Circumstances that were "all too familiar" led to the death of two teens in Acacia Bay, Taupō - an inexperienced, unlicensed driver who'd consumed alcohol and drugs, and got behind the wheel.
Coroner Ian Telford's findings said the "needless deaths" of Purity Anne Te Pairi and Tamatoa David Kimi Jnr, who were both 19, were a tragedy, but the surrounding circumstances were those seen with "alarming regularity year after year".
"At its core, this is yet another case of a young, inexperienced driver - on a learner's licence - who'd consumed alcohol and other drugs.
"History shows with absolute consistency, this combination is a recipe for disaster," Coroner Telford said.
The events unfolded on January 17 of this year, when the pair, who were longstanding friends, had been driving around Taupō late at night.
The coroner's findings said initially the pair had planned for Kimi Jnr to pick Te Pairi up from work when she finished for the night.
But after he became too intoxicated to drive, he was instead driven to her workplace by a sober friend, in her car.
When they arrived, Te Pairi wasn't there, so they instead met her at a bar in Taupō, where she'd been having a drink.
She got in her car and drove off with Kimi Jnr and her mother as passengers.
The findings said that at some point, her mother was dropped off, and the pair continued driving around town.
Shortly before midnight, tragedy struck when Te Pairi was driving west along Taupō's Mapara Rd.
Crash analysis showed that as she approached a moderate left-hand bend on a slight downhill, the car crossed into the wrong lane.
Te Pairi steered sharply in response and over-corrected, causing the car to slide across two lanes and on to the grass verge.
The passenger side hit an embankment, the car rotated, and the rear of the car went up the embankment.
Other road users came upon the crash, and contacted emergency services, later giving evidence that the car had, moments before the crash, overtaken them "erratically and at speed, without indicating".
Both teens sustained fatal injuries and were confirmed dead at the scene.
A post-mortem examination confirmed their deaths had been caused by blunt force injuries, while toxicology reports confirmed alcohol was present in Te Pairi's blood, and cannabis was detected, as was the case for Kimi Jnr.
Te Pairi's blood alcohol reading was "just under" the legal limit for drivers aged 20 years and over, but as a 19-year-old she was not meant to consume any alcohol before driving.
"In any event, I consider that alcohol was a contributing factor to the crash," Coroner Telford said.
The coroner also considered the police's view that, given Te Pairi was on a learner's licence, which she acquired in August 2023, her driving manner contributed to the crash.
She had not had an appropriate supervisor with her in the car, and her "abrupt manoeuvre" to try to correct her being in the wrong lane was indicative of her inexperience.
Police speed calculations indicated that speed was not a factor in the crash, however.
The coroner said it was widely understood that driving while intoxicated is dangerous, and the message was "regularly reinforced" by police and the NZ Transport Agency.
However, he said, there appeared to be a "persistent and deeply ingrained tendency within our society to overlook, or silently tolerate, unlicensed driving on our roads".
"This is a contributing factor in a significant number of cases that come before the Coroner's Court."
In this case, he said, Te Pairi should not have been driving that night, had consumed alcohol and possibly cannabis, had no supervisor with her, and "had not passed a test to show she could drive a car".
He said the driver licensing system existed to ensure those who get behind the wheel have the competence to drive.
"Before you drive on public roads, get properly trained, get properly licensed, and follow the road rules.
"These are not merely legal formalities," Coroner Telford said.
"They are essential safeguards designed to protect life. The deaths of Tamatoa and Purity are a heartbreaking reminder of what can happen when those safeguards are disregarded."
