Karnin Petera died during a school trip to Abbey Caves - a coroner reveals what went wrong

A coroner is calling on schools around the country to take a more cautious approach to the risks of outdoor trips following the death of a Whangārei boy in a caving tragedy.

Karnin "Tino" Petera, 15, died in 2023 during a Whangārei Boys' High outdoor education trip to Abbey Caves, on the outskirts of the city, when he was trapped in a flash flood.

Northland was under an orange heavy rain warning at the time.

Sixteen other boys, a teacher and an instructor survived.

Coroner Ho described the flood, which rose from waist-high to neck-deep in a matter of minutes, as "terrifying".

The central theme of his findings, which were released Thursday morning, was that organisers had an "overly optimistic" tolerance for risk.

That was compounded by misinterpretation of, and a lack of clarity in, the MetService weather forecast, along with uncertainty around who had authority to cancel the trip, and what the criteria for cancelling were.

"The excursion involved a group of teenage schoolboys, most if not all of whom were inexperienced cavers. In those circumstances, it would have been prudent for [the head of outdoor education] or [the trip leader] to account for a greater chance of things going wrong: that the heavier rain forecast for the afternoon might arrive earlier, that the hourly rainfall forecast for Whangārei might be incorrect, or that the cave could be affected by high or rising water."

Coroner Ho found the organisers, whose names are suppressed, had relied on hourly rainfall forecasts for the Whangārei area, which showed only light rain during the trip.

They believed hourly local forecasts were more reliable than general, region-wide warnings.

However, they did not realise the hourly rainfall forecast for 9am, for example, was not for the hour from 9-10am, but the hour leading up to 9am.

Similarly, another forecast giving three-hour predictions was for the three hours prior to the specified time.

That error of interpretation was compounded by the storm's earlier than predicted arrival in Whangārei.

Also, Coroner Ho said the organisers did not put enough weight on the weather forecast being just that - a forecast of what was likely to happen, rather than a certainty.

He said MetService's warnings about the limitations of its data, or the fact that some data was generated by computer modelling without human checks, were only visible after the user clicked on an icon.

The school's own outdoor education policy called for trips to be cancelled if a weather warning had been issued, but left just enough ambiguity so the organisers felt the trip could proceed.

It was also unclear who had authority to cancel the trip.

Coroner Ho said planning forms needed to be updated to remove any possible ambiguity, including more specific criteria for when a trip should be cancelled - for example, a red or orange weather warning - and who had the authority to do so.

He said the school had already taken steps to improve its outdoor education policies and procedures.

He did not find fault with the trip leaders' actions once the group was inside the cave.

During the inquest, in April this year, the teacher and contractor were quizzed about why they did not take the boys to a higher passage within the cave to wait out the flood.

Coroner Ho said they had to choose between getting out as quickly as possible or retreating to the higher passage.

However, he said the teacher was concerned about the risks of hypothermia and lack of food while they waited for the flood to subside - plus he could not be certain the water would stop rising before it reached the upper passage.

Once the group committed to trying to get out there was no way back.

Coroner Ho suggested "confirmation bias" may also have been at play in the fateful decision to proceed with the trip.

The trip organisers were highly experienced cavers who had never known Organ Cave, where the tragedy occurred, to flood even in heavy rain.

Past experience had convinced them hourly rain forecasts were reliable, and a trip to the same cave a day earlier had gone smoothly with rainfall matching MetService predictions.

The outdoor education contractor hired to accompany the group that day told the inquest he had planned a "robust discussion" about the decision to go ahead with the trip.

However, he was not told the excursion had been brought forward by half an hour, so he arrived as the group was getting ready to leave.

During the inquest, the trip leaders suggested the Ministry of Education impose clear rules about when outdoor trips should be cancelled.

Coroner Ho said that was an attractive idea, but the "impossibly vast range" of outdoor education activities made that impracticable.

It also introduced a new risk that decisions would be shifted to some centralised body with no on-the-ground knowledge of specific locations or activities.

However, the coroner said the ministry needed to improve its outdoor education guidelines.

He described the guidelines as "wordy and dry" without logical format or arrangement - a problem "sadly symptomatic" of government documents.

Schools and trip leaders needed to be able to access the information they needed quickly, he said.

