Warning: This story contains upsetting content.
A coroner is recommending councils consider regulating the installation of free-standing ovens after a Rotorua toddler was killed when one fell on her.
It's believed the 19-month-old girl and her 4-year-old brother were climbing up the oven when it toppled and landed on the youngster, trapping and suffocating her.
In his findings into the little girl's death released on Thursday Coroner Matthew Bates said the events of 28 April, 2022 were a tragic accident.
The girl, who RNZ has decided not to name, lived at home with her parents and three older siblings aged 5, 4 and 2, at the time of the accident.
Her parents worked nightshift and two relatives, who also lived at the house, looked after the children together with another relative who was staying temporarily while working during the school holidays.
The toddler was described as being very active and was known to climb many things, including tables, chairs, pantry shelves, and bunk beds, the Coroner said.
Though she had started pushing dining chairs next to the kitchen bench so she could get food, none of the children were known to have climbed on the open door of the free-standing Simpson Atlas oven before that day.
Just before 11am that day, the younger relative woke and realised the adults had slept in and not taken the children to school or day care at 8am as they usually would.
She woke up the girl's parents who both got up and the children's mother went to the kitchen where she saw her daughter trapped underneath the fallen oven.
"It was crushing her neck and torso. [She] was not moving," the Coroner said.
The mother lifted the oven and picked up her daughter who was cold.
Her 4-year-old brother was sitting nearby pointing toward her and later, when asked, told his parents "the oven had fall".
He was covered in cooking oil from a pot that had been sitting on the stove, and had uncooked noodles in his hand - the children loved noodles which were stored in the pantry.
The mother screamed, alerting her partner, who went to the kitchen and saw the stove on an angle with the oven door open.
The family rushed the girl to the emergency department where unsuccessful attempts were made to resuscitate her.
Coroner Bates said the girl weighed just under 12kg and her brother 20kg.
The police investigation reconstructed events using weights to see if the children's weight would cause the oven to tip over.
"They concluded that 20kg of weight on the edge of the open oven door would cause the oven to completely tip forward in a violent fashion."
Police also confirmed there were no council regulations requiring free-standing ovens to be fastened to a wall, bench or floor and New Zealand tenancy regulations also do not require fastening.
Coroner Bates ruled the death a tragic accident and made two recommendations.
They were that councils consider implementing regulations applying to the installation of free-standing ovens that require fastening them in place, and that manufacturers including - either in user manuals or labels - give clear messaging that the oven may tip forward when weight is placed on the open oven door if it is not securely fastened in place.
The coroner also made several comments including that the death was a tragic reminder of the need for young children to have constant supervision.
If that was not possible at home then all care must be taken to ensure the home environment was safe and childproofed, particularly on items that could be climbed or prone to tipping.
He said his comments were not a criticism of the little girl's parents, "who clearly loved her [and] took good care of her".
In 2012 an 18-month-old Te Aroha boy died after he opened the door of a free-standing oven at the home he lived at, and used it as a step to climb up.
The oven fell onto the boy and killed him.
At the time a family member said free-standing appliances should be bolted to the wall and he hoped such a tragedy would never happen again.