simply put, the memorial had been constructed in such a way that its headstone was unable to resist the lateral forces expected to be imposed upon it."
As a tribute to Indy, the inquest heard the Mid North Council had helped build a "special little memorial" in her honour near to where the tragedy took place.
"It is a timber look out platform built on the coast line nearby for people to use for whale watching," Coroner Ryan said this morning.
"I hope that visiting this special place brings comfort to Indy's family.
"Although they will always mourn for her, I hope this inquest has helped to answer some of their questions and gives them some hope for change."