Coroner finds small acts combined caused tramping fatality

17th August 2022|2min
Media Release | Embargoed until 5am on August 17 

A coroner has found that Tākaka woman Tracey Smith tragically passed away from hypothermia while tramping with her son in Nelson Lakes National Park, on Queens Birthday weekend in 2019. 

The recommendations adopted by Coroner Meenal Duggal highlight many common factors trampers face, says the NZ Mountain Safety Council (MSC). 

MSC provided a report to support the coronial investigation, this included identifying contributing factors specific to her death and provided recommendations to prevent future similar tragedies.

The report highlighted critical decisions including the choice to proceed to Angelus Hut, and not turning back once conditions became impassable. The severe weather including low temperatures, deep snow and poor visibility made things more difficult. Compounding factors were the lack of quality food and rest, and the cotton clothing she was wearing directly on her legs. 

MSC Chief Executive Mike Daisley says unfortunately this tragedy highlights how small seemingly independent decisions can often compound into a series of errors, each making the situation worse until they become fatal.  

“Tracey’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, Tracey may have survived.  

“It’s often easy to underestimate the importance of seemingly small decisions. There are lots of little things that can be easily overlooked, and when combined, each of these compound the seriousness of the situation,” Daisley says.  

The coroner noted MSC’s mention of two heuristic traps; social proof and scarcity, which influenced Smith's decision making. These are two serious yet common traps for trampers. Social proof is the tendency to think a situation is safe because others are doing it, while scarcity refers to taking the risk due to a lack of opportunity, such as time or weather window.    

Coroner Meenal Duggal endorsed the NZ Mountain Safety Council’s recommendations, as follows: 

  1. Act on advice given by trusted sources such as DOC visitor centre staff;  
  2. Always carry an emergency communications device, whenever heading into the backcountry or outside of reliable cell phone coverage.  
  3. Consider the experience and fitness levels of all members of your group and anticipate how the terrain may change in different weather conditions. Allow enough time to complete your trip in daylight hours and have alternative plans in case it takes longer, or conditions change.  
  4. Allow enough time to take regular rest breaks to eat and hydrate, particular in cold and wet conditions. If this is not possible, plan for refuelling or turning back.  
  5. Be prepared to make early and conservative decisions to stop and turn back, especially when encountering terrain and weather conditions beyond your experience and fitness.  
  6. Do not wear cotton layers as they draw heat away from the body when wet.  
  7. Always carry some form of emergency shelter, such as a tent fly, tarpaulin or bivvy bag on all tramping trips, even in summer.  
  8. Learn to identify the signs of hypothermia and act quickly to get warm again. 

The Coroner also endorsed that trampers who are in possession of an emergency communication device should not hesitate to activate it when a person’s life is or may be at risk. The relevant emergency response authority will make appropriate risk assessments and respond accordingly. 
The MSC extends its sincere condolences to Tracey Smith’s son, family and friends, and the trampers at Angelus Hut at the time of the incident. 

pdf Coronial Findings: Tracey Smith pdf – 175 KB


Prevention work - NZ Mountain Safety Council: 

MSC have long identified the routes and tracks leading to Angelus Hut, notably via Robert Ridge, in the Nelson Lakes National Park as a hotspot for tramping incidents in Aotearoa. MSC insights show an incident rate of approximately 1 in 700 trampers requiring search and rescue (SAR) assistance between 2010-2019.  

To improve safety along those tracks, Department of Conservation (DOC), NZ Police and MSC formed an independent Issue Specific Advisory Group to look at the key safety issues, and developed a report with proposed solutions that could be taken to better provide people with information that will allow them to make informed decisions. The report analysed Smith’s death, and other tramping incidents.  
Two of the six proposed solutions have been completed, and the other four will lead to shared projects between MSC and DOC. 

We encourage you to continue gaining the skills and knowledge required for a safe trip.  

  • Download the Plan My Walk app: experienced and beginner trampers can find the right track for their abilities, check for any track alerts issued by DOC and MetService weather warnings, and a suggested gear list which can be sent to group members and emergency contacts. 

MSC has many free resources and information to support basic skills and knowledge.  

Additionally, check out its range of helpful videos available. 

Contact Communications Advisor Rebekah Wilson at with any other queries, data or photos.

Header photo: Angelus Hut in winter conditions | Loic Lassueur