Three dogs that mauled a 90-year-old woman to death had escaped and attacked another person a week before, with the local council's initial response inadequate, a coroner has found.
Ada 'Sally' Holland died of her injuries after three dogs escaped a property and mauled her on Collingwood Beach about 200km south of Sydney on March 29, 2020.
The court was told in the week prior to Mrs Holland's death, the three dogs had previously been reported to Shoalhaven City Council after they escaped from the same property and attacked another person.
Coroner Carmel Forbes told the NSW Coroners Court the response to the attack that happened a week before the fatal mauling was "inadequate".
"It was a real missed opportunity by the council to prevent the attack a week later," she said on Friday.
"At the very least the council should've assured the dogs had been secured in the yard."
The owners of the three dogs had already been visited by rangers before the attack, for failing to register the three dogs.
Ms Forbes in her findings noted the council had implemented changes since Mrs Holland's death..
"Council has implemented a zero-tolerance policy of non-compliance of registration," Ms Forbes told the court.
The owners of the three dogs were fined only $10,000 for their negligence of failing to secure their dogs correctly on their property, which resulted in Mrs Holland's death.
Ms Forbes set out her recommendations to both the local council and the Office of Local Government aimed at preventing another vicious dog attack.
"Firstly to the chief executive of Shoalhaven City Council, the council review its procedures and training to rangers responding to reports of dogs who leave their yard or attack," Ms Forbes told the court.
It recommended that the council must design and implement a new training program for rangers who are attending to calls about dangerous dogs.
Ms Forbes recommended the Office of Local Government consider implementing a public awareness campaign about the dangers imposed by specific breeds of dogs.
In her recommendations, Ms Forbes also noted the lack of penalties imposed on owners who fail to secure their dogs who then go on to attack a member of the public.
"Office of Local Government needs to assess the adequacy of statutory conditions concerning maximum penalty," the court heard.
Third-born son of Mrs Holland, John Holland said while the coroner's recommendations were welcome, it would not bring his mother back.
"You just can't get it out of your system ... the tragic nature of the viciousness of it, the whole surroundings, the facts behind it, you just sort of say this happens on TV, it doesn't happen to your family," Mr Holland told AAP.
"When it's gone, it's gone."
