Coroner David Crerar was "not able to state unequivocally" that an Invercargill infant died as a result of overheating in 2010, but said it was a "risk factor" for premature deaths of vulnerable children.
Chesara Anna-Rose McMurdo, 18 months, was put to bed by her mother, Taryn Latchford, on September 28.
About 6.45am the next day, Ms Latchford found the toddler dead.
In his formal written findings, Mr Crerar said two infants had died in Invercargill within a week of each other, with the deaths having some similar circumstances. The homes of both children had heat pumps in operation when they died.
At the inquest, Constable Regan Price of Invercargill police said the temperature in Chesara's bedroom was "very warm - 20 to 25 degrees". The temperature panel on the heat pump remote read 28C.
Detective Sergeant Mark McCloy of Invercargill CIB said Chesara was dressed in pyjamas with a singlet and a nappy. She had been put to bed restrained by a sheet, folded and tied around the mattress in a strip about 15cm wide.
This was covered by a sheet, a blanket and a duvet.
Mr Crerar said that after the inquest in Invercargill, he obtained comments from Southland Hospital consultant paediatrician Dr Ian Shaw, who said "hyperthermia is a significant risk factor".
"Children are often able to cope with quite heavy wrapping if their head is free, as they have a very good ability to dissipate excess heat through their head. This could be compromised by a high ambient temperature, such as might have been present in the small bedroom," he said.
Mr Crerar said the community at large needed to know why babies died. "I hope and trust that the airing of the facts relating to the tragedy which has occurred to the family of baby Chesara will both comfort the family ... but significantly, that risk factors have been able to be identified and that the community will learn from these so that other babies may live."
In finding Chesara's death was "unexplained", he recommended a copy of the finding be forwarded to the Child Youth Mortality Review Committee so her death could be further explored, and publicity given to prevent deaths in similar circumstances.
- Otago Daily Times