Mr Matenga conducted an inquest in 2012 into the deaths of the eight students who were known to be alive after the collapse of the CTV building in Madras Street at 12.51pm on February 22, 2011.

He found that Tamara Cvetanova, 42, Rika Hyuga, 30, Ezra Mealle, 24, Jessie Redoble, 24, Emmabelle Anoba, 26, Rhea Sumalpong, 25, Chang Lai, 27, and Mary Louise Amantillo, 23, died from crush injuries, the effects of fire or injuries suffered after the collapse.

He said five of the eight students were still alive on the eastern side of the collapsed building at least 12 hours after the quake.

The search and rescue effort at the site, which has been criticised for being unco-ordinated, leaderless and ill-equipped, had not contributed to the deaths, he said.

‘‘My view is the police, USAR [Urban Search and Rescue], firemen and members of the public were doing all they could in a difficult situation to effect rescues and save lives. The rescue efforts of those who worked at the CTV building were outstanding, courageous and selfless and a number of people were saved because of it.

‘‘More people, more resources, better communication and a better structure would, I am satisfied on the evidence, have improved the situation overall and may have improved the chances of saving more lives.’’

However, he was not satisfied ‘‘to the standard required’’ that such improvements would have resulted in locating and saving the lives of the eight students.

Mr Matenga found two main shortcomings in the performance of the Fire Service and USAR, which is made up of mostly firefighters who are specially trained to extricate people from collapsed buildings. The first was a failure by senior Fire Service staff to establish an overall incident controller and command post at the CTV site. The second was failures in getting USAR staff and their equipment to Christchurch.

Police, who were at the site first, should have made a clear handover to the Fire Service.

‘‘There was confusion amplified by dividing the site into two sectors ... The problems were further compounded once USAR arrived on the scene. Mr Berry [senior USAR officer] did not regard himself as being in charge of the NZFS while he was there, although others did,’’ he said.

Transport difficulties meant Auckland and Palmerston North USAR staff were not at disaster sites until about 12 hours after the quake, Mr Matenga said.

The equipment belonging to the Palmerston North USAR taskforce, who were assigned to the CTV building, did not arrive until 4am on February 23.

Rescuers working on the eastern side of the building were not aware a listening device and concrete cutter were being used on the western side. Core drills, which remove a cylinder of material, were unavailable and a concrete cutter was not used on the east side of the building until 9am the next day, he said.

Mr Matenga referred to expert evidence from a captain in the Los Angeles Fire Department, Ernesto Ojeda, who said correct tools and more people cutting more holes would have significantly increased the chance of finding survivors.

The coroner reserved his worst criticism for Fire Service executive officers: ‘‘It is difficult for me to understand why it was felt at the time that one or more of those 13 executive officers could not have been sent to the CTV site to set up a proper structure and provide support for those working there.’’

Fire Service chief executive and national controller Paul Baxter said the earthquake was recognised as one of the most ‘‘complex and challenging natural disasters for emergency responders in the world’’.

The Fire Service had acknowledged it needed to be ‘‘even better’’ prepared: ‘‘It is widely accepted that a natural disaster of this scale presented challenges beyond the training, experience and resources of the service, particularly given multiple sites.’’

New Zealand Prime Minister John Key said rescue services went "way beyond the call of duty" in trying to save the lives of the eight students trapped in the CTV building, but there were areas where improvement was needed, he said.

"I think everyone will go away now and say, 'what were the lessons learnt, what could we do in case there was a repeat of this sort of situation?'" he told TVNZ's Breakfast on Monday morning.

Fairfax NZ News