Rotorua coroner Dr Wallace Bain wants the findings into the death of Rotorua baby Tahi Elvis Edwards to be forwarded to the Minister of Social development to prevent further deaths.
Dr Bain says babies in New Zealand are dying unnecessarily because the message about not sleeping with babies is not getting through.
Dr Bain released his findings into the death of Rotorua baby Tahi Elvis Edwards, who Dr Bain said died as a result of accidental asphyxia due to an unsafe sleeping environment.
The baby's mother, Ngaire Kura Tukiwaho, who previously lost a child to SIDS, was jailed for the death of her baby.
Dr Bain said Tahi, who was two months old, was sleeping cuddled into his mother's shoulder in the back seat of a car while she was heavily intoxicated on January 5, 2011.
He slipped under her arm and suffocated. She was charged with manslaughter, pleading guilty and was jailed for two years and one month jail in May last year. The Government ordered an investigation on the family.
Tukiwaho's three other children are in the care of Child Youth and Family.
Dr Bain said he has reviewed several findings in relation to unsafe sleeping practices.
"The chilling facts from a review of all these findings relating to baby deaths from unsafe sleeping practices, include co-sleeping or bed sharing, making sobering reading".
He said parents were "unwittingly killing" their children.
"This is a very very sad state of affairs and it seems to me, can only be rectified by education and on the ground assistance for mothers," he said.
"The court sadly has to repeat the chilling message that keeps coming out from these very sad inquests."
He said all of these deaths were preventable.
"In my view the message is simply not getting out there to the level and extent it should. Babies in this country are dying unnecessarily. Latest figures suggest it could be as many as 55 to 60 babies dying each year from unsafe sleeping arrangements who might otherwise be alive.
"It can be corrected very simply by education and on the ground assistance to families with new babies. Whilst tragically it seems there will always be SUDI deaths with young babies, it is clear that if unsafe sleeping arrangements were eliminated then a very significant number of babies and young New Zealanders would survive."
Dr Bain said it needed to be made clear to parents that bed-sharing by adults and siblings with infants under six months exposed the infant to the risk of death and should be avoided. He said the safest place for babies to sleep for the first six months of life, was a cot next to the parents' bed.
"The court sadly refers to a number of detailed findings that this court has given in this region in terms of unsafe sleeping practices and entirely preventable death," he said.
"That steps be taken by the Ministry to ensure that the same advice is given by public health educators and health professionals in those public heath sectors over which the Ministry has influence."
Dr Bain said he wanted his findings to be forwarded to the Minister of Social Development so further deaths were prevented.
"It is even more of a tragedy that we do not appear to be putting the necessary resources in place so that these preventable deaths are in face prevented."