The death of a Papamoa baby who died while sleeping between his parents was "100 per cent preventable", the coroner said.
Bay of Plenty coroner Wallace Bain held an inquest into the death of the 2-month-old baby in Tauranga yesterday.
Mr Bain heard the baby, who was born one-month premature, slept between his parents with his head resting on a tri-pillow every night.
Mount Maunganui police Constable Lorimer Naude told the coroner the couple set up a make-shift bed in the lounge last August. "This bed consisted of two mattresses side by side, a sheet covering the two mattresses, bedding, pillows and a tri-pillow," he said. "[The baby] was placed tummy-down on his bed. His arms up by his face, his head turned sideways facing to the left and resting on the tri-pillow."
His parents checked on him before going to sleep about 10.50pm and noticed he had turned on to his side. Some time during the night the baby's mother heard him grizzle and saw he was still in the same position, Mr Naude said.
"[His mother] awoke at around 4am to check [the baby] and found him face down in the tri-pillow.
She picked him up and found that he was cold."
As she tried to put more warm clothes on him she realised he was not breathing and decided to rush him to hospital, he said. The baby's father instead called an ambulance.
They performed CPR until the ambulance arrived but he could not be revived.
Pathologist Dr Fintan Garavan, who examined the baby, said that in his opinion the baby died of positional asphyxia.
In summarising the pathologist's comments Mr Naude said: "At less than three months of age, a child cannot support its own head with their underdeveloped neck muscles."
Mr Bain reserved his decision but pleaded with parents to avoid sharing a bed with their babies. "All of these deaths are 100 per cent preventable."