A coroner has not made a recommendation that a public duck pond be fenced despite a toddler drowning last year and has suggested a lack of supervision was a factor in the death.
Twenty-month-old Zachary Michael Kennedy visited the Queens Gardens in Nelson with his family last September but went missing within 30 minutes.
A member of the public found the boy submerged in the pond 10 minutes after the alarm was raised and could not revive him.
In her findings issued on Tuesday, Carla na Nagara says fencing off the pond is not practical, nor necessary, given that there has been only four other deaths of this kind since 1980.
Ms na Nagara has suggested a lack of supervision was a factor in the drowning.
Water Safety New Zealand says the coroner's finding regarding a lack of supervision is a wake-up call for parents. It says children who are near water need uncompromising, vigilant supervision at all times.
Nelson City Council parks and facilities manager Paul McArthur says it would have looked at installing a fence should the coroner have recommended this.
However, Mr McArthur says it would have been difficult and is pleased with the findings.