A coroner says a child's drowning in a septic tank last year is a "tragic" example of the need for vigilance around young children and water.
Courageous Atkinson-Walker died on 30 January 2025 when he was "momentarily left unsupervised" near the open top of the septic tank on his family home in Hicks Bay.
Coroner Ruth Thomas highlighted the dangers posed by "buckets, drains, ponds, and other waters around the house and rural properties", and said such hazards were the second biggest cause of drowning deaths in children four years old and under in New Zealand.
The child's grandfather, referred to in the report as Mr Walker, had been working to replace a broken lid on the septic tank on the property and had removed the lid to measure it and construct a new one.
Courageous and his brother were in and around the property with their mother when his grandfather went to a nearby shed to look for something to temporarily cover the access hole to the tank until materials to construct a new lid became available.
Walker spent "no longer than a couple of minutes" looking for materials in the shed, while the child's mother was just finishing mowing the lawns.
She recalled Walker telling the boys to stay away from the hole. Courageous's brother followed his grandfather to the shed but the younger child did not.
The boy's mother turned away briefly to put the family's mower under the carport then - upon hearing yelling - turned back to see Walker holding the child in his arms.
Walker had found Courageous face down in the septic tank. He was limp and not breathing.
The two performed CPR on the child and emergency services were called and dispatched around 3.43pm.
A family member - who was an emergency medical technician - arrived on the scene ahead of emergency service staff and continued CPR but the child could not be revived.
Courageous was pronounced dead by paramedics at 4.49pm.
He was just 107cm tall and could not swim. The depth of the septic tank was approximately 120cm to 150cm deep and was about three quarters full.
The Coroner said a police investigation found no suspicious circumstances and she described the death as "a tragic illustration of a preventable drowning death of a young child near water".
She said the child was only "momentarily left unsupervised".
Coroner Thomas reiterated Water Safety NZ messaging that it takes less than two minutes for a child to drown, and to never turn away or leave a child unattended while they are near water.
Review of septic tank safety standards instigated following a prior fatality
Thomas also pointed to a revision of trans-Tasman septic tank standards, proposed in response to a similar death in 2023, when a 22-month-old died after falling into a tank when its lid had been removed for maintenance work.
"The proposed design of a security grate to be fitted within the access opening of septic tanks is a change that would reduce the risk of accidental falls into the liquid within the tank and thereby reduce the risk of drownings in the future," Thomas said.
She observed that any changes to standards would be unlikely to affect existing tanks such as the one in Courageous' home.
MBIE building performance manager Richard London confirmed that consultation on the proposal to review the septic tank standards had finished in 2024 but the formal joint standards committee - to undertake the revision - was yet to be put in place.
"The proposal is to revise the standard to mandate the installation of fixed security grates in septic tank openings with a view to preventing accidental drownings, facilitating safe maintenance practices, and promoting standardisation and compliance," London said.
He said it was currently the responsibility of property owners and installers to ensure the safety of septic tanks through safe design, installation, and ongoing maintenance.
London outlined practical steps to improve safety around septic tanks including:
Ensuring lids are secure, locked or child resistant, and cannot be easily removed.
Installing fixed safety grates or mesh barriers beneath access openings.
Regularly checking lids and covers to ensure they are not degraded, shifted or damaged.
Restricting access to tank areas through fencing, covers or raised access points.
London said septic tanks should be treated with a similar degree of caution and water safety awareness as ponds, drains, streams and other hazards about the home.
