Circumstances surrounding the death of a 15-year-old Whakatane boy who died when shot while duck shooting with friends, are truly tragic, says Bay of Plenty Coroner Wallace Bain.

Jamie Ross Johnson was shot in the head by his own gun while sitting in a maimai off Grieg Road, near Matata, on May 10, 2015.

'This is a death that should not have happened and could have been avoided,” says Wallace in a report released this week.

'The police rightly point out that there is a requirement of supervision and this is a nation of outdoorsmen with a high percentage of new Zealanders carrying firearms.

'The main issue here is that firearms were provided to the boys and the use of them was facilitated and there was no proper supervision.”

On the morning of Jamie's death, duck shooting was slow. The sky was clear and ducks were flying high. Only one had been shot.

Jamie and three other boys were sitting in and around the maimai when a shotgun blast sounded, and they saw Jamie fall off a chair, Wallace's report states.

Police say Jamie's gun was resting against the left side of his face where he had slumped down and the safety mechanism was not engaged. No other person or weapon was responsible for the injury.

Police report all three boys had experience with firearms and were aware of firearm safety. The guns were in good condition and there was no evidence of any consumption of alcohol or drugs.

Jamie was well equipped for the weather conditions and the swamp environment. There were no other factors and no relevant health issues.

One of the fathers was an adult supervisor of the boys. He was charged with criminal nuisance for failing to discharge a legal duty by permitting under aged persons to be in charge of a firearm.

That resulted from a breach of the legal duty in providing unlicensed firearms holders with firearms knowing that the firearms were dangerous weapons.

'The police maintain this should not have happened and the boys should have been accompanied. The Court agrees with the police,” says Wallace.

'Further this court is of the view that licenced adults in charge of minors using firearms have a far greater duty of care in regards to the immediate and active supervision of unlicensed minors. It's very dangerous to let even a single unlicensed minor be unsupervised around firearms.

'It's imperative that adults are present to model the correct safety procedures by their immediate and active supervision of unlicensed minors - adults need to be with minors to supervise every move, every minute every time firearms are used. Young lives are very precious and constant supervision is needed.”

The court established that all parents knew what the boys were doing but it seems there was some dispute about that, says the Coroner.

The coroner notes the findings coincide with the shooting season for both deer and ducks. He incorporated other coronial findings on deer stalking deaths and in the hope that hunters become more aware of the safety issues surrounding hunting.

The recommendations also one that the Law Commission urgently investigate appropriate charges for hunting accidents with a view to making the offence one of strict liability.

Seven firearms safety rules

Treat every firearm as loaded

Always point firearms in a safe direction

Load a firearm only when ready to fire

Identify your target beyond all doubt

Check you firing zone

Store firearms and ammunition safely

Avoid alcohol and drugs when handling firearms