A five-year-old girl riding a 50cc motorbike died when it revved and she panicked, crashing into a paddock fence.
Coroner Carla na Nagara said the death of Sarah MacDonald in Tapawera served as a very sad reminder of how quickly, and how tragically, things can go wrong for such young riders of motorbikes.
Sarah died on April 29, 2012 and the coroner has now released her findings that she died from serious neck and spinal injuries.
It was her first ride on the family's 50cc KTM motorbike, although she had previously ridden another 50cc motorbike and a 50cc quad bike, the coroner's report said.
Her mother said she could ride the bike, and Sarah got her safety gear including a well fitting helmet.
Her stepfather John took her outside and taught her about the bike.
After practising they went into a paddock and he described how she was ''just cruising and was slowing down on corners'' and he was proud that she was not getting carried away.
He said: ''She then went past me and I heard the bike throttle rev a couple of times. She looked at me with a big cheeky smile.''Then the throttle revved up to full noise, for some unknown reason. The bike never wobbled or shaked.
''Sarah appeared to be frozen on it. She rode straight into a nearby fence.''
The top wire of the fence appeared to catch Sarah across the neck and chest area, she and the motorbike completed a backwards flip around the wire before coming to rest on the opposite side of the fence.
She was declared deceased at the scene.
The coroner said it was entirely possible given her age and inexperience. She simply panicked, and lacked the maturity and presence of mind to respond appropriately to the situation she was in.
''There is nothing to suggest that there was a lack of care or oversight on the day the accident happened, but it is noted that these vehicles do pose significant risk to young riders when things go wrong,'' the coroner said.
Police who investigated the accident were satisfied that the circumstances were not suspicious and no charges were laid.
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