Soon after celebrations began at a woman's 50th birthday party at the Black Head Bowling Club a 425-kilogram sandstone Anzac memorial suddenly collapsed and crushed her three-year-old grand-daughter.
The little girl was handed to her mother, Tamica Harrower, who desperately said: "You've got to wake up Indy" before telling her own mother: "Mum, she is not waking up, she's not breathing."
Indy Lee Henderson, from Airds in Sydney, was killed in November 2016 while playing at the club.
Deputy State Coroner Liz Ryan on Monday, December 17 found she died as a result of the collapse of a sandstone headstone which had not been properly affixed to its base when built by third generation stone mason John Edstein in 1997.
Children were seen climbing on top of the headstone shortly before it collapsed, which may have triggered its dislodgement.
"Indy's family did not lay blame on the actions of children, recognising that these ought not to have caused a properly built structure to collapse in this manner," the coroner said.
Ms Ryan recommended the NSW government consider amending development standards so a masonry construction the size of the Anzac memorial could not be an exempt development and would, therefore, be subject to regulatory oversight.
This would apply to constructions higher than one metre from ground level.
"The evidence enables me to find that the Anzac memorial headstone collapsed because the manner of its fixing to its sandstone base was inadequate," she said.
"The use of silicone as a fixing agent to secure the dowels to the surrounding stone did not provide sufficient adhesion."
The coroner accepted that under the regulatory framework at the time there was an "implied" obligation" for the memorial to be constructed in a way complying with a general engineering standard dealing with structural stability - but this did not then require the oversight of the local council.
She welcomed action by the MidCoast Council after Indy's death to identify and inspect all monuments on council-owned and controlled land including those inside cemeteries.
"It was very moving to hear that after Indy died, with the council's assistance, a special little memorial has been built in her honour," Ms Ryan said.
"It is a timber lookout platform built on the coastline nearby, for people to use for whale watching. I hope that visiting this special place brings some comfort to Indy's family."
Outside court, Indy's mother, Tamica Harrower, and grandmother, Shiralee Walker, stood beside the family solicitor, Joe Bonura, who told reporters nothing would ever make up for the loss of the little girl.
But the family hope the findings and recommendations will be given due consideration to ensure other families don't suffer the same pain, the lawyer said.
Australian Associated Press