"There is little point in publishing useful information buried in a mountain of irrelevant material and which requires extensive effort to find and read."

Regarding weather forecasts, Coroner Ho urged MetService to make the information on its website, and its limitations, clearer.

The forecaster also needed to make sure the disclaimers were the same on the website and the app.

Overall, schools needed to take a more cautious approach.

"It is likely prudent to apply a more conservative risk tolerance, and to allow a greater margin of error for things to go wrong, where a group of novice school children are engaging in an outdoor activity the safety of which is materially influenced by inherently uncertain or evolving factors."

All three of the caves - Organ, Ivy and Middle - were currently subject to a rāhui and closed by the Whangārei District Council.

Coroner Ho said it was not his call whether the caves should reopen or not.

If they did reopen in future, the council should consider warnings on the council website, at the car park and the cave entrances.

He said a specific warning saying someone had died in the caves was more likely to be taken seriously than "a general vague warning of death".

The council had suggested a permit system for entering the caves, but Coroner Ho said unenforced permits might not be enough to control the risk.

The caves were on council land but the council did not have any health and safety duties to cave visitors.

Coroner Ho said Karnin's family believed that was a gap in the law, but questions of liability were outside the scope of the inquest.

He praised the efforts of Karnin's whānau to make sure no other family lost a child in similar circumstances.

'Our heads are still clouded by grief': Karnin's family responds

Andre Petera and Alicia Toki said their son's death was entirely preventable, and they hoped Coroner Ho's recommendations would be implemented.

Changes the couple wanted to see included:

• The Ministry of Education reviewing its guidelines for school trips. The guidelines needed to specify who was in charge of checking trips and when a trip had to be cancelled. The guidelines should use real examples, such as Karnin's death, to show how things can go wrong with insufficient training, knowledge or planning.
• Clear rules about when a trip had to be cancelled because it was unsafe.
• Regular safety training for teachers and staff involved in outdoor education.
• Scope for MetService and other forecasters to present information even more clearly - although Petera and Toki believed the warnings were clear enough on the day.
• Proper warning signs about the dangers at Abbey Caves, as opposed to something that looked like "a box-ticking exercise".

Karnin's parents said the coroner's call for clear, objective criteria for cancelling a trip was important.

"In this case, the teachers in charge of the trip really lacked self-awareness. They believed they knew better than the MetService weather warning issued for the area, and better than the council signs warning of the danger of the caves. They believed their own knowledge and experience outweighed the information they were given by other professionals.

"The weather report, the warning signs, and the school EOTC (Education Outside the Classroom) risk assessment form that said to cancel the trip if a weather warning was in place. They were wrong to ignore all of that. As our lawyer put to the main teacher in the inquest, 'A little knowledge is a dangerous thing'."

The couple said the inquest was thorough and the coroner's recommendations were helpful, but the system overall had failed to keep their trust and had left them feeling empty.

After Karnin's death, they expected the teachers responsible for the trip to be stood down until the WorkSafe investigation was complete.

They also expected the Teaching Council to step in and cancel their registrations, given the failures to keep students safe.

Instead, the Board of Trustees was charged, and then the fine was wiped.

"What we've learnt is that the courts won't fine a school for health and safety offending if the financial impact of doing so would affect its current students, and it seems that it always will," they said.

"What consequences have the teachers faced? We understand that the teachers will live with their guilt, but that does not lessen our loss. We believe WorkSafe should more readily consider charging individuals if individual decisions led to the outcome."

They did, however, appreciate the reparation from the school's insurer, which helped them through a long period in which they were unable to make good decisions and were "just trying to live".

They also acknowledged the support they had had from family since Karnin's death.

"Our heads are still clouded by grief, and we have not yet been able to make full sense of our feelings about Karnin's death and the legal process.

"Although Karnin has died, we still feel he is here with us. We will continue to look to him to guide us in how we live our lives. Ko te ruru te kai whakaatu i te pō."

'One of our boys'

Whangārei Boys' High School principal Alec Solomon said Karnin's whānau had endured the "unimaginable pain" of losing a much-loved son, mokopuna and brother.

"The coroner has found that the trip should not have gone ahead that day. Karnin was in our care, and he did not come home. We are deeply sorry," he said.

"We acknowledge the strength and dignity shown by Karnin's whānau throughout this long and difficult process. We share their determination that no other family should lose a child in these circumstances."

