A Kaikoura three-year old's death has been blamed on systemic and individual failures, and treatment below expectations

Everly Anne Dunfoy died in the town's after-hours clinic in April 2019, after struggling to breathe.

Coroner Ruth Thomas says a review's found the rate of chest compressions was incorrect for the first half-hour of CPR, with thumbs used instead of the heel of one hand.

She says the review also found inadequacies in facility equipment, organisation and management -and made 19 recommendations.

Mother Pip, says she hope the recommendations prevent other children suffering the same fate.