New Zealand Army medical officer Major Charmaine Tate gave further evidence on the effect of fatigue. The group had just completed the Tongariro Alpine Crossing and were returning to Rotorua when the crash happened.
In his findings, Dr Bain said while the Runge family raised a number of questions about duties, care and negligence, the court "cannot consider, assess, or make any conclusions about the allegations of negligence or breach of duties that were levelled at Mr Vogel, Ms Jeffree and the school".
Some of those concerns were that Mr Vogel knowingly drove in a fatigued state and that there was no sufficient fatigue awareness training in place.
"Put simply, it was clear Mr Vogel had undertaken a number of physical tasks in the days leading up to the accident. In addition, he was one of the teachers in charge and had a number of additional duties associated with that. As identified by Major Tate, it seems he may not have had sufficient time for himself to recover.
"Having said that, it's clear to the court that he was a devoted teacher and devoted to the students in doing everything possible to make their experience a most memorable one.
"It seems clear however he did not act on the symptoms within himself leading to the drowsiness that occurred."
In his recommendations, Dr Bain said organisations and drivers "in general need to look at their driving protocols to see whether they are sufficient in terms of fatigue or drowsiness".
"There is a need for extreme care and vigilance when there is a physical activity such as hiking reasonable distances for several days prior to a road trip, and proper procedures are in place to ensure the driver is properly monitored."
Dr Bain recommended his findings and the specific recommendations from Major Tate relating to driver fatigue be forwarded to the Ministry of Transport and the Ministry of Education to review and or establish specific policies for identifying and preventing driver fatigue.
As well as this, Dr Bain made the recommendation that as a requirement for outdoor education excursions, an observer in the vehicle is awake and observant at all times and trained in the signs of driver fatigue.
In a written statement to the Rotorua Daily Post, Noosa Pengari Steiner School principal Michael Layden said the school community had been deeply affected by the tragedy.
"An accidental death occurring in the course of an educational activity is a shocking and profoundly distressing event in the life of any school. The accident that occurred in New Zealand two years ago, taking the lives of a student and a teacher, both much-loved members of our community, has been so for Noosa Pengari Steiner School.
"Our priorities since have been to support all those in our care who have been affected and to seek out the causes and ensure that we do all in our power to ensure no such tragedy occurs again.
"We are in full agreement with the coroner's recommendation that education authorities give consideration to more specific guidelines, information and policies around the issue of potential driver fatigue, particularly with respect to outdoor education excursions.
"We acknowledge that the release of the coroner's findings reawakens profound hurt for the students, teachers and families involved. Two families have lost a son; one a husband and father, the other a young student with his life before him. The impact on the other passengers in the bus, and on their friends and colleagues in our wider school community, has also been profound."
Mr Layden said the school had since adopted a policy of engaging commercial bus companies to handle the transportation of outdoor education groups to and from locations where strenuous physical activity is required.
Ministry of Education Sector Enablement and Support head Kim Shannon said the ministry already provided recommendations to schools around planning for long journeys in its Education Outside the Classroom Guidelines.
"We recommend that schools give careful thought to planning their travel and have good transport policies in place, including that the number of driving hours and the length of the driver's working day [including non-driving hours] should comply with NZ Transport Agency regulations.
"Strategies should also be in place to avoid driver fatigue, for example, having more than one driver or planning stopping points on long journeys.
"We regularly review and update our guidance for schools, and we will consider the coroner's recommendations to see if anything further is required."
