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A man fatally struck by the steam train he was photographing did not realise how close it was to him because he was looking at it through his camera lens, the coroner has ruled.
On September 7, 2013, Gregory John Duncraft, a meatworker from Kaiata, was standing on the railway track near Kokiri when a Mainland Steam charter steam train struck him at 5.45pm, throwing him into the air.
Mr Duncraft, 50, was still alive and taken to Grey Base Hospital with an open skull fracture and serious internal injuries. He died at 7.37pm.
Coroner David Crerar said Mr Duncraft had gone to see the train with friend Caroline Milne. She stopped pressing the button on her camera when the engine was 30m away, and turned away. Next, she heard someone calling for an ambulance.
The train crew, and a doctor and ambulance officer who had been on board the train, gave aid.
Lisa Hartigan, who was driving to Moana to meet the train with her children, expressed concern that Mr Duncraft was still on the track.
The train "gave a loud toot" but he was still standing there "with his face to the camera".
When it was just 3m away he took the camera down from his face and tried to step away quickly, but the train clipped his legs.
Norman Leonard and Alfred Wilson were in the locomotive cab. Mr Leonard blew the whistle and saw Mr Duncraft get hit, the impact throwing his body to the left side of the locomotive.
Grey Base Hospital staff later reviewed the case and found potential for improvements in emergency trauma practice.
Pathologist Dr Martin Sage noted the nasogastric tube during resuscitation was incorrectly sited.
Mr Duncraft's son Lucas had told the coroner his father's medication had been changed and that had affected his balance, though the coroner thought he would have stabilised by the time of the accident.
Although Mr Duncraft's wife had died 18 months previously, his son said he appeared a little happier when he last saw him, though his eyesight was not the best and he needed glasses.
Lucas Duncraft said, "sometimes when dad was concentrating on someone or something, he would be hard to get out of it ..."
Mr Duncraft's sister Elizabeth Beresford said he could hardly see without his glasses, which were always dirty.
The coroner said it was probable that had he looked at the train directly, he would have more immediately recognised the hazard.
There was no evidence that a failure by his GP or the district health board had contributed to the death. His condition was terminal due to the scale of his injuries.
There was nothing Kiwi Rail, which chartered the train, could have done.
The coroner ordered the return of Mr Duncraft's camera to his family.
From the Greymouth Star