A Balclutha girl who drowned five days before her 14th birthday had swapped her life jacket for an inferior one before she was tossed from a boat into rough seas, a coroner's report says.
Catlins Area School pupil Eluned Finney and a friend were aboard a 5m powerboat driven by her father when it capsized on a sandbar at Surat Bay on January 15, 2014.
Eluned's father, Geoff Finney, and a friend, Finn Smith-Bingham (then 14), of Kaka Point, both swam to shore but she drowned.
Coroner David Crerar yesterday released his findings into the accident.
On the day of the tragedy, Mr Finney had checked the marine forecast and decided to go to Kaka Point, the coroner's report said.
They could not launch the boat because the sand was soft, so launched at Hinahina, near Owaka.
All three occupants put on life jackets.
As they left shore, Eluned was wearing a compliant red Body Glove life jacket that had been bought for her.
The boat became stuck on a sandbar on its way through the estuary.
Mr Finney got out and pushed it into deeper water and they had lunch until the tide rose.
In deeper water, Mr Finney successfully navigated the first set of breakers, which he described as huge, into the open sea.
Beyond the last set of breakers, the boat's main engine stalled but Mr Finney was able to restart it.
He described the engine as ''failing slowly'' and ''struggling''.
Returning through the breakers at low revs, the boat overturned, throwing all occupants into the water.
Mr Finney later told police he lost his cellphone when he was tossed into the water and regretted not having a GPS distress beacon.
A VHF radio checked before leaving land had also failed when it was needed, he said.
Witness Nicole Lauenstein, of Christchurch, said in a statement she saw the boat out at sea and thought the waves were very large.
Only when she saw two yellow dots moving towards the shore did she realise the boat had overturned.
As she helped Finn, who was cold and in shock, to shore, Mr Finney asked: ''Have you seen a girl?''
Two other men, Phillip Martin and Brent Nicholson, both of Blenheim, searched the estuary in an inflatable dinghy and found Eluned face down wearing a camouflage life jacket, not the same one she had been wearing earlier.
She was taken to shore, where Mr Finney and Jacqueline Martin, who is a qualified nurse, began CPR.
Attempts to resuscitate Eluned were unsuccessful and a paramedic who arrived with the rescue helicopter declared her dead.
The boat could not be recovered because of dangerous conditions.
A postmortem examination found Eluned's death was due to asphyxia consistent with drowning.
Mr Crerar's report said that Eluned's death occurred after a series of events or contributors that included Mr Finney's decision to take his boat, ''virtually alone'', into rough seas. However, Mr Finney had ensured the motor was in good running condition.
Mr Finney told police that the sea was not rough when they set out and he was caught out by a change in conditions.
Had the motor not failed, ''we all would have returned safely'', he said.
Mr Crerar said the life jacket Eluned was found wearing in the water was not appropriate for heavy seas.
Without Mr Finney's noticing, she had exchanged her own, compliant life jacket for an inferior one.
The coroner said Mr Finney had been unaware of the dangers of the estuary and sandbar at Surat Bay.
Among his recommendations was that life jackets should be appropriate for the conditions.
As well as checking the marine forecast, a boat user should also check sea conditions where the boat was being launched, he said.
Mr Finney asked the coroner to include a recommendation signage be installed at the Hinahina boat ramp to advise other boat users of the dangers in the area.
The coroner included the recommendation and forwarded his findings to the Clutha District Council.
Yesterday, council district asset manager Jules Witt confirmed the council's intention to install signage at Hinahina in line with the coroner's recommendation.
He said the council would install signs once the wording and other details were confirmed.
In his report, Mr Crerar expressed his sympathy and condolences to Eluned's family and friends.
