The coroner is asking for the urgent introduction of new regulations to stop roman blinds from strangling toddlers.
Coroner Mary-Anne Borrowdale's recommendations were in response to the accidental strangulation of a 19-month-old girl in 2018 after she became caught in the cord that held the blinds together.
Roman blinds, described as a "silent killer", had taken the lives of six toddlers in the past nine years - the coroner labelled each of those deaths "a completely avoidable tragedy".
Unlike Australia, Canada, the US and the EU, New Zealand had no safety regulations such as requiring loops to be smaller than a child's head.
In her findings, Borrowdale outlined the Ministry of Business, Innovation and Employment (MBIE) refusal to recommend to the minister of commerce and consumer affairs the need for a mandatory safety standard, opting instead for education.
The rationale used by its senior advisor for product safety, Brendan Noonan, was that there would remain a large number of blinds still in use.
"These tend to remain in use for decades and as such will present a long term risk that can only be mitigated by information that encourages the occupant to take the necessary action in relation to child proofing."
Borrowdale countered with evidence from Australia revealing that fatalities halved following the enactment of mandatory regulations there from 15 deaths in the 11 years before the standard was introduced to six in the following nine years.
She described as "regrettable" the fact no such standard had been introduced by MBIE here.
"I recommend that MBIE includes as a priority in its policy planning the goal that the Minister of Commerce and Consumer Affairs will declare prescriptive mandatory regulations or standards designed to protect young New Zealanders," she said.
She also called for the retrofitting or replacing of existing blinds to be made "low cost (or costless)" and warned against the use of any sort of Roman blind in a child's room.