The inquest into last year's Tathra Wharf tragedy was a short affair, but the recommendations from it could be far-reaching.
Magistrate Chris Bone recommended Shane O'Neill be given a posthumous award for bravery and that Robert Brown, who jumped into the sea to help, should also receive a bravery award.
Mr Bone also said a list of other recommendations concerning the safety measure at Tathra Wharf be considered by Bega Valley Shire Council.
Held yesterday morning in Bega Courthouse, the inquest was conducted into the deaths of Shane O'Neill, 28, and his sons Riley, 4, and Travis, 15 months, who fell from the wharf during a fishing trip at Tathra last November.
It began with the officer in charge of the investigation, Detective Inspector Kevin Coady of Bega police, informing the court he had delivered all the relevant documents, after which Mr Bone said he had no questions for the officer.
Sitting and listening to proceedings were Mr O'Neill's parents Linda and Phillip O'Neill, as well as Mr O'Neill's partner and mother of their two children, Stacey Lambert, and her parents.
Mr Bone delivered his formal finding in a one line statement: "Shane Anthony O'Neill, Riley James O'Neill and Travis Anthony O'Neill died from drowning at Tathra on November 18, 2008."
Mr Bone gave a summary of the circumstances on that night and said that when Mr O'Neill caught a fish, one of the boys - probably the older boy - became very excited and in his excitement he and the pram fell into the water.
Mr O'Neill then jumped in to try and save the boys and because of the conditions all of them were washed under the wharf and probably came into contact with the pylons, Mr Bone said.
One of the people on the wharf that night was Robert Brown, who later said in his statement to police he saw the pram tip backwards and fall over the edge of the wharf into the water.
Mr Brown said he could hear Mr O'Neill's cries for help and when another person on the wharf said he couldn't go in because he couldn't swim, Mr Brown stripped down to his underwear and jumped in.
Tathra Surf Life Saving Club members Scott Meaker and Tony Rettke, who were in a meeting at the surf club when they received a message for help, were also praised by Mr Bone. They grabbed a rescue tube each and raced to the wharf where they jumped into the water in an attempt "to do what they could", he said.
Mr O'Neill, Mr Bone said, had done what every parent hoped they would be able to do in such circumstances.
"I suppose that all of us who are parents hope that if our children fell into danger that we would do everything we could to help them ... but when it came to the crunch none of us really know exactly what we would do," he said.
"What we know in this case is Shane O'Neill acted absolutely immediately, he acted without any thought whatsoever for his own welfare and he jumped into the ocean trying to rescue his two sons. He did everything that we hope as parents we would do in the same circumstances, which I think many of us would not be able to do for one reason or another."
Mr Bone also praised the effort of Mr Brown.
"He did exactly what Mr O'Neill did," he said. "He must have known when he jumped into the water that there was a chance that he wouldn't be coming out."
Lastly, Mr Bone spoke about the wharf, owned by the Crown but maintained by Bega council.
He recommended that statements and letters from the police in charge of the investigation, and from Surf Life Saving NSW and Mr O'Neill's parents, be sent to the council "to minimise the potential of another tragedy".
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