A coroner is warning parents to make sure cots are well-constructed after a 1-year-old girl died when she became trapped by loose cot railings.
Ashburton girl Liiana Ato Mamapomisa died in Christchurch Hospital's intensive care unit on her first birthday - March 26, 2012, after the accident at her home two days earlier.
Coroner Richard McElrea found Liiana had died of a global ischaemic brain injury as a result of positional asphyxia.
Her standard wooden cot was loosely assembled, and a gap had formed between the side rails on the frame and the mattress.
Liiana had partly fallen over the side of the mattress and through the gap in a standing position, her head remaining trapped against the mattress by the loose railings.
Family members attempted to resuscitate her before paramedics arrived to rush her to hospital.
The decision was made to turn off life support two days later.
Coroner McElrea recommended parents follow the Ministry of Health's advice to keep babies safe by making sure cots had no gaps between the frame and mattress that could trap or wedge a baby.
Liiana had been put into her cot for a sleep about 9.10am on March 24, 2012, but her aunt found her pushed up against the railings sometime later.
Ashburton police examined the cot after they became aware of Liiana's death two days later, and found several parts of the frame were loose, the coroner's finding found.
Not all the bolts were fitted, and the dowels were not properly fitted into the woodwork at the top of the cot.
A detective noted that when tested, the cot rails could be pulled out easily.
Liiana's mother said in a statement the cot was "one of those normal ones like you would see in Farmers".
It had been taken apart and put back together when the family moved from Dunedin to Ashburton.
Liiana could not walk or talk and was not in danger of getting up and falling out, so her mother had kept the bars down.