A coroner has found “systemic and individual failures” and treatment that “collectively fell below the expected standard of care” led to the death of a Kaikōura toddler. The investigations revealed “systemic and individual failures” in Everly’s case, and treatment that “collectively fell below the expected standard of care”. On April 4 her mother took her to Kaikōura Health, the local after-hours clinic, as her cough had returned. Why did Everly Dunfoy die? He had also written a letter of apology to the Dunfoy family.