The coroner investigating the drowning of Auckland toddler Aisling Symes has called for a major overhaul of the way manholes are monitored.
The two-year-old's disappearance in 2009 sparked a week-long search before it was discovered she had drowned after falling into a partly open manhole in Henderson.
The public had complained about the manhole 11 times before the incident but no action had been taken by the local council.
Coroner Garry Evans is recommending the umbrella organisation for councils, Local Government New Zealand, adopt new guidelines for stormwater systems, including checking all manholes. He wants secure covers or safety grills to be fitted to those which pose a danger.
Auckland Council says it now acts to make dangerous manholes safe within hours of a report but putting safety grills on all 160,000 would be too costly.
The council's lawyer Grant Illingworth QC says the coroner's findings are a serious warning. He says if the recommendations are ignored, the consequences of any future accident would be very serious.
Not practical, says president
Local Government New Zealand president Lawrence Yule says that with a total of 145,000 manholes in New Zealand, it would not be practical to inspect every one of them.
He says most local bodies already know where the potentially dangerous manholes are because residents complain when they have stormwater surges and they should be taking steps to ensure they are secure.
As a result, Mr Yule told Checkpoint. the most dangerous manholes already have risk profiles and most of the rest are safe.
He says the coroner's report has been sent to all members asking for feedback on the implications of implementing what is being recommended.
He says the organisation is, however, considering setting up a working party to see if better safety standards are needed.
Changes to police process
Mr Evans also found that police officers' failure to properly debrief each other about seeing a partially open manhole meant Aisling's body lay in the drain far longer than it might have.
Police say a new debriefing system is helping prevent a repeat of that miscommunication.
The Auckland Search and Rescue team has since introduced what it calls a "hot debrief" process in which frontline officers not involved in the investigation keep in touch with searchers about possibly significant clues.
Co-ordinator Dean Duffy says the new process is working.