The family of a 1-year-old girl who died when she became trapped by loose cot railings are angry they are being blamed.
Liiana Ato Mamapomisa died in Christchurch Hospital on her first birthday, March 26 last year, after the accident at her home two days earlier.
Coroner Richard McElrea found she died of a global ischaemic brain injury as a result of positional asphyxia.
Liiana's standard wooden cot was loosely assembled and she had fallen into a gap between the side rails and the mattress, with her head trapped against the mattress.
Ashburton police examined the cot and found that several parts of the frame were loose. Not all the bolts were fitted, and the dowels were not properly fitted into the woodwork at the top of the cot.
Mr McElrea recommended parents follow Ministry of Health advice by making sure cots had no gaps between the frame and mattress that could trap or wedge a baby.
"The infant was in an unsafe sleeping environment due to the looseness of the assembly of the cot," he concluded. "This has directly resulted in the infant's death."
Liiana's aunt Krystle McIntosh said the coroner's findings had come as a complete surprise. "It's terrible ... You feel like you're just getting through it and then - boom. I'm very angry, but I can't do much about it."
The cot was second-hand, and no one had thought about the danger it posed, Ms McIntosh said.
"I personally think that cots should be made illegal. I guess it has to happen to you to think things like that, but keep an eye out."
Parents needed to watch out for seemingly harmless things, she said.
Sudden Infant Death Syndrome NZ chief executive Margret Free said deaths from badly constructed cots were rare.