A 10-month-old girl died of accidental suffocation in Nelson after she became stuck in the side of a portacot, a coroner has found.
The infant, who can only be identified as "baby D" because of a suppression order imposed by coroner CJ Devonport, died on December 16, 2014.
She was placed in a portacot by her mother about 7.30pm and when her father checked on her an hour later she was "limp and purple, unresponsive and with her eyes fixed".
Her parents began CPR and an ambulance was called, but baby D was unable to be revived and she was declared dead at the Nelson Hospital emergency department, the report said.
"Baby D's death appears to have been the result of becoming wedged between the soft mesh side of a portacot and a thicker mattress than was supplied with the portacot.
"It is important that babies are put to sleep face up, face clear, and while this occurred when baby D was put to sleep in the portacot, she appears to have removed the loose-fitting wrap and rolled between the soft mesh on the side of the portacot and thick mattress, with her face into the side of the thick mattress.
"Baby D's tragic death highlights the importance of ensuring that the possibilities of accidental asphyxia are eliminated, including that baby sleeps on a thin, firm mattress."
The facts in the report stated that the baby's cot was purchased on Trade Me and in good condition, although the extra mattress was added to the firm base and thin cot mattress.
She was wrapped loosely in a cloth by her mother, and put to sleep on her back with no blanket because of a hot temperature that night.