A three-year-old boy drowned after falling into an open septic tank at his family's rural Gisborne property while his grandfather was preparing a replacement lid, a coroner has found.
Courageous Atkinson-Walker died on January 30, 2025, at his home in Hicks Bay.
In findings released today, Coroner Ruth Thomas described the death as a "tragic illustration of a preventable drowning death of a young child near water".
The coroner identified three factors that contributed to the tragedy:
- Courageous was momentarily left unsupervised
- the septic tank had been left open without a temporary cover while young children were nearby
- the boy was unable to swim and shorter than the depth of the tank
The boy's grandfather, identified in the coroner's report as Mr Walker, was at the property that day to repair the concrete lid of an inground septic tank. The lid had been damaged after being run over.
He removed the broken lid to measure it and prepare a replacement, leaving the tank open. The tank was roughly 1.2m to 1.5m deep and about three-quarters full of raw sewage at the time.
According to the coroner's findings, Courageous and his older brother were playing in and around the property with their mother while their grandfather worked.
Warned the boys
Mr Walker had warned both boys to stay away from the hole. As the afternoon continued, he realised he would not be able to finish the repair in a day and decided to cover the opening before heading home.
He drove his truck to a nearby shed to find a covering. Courageous and his brother followed the truck, but only the older boy went inside the shed with him. Courageous' mother, who had just finished mowing the lawn, recalled her father's earlier warning to the boys before turning to put the mower away.
Mr Walker told the inquiry he spent "no longer than a couple of minutes" searching the shed for something to cover the tank.
When he emerged with a piece of plywood, he saw Courageous face down in the tank. He pulled the boy from the tank and began CPR on the lawn. Liquid came from Courageous' mouth as resuscitation efforts began.
Courageous' mother joined him in performing chest compressions and the pair moved him inside to shower him with cold water before continuing resuscitation efforts on the bathroom floor.
Emergency services were called and dispatched at 3.43pm but the property's remote location meant they took some time to arrive.
A family member trained as an emergency medical technician reached the scene first and took over compressions, describing white foam coming from the boy's mouth.
Arriving paramedics continued CPR but Courageous could not be revived and was declared dead at 4.49pm.
No suspicious circumstances
Police investigated and advised the coroner's inquiry that they found no suspicious or untoward circumstances surrounding the death, a conclusion accepted by the coroner.
A post-mortem examination by forensic pathologist Dr Glenn found the cause of death to be pulmonary oedema — or fluid in the lungs — consistent with drowning. The examination also identified bruises and abrasions consistent with an accidental injury.
Courageous measured 107cm in height. The septic tank was deeper than that, at an estimated 120 to 150cm.
Water Safety NZ statistics show drowning is a leading cause of death in New Zealanders under five, with the number of preventable drownings of newborn to four-year-olds who drown in “buckets, drains, ponds, and other waters around the house and rural properties" second to home pools.
Coroner Thomas expressed her condolences to Courageous' family for the "sudden loss of their much-loved son, grandson and sibling".
Renewed calls for septic tank security grate
The coroner also revisited a stalled proposal to amend the Australian/New Zealand standard for septic tanks, referencing an earlier inquiry into a 22-month-old boy's similar death in January 2023, which had supported requiring a security grate within tank access openings.
An update from the Ministry of Business, Innovation and Employment confirmed the consultation period closed in 2024, with Standards Australia still discussing the review's scope and MBIE's Senior Plumbing and Hydraulics Engineer joining the committee.
While the coroner found the proposed grate "would reduce the risk of accidental falls... and thereby reduce the risk of drownings in the future", MBIE confirmed any amendment would apply only to new or altered tanks, not retrospectively to existing ones like that at Courageous' home.
As the change would not address this gap, the coroner found it fell outside the statutory scope of a formal recommendation and made none regarding septic tank design.
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