A poorly affixed foundation has been blamed for an ANZAC monument falling and fatally crushing a toddler on the mid-north NSW coast.
Indy Lee Henderson, three, was killed when an upright sandstone slab — which weighed nearly half a tonne — fell on her at the Black Head Bowling Club on the mid-north coast in November 2016.
She had been playing around the monument with other children before the headstone fell, causing crush injuries on her chest and abdomen.
The NSW deputy state coroner Elizabeth Ryan has recommended new standards for monuments after an inquest found the monument's foundations were "wholly inadequate".
The inquest heard a boy was "riding the monument like a horse" during a birthday celebration for Indy's grandmother when it fell.
Ms Ryan said it was a "terrible thing to happen to poor little Indy", and her family's grief, particularly that of Indy's mother Tamica Harrower, were obvious throughout the inquest.
"Indy was much-loved by her family and they miss her very deeply," Ms Ryan said in the coroner's report.
"Despite their distress, Ms Harrower and her mother Shiralee Walker attended each day of the inquest."
Ms Ryan urged the Government to change the law so all monuments higher than one metre from ground level are subject to development standards in the future.
Ms Ryan said the Mid-north Coast Council had performed an audit of all monuments since the tragedy, and she would write to Local Government NSW recommending all councils do the same.
She said she hoped Indy's family would get some comfort from the findings.
"[We are] so sorry this happened to your little girl," she said.
Ms Harrower cried as the coroner made her remarks.
Outside the court her solicitor, Joe Bonura, read a statement on behalf of Indy's family.
"Nothing will ever take away the loss of Indy, a much-loved daughter, granddaughter and sister," Mr Bonura said.
"We hope that Her Honour's findings and recommendations will receive due consideration and will result in other families not suffering a similar tragedy."
