Although she did not make any recommendations regarding septic tanks specifically, she urged parents to follow Water Safety New Zealand’s public education safety messaging, which states children should never be left unattended near water.
“If drawn to public attention, I consider it possible that these comments may reduce the chances of further deaths occurring in similar circumstances,” she said.
Tank lid could not be fixed that day
On January 30, 2025, Courageous was at home with his brother and mother.
His grandfather, referred to as Mr Walker in the report, was at the property to fix the concrete lid on the inground septic tank system that had been run over and broken.
The septic tank was approximately 1200mm to 1500mm deep and was about three-quarters full with raw sewage.
Walker pulled the lid off the tank to measure it and box up an area to make a new lid.
While he was working near the septic tank, Courageous and his brother were looking at what their grandfather was doing. Their mum was mowing the lawn.
Walker told both of his grandsons to stay away from the hole.
As the day progressed, Walker realised he wouldn’t be able to finish making the lid as he needed metal before he could pour the concrete lid.
He was waiting for a call to say the metal was ready to collect but it was taking too long.
He decided he would cover up the hole to the tank and go home. He drove his truck over to a shed near the tank to find something to temporarily act as a lid.
Courageous’ brother followed his grandfather, but Courageous did not.
The boys’ mother was about to put the lawnmower away under the carport when she heard her father yelling, holding Courageous in his arms.
Walker said he spent “no longer than a couple of minutes” looking for a covering and, when he came out of the shed with a piece of plywood, he saw Courageous was face down in the septic tank.
Courageous could not swim.
Walker pulled Courageous out of the tank, laid him on the lawn and started CPR. He was limp and not breathing.
Courageous’ mother was helping with the CPR. They took him inside to shower him with cold water and continued with CPR on the floor in the bathroom.
Emergency services were dispatched at 3.43pm but because of the remote rural location they took some time to arrive.
A family member, who was an emergency medical technician, arrived on the scene before the emergency services and continued with CPR on the floor of the living room. She described a white foam liquid coming out of his mouth.
When the emergency services arrived, they continued CPR, but he could not be revived. A paramedic declared Courageous deceased at 4.49pm.
The police attended the scene and concluded there were no suspicious or untoward circumstances surrounding Courageous’ death.
An autopsy indicated Courageous had died by drowning.
A sample of blood was tested for thiosulphate, which is a major metabolite of hydrogen sulphide, a toxic gas produced naturally by decaying organic material such as sewage. The toxicological analysis showed there was no thiosulphate detected.
Second cause of drownings for under 4-year-olds
Water Safety New Zealand data showed drowning was a leading cause of death in New Zealanders under 5.
Between 2015–2024, the number of preventable drownings of newborn to 4-year-olds who drown in “buckets, drains, ponds, and other waters around the house and rural properties” was the second-highest category of drowning deaths for this age group, second only to at-home pools.
The Water Safety New Zealand public education safety messaging said it takes less than two minutes for a child to drown. Adults should never turn away or leave a child unattended while they are near water and should remain close enough to be able to reach a child and intervene immediately.
“These comments are directed to all parents and guardians of young children in New Zealand, for the purpose of education on how to reduce the risk factors of drowning deaths,” Thomas said.
Thomas said a previous coronial inquiry, investigating the death of a 22-month-old boy who fell into a septic tank when the lid had been removed for maintenance work, supported the proposed revision of the Australian/New Zealand Standards for Septic tanks.
The proposal advocates for an amendment to the standard specifically to incorporate the installation of a security grate within the access opening of septic tanks.
Thomas sought a progress update from the Ministry of Business Innovation and Employment (MBIE), which confirmed the consultation period ended in 2024, and Standards Australia are discussing the scope of the review of the standard this year.
MBIE has nominated its senior plumbing and hydraulics engineer to join the committee reviewing this standard.
Richard London, building performance manager at MBIE, said the formal joint standards committee to undertake the revision had not yet been established, and the review remains in its early stages.
The proposed design of a security grate to be fitted within the access opening of septic tanks was 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.
MBIE confirmed that amendments to the standard, if adopted here, would not have an impact on existing septic tanks, unless new building work or an alteration to an existing tank was to take place.
“If the proposed amended standards for new septic tanks installed in the future is adopted, this change would improve death prevention in New Zealand,” Thomas said in her report.
But as it was not an amendment that would change the lack of safety features of existing tanks, such as the one at Courageous’ home, it was not within the statutory scope of a formal recommendation which the Coroner could make under the Coroners Act.
Brianna McIlraith is a Queenstown-based reporter for Open Justice covering courts in the lower South Island. She has been a journalist since 2018 and has had a strong interest in business and financial journalism.