Solomon said the school recognised the lasting impact of the tragedy on the boys and staff who were at Abbey Caves that day, their whānau and the wider school community.

The school would continue to support those who needed it.

"Keeping the young people in our care safe is our most important responsibility. We are committed to learning everything we can from this tragedy and ensuring those lessons lead to meaningful change."

The school had since had its outdoor education policies and procedures independently reviewed, and a new safety framework had been introduced with stronger oversight and clearer processes for assessing risk.

The coroner had acknowledged these changes, he said.

"But we recognise that our work is not finished. We will carefully consider and act on his recommendations, including strengthening the criteria for cancelling trips and clarifying who has the authority to make those decisions. We hope schools throughout New Zealand will learn from this tragedy, so that what happened to Karnin never happens to another child."

Solomon said no findings or recommendations could ease the loss suffered by Karnin's whānau, but he hoped the coroner's report provided some of the answers they had sought for so long.

"Karnin was just 15 years old. He loved basketball and performing, he was learning the guitar, and he was deeply loved by his whānau and his mates. He was one of our boys, and he always will be."

Weather warnings always take precedence

MetService chief meteorologist Chris Noble said the agency was committed to improving the way forecasts were presented so people could better understand their risks and make informed decisions.

Severe weather watches and warnings should always take precedence over other forecast information, he said.

Watches and warnings were displayed prominently across the website and app to help people recognise when severe weather was expected and to take appropriate action.

Noble said the MetService had reviewed the coroner's recommendations, which built on improvements that were already being implemented.

"Recent improvements include making it clear that model-based forecasts, such as our forecast graphs and three- and five-day rainfall maps, can differ in detail from the written forecast and should not be relied on alone. Written forecasts that are prepared and reviewed by our meteorologists using multiple data sources and professional expertise take precedence over model data used in isolation," Noble said.

MetService had also increased the visibility of its orange and red warnings, including when app or web users were studying the more detailed hourly data.

Education services deputy secretary Geoff Short said the coroner's recommendations would inform updates to the Ministry's Education Outside the Classroom (EOTC) guidelines.

"Since the events examined by the coroner, we have worked with Education Outdoors New Zealand, Recreation Aotearoa and other sector partners to strengthen the support available to schools. This includes updated guidance, practical tools and clearer processes to help schools assess risk, make informed decisions about activities, and provide appropriate oversight for higher-risk activities," Short said.

The ministry was also looking at how it could strengthen professional learning for EOTC staff.

The ministry did not respond directly to the coroner's criticism of the way the guidelines were written.

'I thought I was going to die'

During the inquest, the teacher leading the trip said the tragedy had devastated him and shaken him to his core.

He told the court he had never seen a river in a cave rise so fast, even in heavy rainfall.

He described how his head was completely underwater as he used his body to block the flow and tried to push students out the cave exit.

"I was completely out of breath and thought I was going to die. I tried to calm my mind. I had all kinds of vivid memories coming into my mind from childhood and then a strong image of my wife and children came into view."

WorkSafe has already prosecuted Whangārei Boys' High over the 15-year-old's death.

The school pleaded guilty to two charges of putting people at risk of serious injury or death and in 2024 was ordered to pay the victims more than $500,000 in reparations.

The judge remitted a fine of $300,000 because the school was unable to pay.

There were also concerns that making the school pay a fine could harm student education, including for survivors of the trip who were still at the school.

Coroner's recommendations

• That education providers review their outdoor education policies and procedures now, and at regular intervals, to make sure there are no ambiguities about when a trip should be cancelled.
• That the Ministry of Education should, when the time comes to review its outdoor education guidelines, make sure the information is clear and easily accessible.
• That MetService changes or clarifies its website and makes the limitations of particular weather data clearer.

Coroner's comments

• School outdoor education policies should make it clear who has authority to cancel a trip.
• Organisers need to be aware of the risk of confirmation bias when making decisions about a trip.
• Anyone teaching weather interpretation courses should be mindful of, and educate students about, the limitations of weather forecasting data.
• Anyone organising trips in the outdoors should take a conservative approach to risk and allow a greater margin of error for things to go wrong - especially when novice schoolchildren are involved, and safety is influenced by uncertain and evolving factors.