Two-year-old Darcy Atkinson was a stubborn and "charming little man" who liked lots of things, but not the water.
That his death was associated with the very thing he feared only added to the tragedy, says Deputy State Coroner Hugh Dillon.
Many "troubling" questions have been left unanswered surrounding the circumstances of the toddler's death after he suffered a brain injury while in the care of his mother's boyfriend, Adam Taylor, on NSW's Central Coast.
Darcy was being looked after by Mr Taylor on December 6, 2012 when triple zero received a call in which Mr Taylor said: "Oh, what have I done?"
Darcy died the next day in Sydney's Westmead Children's Hospital.
In handing down his findings on Friday, Mr Dillon said the inquest had heard four or five possible explanations as to how the boy had died.
One idea was he hit his head while paddle-boarding with Mr Taylor on the morning of December 6.
Another was he knocked his head later in the day while jumping into the pool with Mr Taylor and had then swallowed water.
Darcy also showed signs of minor injuries, which led to suspicions he had been mistreated.
"If Darcy was physically harmed, we don't know who it was or when it might have happened," Mr Dillon said.
"I don't believe (his mother) Tara-Rae Maxwell is responsible."
This "troubling and suspicious set of circumstances remains unresolved", he said.
Describing Mr Taylor as an "unimpressive witness", Mr Dillon said he may know how a bruise found at the back of the boy's head occurred.
The injury was a "confounding issue" that they are no closer to solving, Mr Dillon said.
"In one way or another, Adam Taylor has more of a story to tell about that," he said.
What the coroner did find was that Darcy had died from a brain injury after inhaling and ingesting water while in Mr Taylor's swimming pool.
Mr Taylor told the inquest Darcy had coughed and then vomited after he had jumped into the pool with the two-year-old and submerged him for less than a second.
The boy soon had trouble vocalising, became "rigid" in a bath and looked as though "he wasn't there", Mr Taylor said.
Darcy's mother Ms Maxwell said outside the court she felt as though Darcy had been "let down".
"I love Darcy and we miss him, and we will live with that for the rest of our lives," he said.
"He was just the most beautiful boy God put breath into."
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