Victoria’s State Coroner has recommended a review of child car restraint system standards following an investigation into the death of a 22-month-old boy in Kyneton in 2015.

Judge Sara Hinchey concluded Noah Zunde died from heat stroke after being inadvertently left in his car seat by his mother, Romy Zunde, on February 19, and conveyed her “sincerest sympathy” to the child’s family and loved ones.

“I accept Romy’s evidence that she did not deliberately leave Noah in the vehicle on the day he died,” she wrote.

Judge Hinchey recommended Standards Australia review its regulations for the purpose of determining “whether the introduction of hard-wired safety features in a child restraint will deliver an overall benefit to the Australian community”.

“If it is concluded that the review would deliver an overall benefit to the Australian community, that Standards Australia take such steps as are necessary to modify AS/NZS 1754 ‘Child restraint systems for use in motor vehicles’ and any other relevant standard to ensure that hard wired safety features are introduced where appropriate,” she wrote.

The recommendation was informed by evidence presented to the inquest by Monash University memory expert, Matthew Mundy, the only witness called to give evidence in person.

Among five factors associate professor Mundy identified as contributing to Ms Zunde accidentally leaving Noah in the car, was what he called the lack of external “cues” to alert the mother to her son’s presence.

Associate professor Mundy testified that “anything that assisted a person by creating cues or reminders that a child remains within a motor vehicle, would be very helpful”.

“In particular, associate professor Mundy clearly preferred products or engineering controls that did not overload or add to the stressors being experienced by that person,” Judge Hinchey wrote.

“Therefore, he preferred those interventions that were ‘hard-wired’ into the motor vehicle or child restraint, as each of these products were designed to provide an audio or text reminder (or cue) that a child remained in the motor vehicle.”

There are no current proposals to regulate or mandate rear seat reminders for vehicles, either in Australia or internationally.

Judge Hinchey also acknowledged the “difficult role” of first responders to the incident, singling out Bendigo sergeant Mark Bell for his “extraordinary empathy” on the day.

“I commend their respectful and professional responses to Noah’s death,” she wrote.

“In particular, I commend the actions of sergeant Mark Bell, who spent approximately six hours with Romy and Noah’s body prior to the homicide squad attending and professionally demonstrated extraordinary empathy during this time, while still discharging his duties as a police officer.”

Ambulance Victoria statistics reveal that in 2016, emergency services responded to 1907 requests for assistance related to a child being left in a vehicle.

Of those 1907 requests, 28 requests resulted in the child being transported by ambulance for medical treatment.

“Associate professor Mundy’s evidence is clear that when a person’s short term memory is compromised, it is possible that the tragic events involving Noah’s death could happen to anyone,” Judge Hinchey wrote.

“Noah’s tragic death was however, clearly preventable and therefore I consider it important to make a number [of] recommendations to ensure that no other children die in similar circumstances.

“I accept associate professor Mundy’s evidence that engineering controls are the best option to ensure that a child sitting quietly in their child restraint, is not forgotten by their parent or carer.”