Chief Coroner Neil MacLean says issues of driveway design, housing layout and safe play areas need to be addressed if more children are not to die from being run over in driveways.
In his findings on one such death, an Auckland coroner has recommended a boundary fence be erected between two Housing New Zealand properties in south Auckland.
Eighteen-month-old Sirj-Michaels Siaea was accidentally run over and killed in an Amuri Place driveway in Otara in September 2010.
Judge MacLean says there have been 22 deaths as a result of being run over in a driveway since 2007 and there is a common theme to all of them.
He says the Child & Youth Mortality Review Committee as well as Safe Kids have also pointed out the same problem.
"Probably we are all hoping," Judge MacLean says, "that they will take a hard look at it and actually do something about starting to address the driveway design issue, the layout issue of housing, the provison of safe play areas so that the driveway isn't the default area for children to be playing in."
More likely 'in deprived areas'
Child & Youth Mortality Committee chair Nick Baker says children are more likely to be run over in driveways of deprived housing areas.
Dr Baker says the committee looked into 27 cases of low-speed deaths in driveways and made specific recommendations to Housing New Zealand about modifying its current housing stocks over time.
"Houses with families living in high levels of deprivation were over-represented," he says, "and Housing New Zealand houses obviously fall into that group - and I think we've probably known that for five, maybe 10 years."
Dr Baker says it's tragic New Zealand has a high rate of such deaths compared with other countries.
Coroner finds inadequate separation
Coroner Morag McDowell says a major factor in Sirj-Michaels Siaea's death was inadequate separation of driveways and places children could access.
She says a boundary fence should be set up between the two homes and any other similarly configured Housing New Zealand properties.
The toddler had been playing on the front lawn of the neighbouring house before moving onto the adjoining driveway. Shortly afterwards, the occupants of the house reversed their car down it without seeing him.
Both houses were Housing New Zealand properties.
Ms McDowell also endorsed the recommendation that, over time, Housing New Zealand modify its current stock so driveways are separated and children have safe play areas.