The death of Tamara Cvetanova, who was speaking by cellphone to her husband as she lay crushed in the Canterbury Television building after the Christchurch earthquake, will haunt the Fire Service for a long time. Coroner Gordon Matenga's report on her death and those of seven others who were waiting to be rescued does not provide much comfort.
He concludes that it was never possible to rescue the eight, who survived the building's collapse, and finds the rescue teams, led by the "outstanding, courageous and selfless" Fire Service, were not to blame.
But he also reports that Fire Service executives "went missing in action". He could not understand why they did not take charge of the disaster area, set up an incident control room and see that resources and manpower went where they were needed.
Voice detectors and cutting equipment were in use on one side of the CTV building but not on the side where eight people were still alive. Alec Cvetanov, who spoke to his trapped wife six times and told searchers where she was, believes the equipment could have saved her life.
The coroner does not go that far. "More people, more resources, better communication and a better structure," he says, "may have improved the chances of saving more lives."