The Department of Conservation has reviewed its hut warden training and improved visitor safety information on several routes in the Nelson Lakes after a woman died while tramping to Angelus Hut.
The coroner found Golden Bay woman Tracey Alison Smith died of hypothermia while on a tramping trip with her teenage son on Queen's Birthday weekend in 2019.
The pair encountered difficulties in adverse weather conditions while hiking up the Speargrass Track to Angelus Hut. They had nearly reached the Robert Ridge when Smith became hypothermic and unresponsive.
Her son was able to carry on to the hut but a search for Smith was not possible given the weather conditions. Her body was found in the Speargrass Valley by a rescue helicopter the next morning.
Coroner Meenal Duggal made a number of recommendations, including that trampers should carry a personal locator beacon when in the back country and not hesitate to activate it when a life was at risk.
The pair were not carrying a personal locator beacon. Trampers at the hut discussed activating theirs at the request of the hut warden once they were aware of the situation, but chose not to believing that Smith had already died and with concerns that initiating a search would unduly place search and rescue staff at risk given the inclement weather.
The volunteer hut warden did not realise the hut radio could be used to call emergency services. She radioed staff at Nelson Lakes the next morning at 8.45am when she realised a beacon had not been activated as suggested and police dispatched a helicopter to search for Smith.
A Mountain Safety Council (MSC) investigation raised questions about the training given to volunteer hut wardens.
A Department of Conservation investigation did not find any issues with its management practices that contributed to Smith's death and Nelson Lakes operations manager John Wotherspoon said it had since revised the hut warden training, including how to respond to an emergency.
"We have made some changes so that the wardens understand they're not making any decisions as to whether to activate a search - they need to let the police know, and then it's a police decision."
Wotherspoon said the training also ensured hut wardens understood the required response to an emergency. In an after-hours medical emergency the warden could use the road to make a phone call to 111 or activate their DOC-issued personal locator beacon.
Wardens were now trained in how to make 111 calls via the radio, as there was no cellphone reception at Angelus Hut.
The most popular back country site in Nelson Lakes National Park, Lake Angelus attracts a significant number of visitors each year.
"There's no there's no easy routes, it all involves a big climb and the Robert Ridge is the most popular route, but it's also the most exposed, you got five to six hours above the bushline, high winds, poor visibility any time of year."
Wotherspoon said it had become apparent over time that people wanting to tramp to Angelus Hut often didn't have the experience to do so.
"There's any number of beautiful pictures on Instagram and social media that makes it look like a place worth visiting but it's beyond the capability of some who go, they haven't got the skills, they haven't got the equipment, and they don't really understand how little they know, or how poorly prepared there might be for it."
More signs would be installed at the Robert Ridge carpark, encouraging people to check they have the correct gear for the journey, Wotherspoon said
A search and rescue officer found Smith's clothing was of reasonable quality but insufficient for the alpine environment.
There are now signs on all the routes into Angelus Hut that ask trampers specific questions, encouraging them to think about where they are on their journey.
"Are you tired? Are you cold? It's this much further to go, if you're not up for it at this point, it's only going to get harder, turn around now, here's another option."
Smith and her son had travelled to Nelson Lakes from Golden Bay in June 2019 and stayed at a lodge in St Arnaud where the manager said tramping to Angelus was not a safe option in the deteriorating weather conditions forecast for the following day that included -16C temperatures with 85km/h winds.
The pair decided to hike Paddy's Track and stay at Bushline Hut given the forecast, a plan Smith discussed with staff at the DOC Visitor Centre the following day.
But after arriving at the Mt Robert carpark on the Saturday morning, Smith saw a large group of people hiking to Angelus Hut and made an on-the-spot decision to do the same via the Speargrass Track.
The pair set off about 9.45am, stopped for lunch at Speargrass Hut at 1pm, and considered staying overnight there, but ultimately set off for Angelus on the climb up to Robert Ridge.
At that time, the weather was overcast, but not windy and the track was lightly sprinkled with snow.
Three quarters of the way up the ascent, Smith and her son became separated from the other trampers.
The snow was thigh deep for Smith and her son had noticed his mother had fallen behind, was taking small steps, experiencing leg cramps and repeatedly falling over.
By 5pm, the temperature had dropped further, the wind increased and the visibility limited to 200 metres.
The other trampers reached the hut around 6.15pm and told the volunteer hut warden two more trampers had been on the track behind them and appeared to be struggling.
The warden went to help a member of their group who was cold and dehydrated. She saw six people and assumed this included the two outstanding trampers.
Meanwhile at the top of the ridge, Smith's son realised his mother had hypothermia as she had icicles on her face, her skin was bleeding, she had stopped talking and was groaning.
He tried to warm her and help her in various ways including trying to lift her and by removing her pack, he attempted to feed her scroggin but his hands were too frozen to open the pack.
He realised he was in danger of hypothermia too and made the decision to carry on to the hut but his progress was slow and he became lost, circling back to where his mother was, where she was face down and not moving in the snow.
He set off again and could see the outline of Lake Angelus and decided to head straight for the lights, sliding over the snow. His legs were cramping and he was falling over and he resorted to crawling, reaching the hut at 11.15pm.
A helicopter was despatched the next morning to find Smith. After a brief search it located a red pack hooked onto a track pole and the outline of a person could be seen about 10m from the pole. She had a complete ice mask over her face and was confirmed dead.
A Mountain Safety Council report found Smith and her son had the experience, knowledge and equipment to hike to Angelus Hut in fine weather conditions.
As warning signs started to appear with Smith lagging behind, she did not make the key decision to stop and turn back to Speargrass Hut.
The MSC noted even experienced trampers can struggle to make the decision to turn around having already invested in the hike, and by the time Smith became hypothermic she had lost the cognitive function necessary to make such a decision.
MSC chief executive Mike Daisley said the tragedy highlighted how small independent decisions could compound into a series of errors, making the situation worse until it became catastrophic.
"[Smith's] tragic death is a very extreme example of how poor decisions can snowball and in the worst situations become life-threatening.
"If any one of those critical decisions had been different, [she] may have survived."
MSC had previously identified routes and tracks leading to Angelus Hut, particularly via Robert Ridge, in the Nelson Lakes National Park as a hotspot for tramping incidents in Aotearoa.
Between 2010 and 2019, one in 700 trampers heading to Angelus Hut have needed search and rescue assistance.
To improve safety along those tracks, Department of Conservation, police and MSC formed an independent advisory group to look at key safety issues, and developed a report with proposed solutions to better provide people with information to allow them to make informed decisions.