By Sarah McDougall
Two-year-old Aisling Symes wandered off from her mother and likely stepped onto a displaced manhole cover, dropping her into the pipe below where she drowned, Coroner Gary Evans says.
It is not possible to tell how long Aisling may have been alive in the pipe, a pathologist says in Mr Evans findings released on Monday.
But it may have only been a few minutes if she was knocked out when she fell or if the drain was full off water.
When a police officer checked the drain about 45 minutes after she went missing in West Auckland on October 5, 2009, the water was shallow and he saw no trace of her.
Aisling's body was found 36m down the drain in a blockage of branches, on October 12.
The council was aware that water sometimes displaced the manhole cover, but the risk of the cover moving the way it did was not widely known.
Mr Evans recommended nationwide public safety guidelines for manholes be implemented for all regional and city councils.
Police did not initially think it was likely Aisling was in the drain because the cover was too heavy to lift.
Officers had suspected foul play because of a sighting of an Asian woman with a child matching her description.
Police knew of an Asian woman in the area trying to lure children into a vehicle with sweets.
Mr Evans described the loss of Aisling as grievous for her family and community.
Aisling's death was a reminder of that "it is in the nature of young children to wander off", he said.
"They may take the opportunity to do so whenever they are unsupervised, especially if a door is left open. That is what happened in this case. The facts speak for themselves. The Court makes no criticism of Mrs Symes in the circumstances."