A coroner has reminded parents about safe sleeping arrangements for babies after describing the death of a Northland infant as "preventable".
According to the findings of Whangarei coroner Brandt Shortland, released today, the baby died as a result of unsafe sleeping conditions and was undernourished at the time.
The child was born about a month before his due date after a pregnancy complicated by poor antenatal care.
He had hypoglycemia and a cleft palate but was considered in good health when discharged from hospital.
At the time of his death, in September 2010, he was being cared for by his father at the baby's grandparents' home, where about 10 people were living. His mother was out of town.
The baby's father and grandmother gave different accounts of his death to the coroner.
His father said the four-month-old was in a crib at the end of his parents' double bed.
The crib was on an upturned crate to raise the height and a folded blanket lined the base with a thin foam mattress on top. There was also a loose sheet in the crib.
When the baby woke about 4.30am, he was given a bottle of warm formula, a nappy change and put back in his crib, the father said. There was no burping or winding.
The father said the next morning he found the ends of the blanket covering the baby's face and head.
"[The father] then recalls his actions as pulling back the blanket and finding [the baby] with his eyes closed and looking blue," Coroner Shortland said.
He picked up the baby and noticed milk-like vomit coming from the his mouth which spilled to the floor.
But during the police investigation, the baby's grandmother said she checked on the child when she got up for work about 4.45am and saw him sleeping in the double bed between his father and two-year-old brother.
The father maintained his mother was confused.
Relatives started CPR and mouth-to-mouth resuscitation, which was continued by ambulance paramedics to no avail.
Police described the room the baby was sleeping in as a "mess".
"There were items in relation to the children and their personal care all over the floor."
A post mortem examination concluded the direct cause of death was acute bronchopneumonia associated with unsafe sleeping conditions.
"The other significant finding from the post mortem confirmed [the baby] was undernourished with numerous bites on his extremities of which had been scarred over," Coroner Shortland said.
"This was an indication of a long-standing problem which had gone unattended."
Forensic pathologist Deborah Johnson concluded there was strong evidence the baby was sleeping in conditions different to those described by his father.
Coroner Shortland said irrespective whose version of events was correct, the baby was in an unsafe sleeping arrangement.
"In my view this was a preventable death and unfortunate in all the circumstances described."
He reiterated the principles of safe sleeping:
* Always ensure babies are in their own beds.
* Place babies on their backs and make sure they are appropriately wrapped.
* Ensure babies faces are clear from soft toys, blankets, sheets, clothes or anything that will compromise their ability to breathe.
* Place babies where they can't wriggle under blankets or become wedged between mattress and cot.
* Don't use pillows.
* Don't let babies sleep beside other people.