The death of Te Anau toddler Shane Holden Price last year had reinforced the "absolute necessity" of parents supervising their children when they were in or near water, Coroner David Crerar said.
The comment was made in Mr Crerar's formal written finding into the 17-month-old Te Anau boy's death, following an inquest held at Te Anau on May 28.
During the inquest, Shane's mother, Kirsty Price, said on August 21, 2007, after a normal morning of activities, her husband Alistair went to work.
Shane and his elder sister Ella had breakfast and played while Mrs Price entertained a visitor, then made telephone calls, sent text messages and communicated on the computer.
Mrs Price later put Ella and Shane in the bath.
Shane was seated on a non-slip bath mat near the plug end of the bath.
Mrs Price said in her evidence she removed the plug from the bath and left Shane standing up holding on to the bath at the plug end, complaining and wanting to get out.
In the written findings, Mr Crerar said Mrs Price left the bathroom to collect towels for the children.
"She heard a splash and later a "hiccup" or "splutter" so returned to the bathroom and saw Shane Price lying face down in the bath.
"He was sitting in the water with one leg bent at the knee underneath him and the other straight out in front of him.
"She saw a white cloth blocking the plug hole."
Mrs Price began CPR and called emergency services.
Mr Crerar said the family's GP, who was called to the house following the incident, commented "the distresses and discomfort of the family was absolutely palpable . . .
Kirsty was in a totally distraught and upset state, blaming herself but wondering what else she could have done in the circumstances."
Mrs Price had "for whatever reason" now accepted Shane received insufficient supervision while he was in the bath, Mr Crerar said.
"It is not the focus of an inquest to extend blame or responsibility.
"I suspect that a majority of parents have, at times, been guilty of insufficient supervision of babies and infants in a bath or near water.
"The facts are now in front of the public and the concerns and allegations can be put to rest.
"The death of Shane is a tragic and regrettable accident.
"I hope this example will educate others to take all possible care."
