Isabella Diefenbach was seven weeks old when her father dropped her after his foot went though a piece of rotten wood in their rented home in Yeppoon, central Queensland.
Isabella suffered a fractured skull and died a few hours later in hospital in May 2010.
Coroner Annette Hennessy handed down her report into Isabella's death this morning, making 13 recommendations mainly in relation to the conduct and responsibilities of real-estate agencies.
She found Isabella's mother, Jennifer Diefenbach, had made numerous complaints to the real-estate agency about the rotting verandah, but because of miscommunications and no clear guidelines on how to deal with the complaint it was not fixed in time to prevent the baby's death.
Among Ms Hennessy's recommendations was that consideration be given to the creation of a peak real-estate body or association to provide guidelines, a code of practice and continued training of members.
All real-estate agents would be required to become a member of the association.
"[I recommend] that Office of Fair Trading and relevant residential rental industry stakeholders, including [the Real Estate Institute of Queensland], review the current property management training program with a view to incorporating a component that provides property managers with an appropriate level of guidance about how to conduct a satisfactory inspection of decks, verandas and stairs for property management purposes," she wrote.
Ms Hennessy also recommended mandatory inspections by independent builders of verandas and balconies older than 10 years in rental properties.
The coroner's report found Isabella's father, Adam Diefenbach, was holding Isabella in the moments leading up to her death when he noticed a piece of rotted wood and called his wife out to see it.
He lightly touched it with his foot and while his horrified wife watched on his foot went through the board and he was thrust forward, letting go of Isabella, who landed on the ground beneath the verandah.
"Ms Diefenbach immediately ran down the front stairs and saw Isabella lying on some concrete mosaic tiles near the bottom of the front steps," Ms Hennessy wrote.
"She recalls Isabella was lying with her head on the concrete with her legs on the bottom step.
"Isabella was not crying but was breathing and making gurgling sounds.
"She had a large lump on the right side of her head near her ear."
Mrs Diefenbach carried her daughter to the living room, lay her in the recovery position and called triple-0.
The baby was taken to Yeppoon Base Hospital and, after being stabilised, the decision was made to transfer her to Rockhampton Hospital. Isabella suffered a heart attack on her way to the hospital and was pronounced dead on arrival.
The autopsy found it was likely she hit her head on a step before landing on the ground.
Lawyer Gino Andrieri, from the law firm Maurice Blackburn, represented the Diefenbach family at the inquest and said they were "relieved" by the coroner's findings.
"The family welcome the findings, they always hoped throughout this process that lessons would be learnt from the tragedy," he said.
"With these findings, the family are genuinely hopeful, that if adopted a tragedy like this can never happen to another family."
Isabella's parents have since had another child, a son called Noah, and still live in the area.
In Ms Hennessy's report it was noted Mrs Diefenbach had reported the verandah needed repairing numerous times to O'Reilly's Real Estate and the sale of the house had been stopped twice when the potential buyer had pulled out because of building repairs that were needed.
The owner had hired a friend to do work on the house and, though he was a qualified carpenter, he was not licensed as he had never been a sub-contractor.
The coroner recommended O'Reilly's Real Estate change its practices to ensure termite and building inspection reports are read by the property manager and brought to the landlord's attention "in a timely fashion".
Ms Hennessy acknowledged if some or all of the practices she had recommended were in place, Isabella's death could have been prevented.