The sister of a man who fell 40 metres to his death has asked his carers if they did enough to keep him safe.
Her question came at an emotionally charged inquest on Tuesday in Christchurch into the death of Darryl Richard Kitto at Rakaia Gorge in April last year.
The 47-year-old had an intellectual disability and was subject to a compulsory care order when he fell from a cliff while having his photo taken by one of those responsible for looking after him.
He planned to give the photo to his sister, Helen Duncan.
Ms Duncan was at Tuesday's inquest and felt compelled to ask questions of his main carer, David Smythe, as he gave evidence.
She said her brother was clumsy and would not have perceived the cliff edge as a risky place to be.
"[You should] tell them to keep safe, you know when he was first on the edge, please be safe...obviously there was a risk."
David Smythe, who had visited the lookout before, insisted he had warned Mr Kitto to be careful as he walked over a bank towards the edge of the cliff.
But he said the true extent of the risk did not become apparent until it was too late.
"Well it seems obvious in hindsight. I can't say I was particularly aware, like [look] I'm standing on the edge of a cliff, rather [I thought] there was a slope over the edge, yes I was aware of that."
Mr Kitto was accompanied to the edge of the cliff by another one of his carers, Kathleen O'Shea.
She took one photo of him but Mr Kitto wanted to take another with more of the gorge in the background.
She held his hand to steady him as he stepped closer to the edge so she could get a better picture.
"When I looked up Darryl was stumbling. He looked like he'd lost his balance and I started to move forward to grab him. I thought Darryl went head first over the bank. He was stable when he let go of my hand...Darryl went head first off the bank, no sound, he just went."
She had no idea of the danger he was placing himself in and did not realise how steep the cliff was until Mr Kitto disappeared over the edge.
She recounted the moment she realised Mr Kitto had not survived his fall.
"I ran up to the fireman and screamed [is this a] body recovery or rescue? The fireman said 'at this stage I obviously don't know and I want you to go back to your car because I don't want you to hear anything over the radio'."
Worksafe New Zealand subsequently identified the cliff as a significant hazard and the Transport Agency was now planning to build a fence to prevent a repeat incident.
Coroner Sue Johnson reserved her findings but gave an indication of them saying Mr Kitto's death was an accident.
She welcomed plans for a fence and confirmed Mr Kitto's sister had been given a copy of the photo taken of him just before he fell to his death.