Sapphire Rose Moengaroa Williams and her twin sister, Honey, were delivered by caesarean to Janice Tua at North Shore Hospital on November 4, 2016. They were pre-term born at 33 weeks gestation with low birth weights and related medical issues.
At the time of the death, Tua and the twins' father Joe Williams were staying in Ahipara with family. She told police they were homeless and were waiting to be assigned a home by Housing New Zealand.
Chief executive of He Korowai Trust in Kaitaia Ricky Houghton said mums with alcohol addiction were unsupported.
"Breast feeding is always the best way to feed babies. Formula costs money and these families can't afford formula even if they wanted to stop drinking they can't because of their addictions so they are forced to breast feed.
Houghton said these families needed to come out of these overcrowded states homes for change to happen.
"You need to disconnect them from the money-machines and state dependence and back to their natural extended support groups," he said.
A toxicology report presented to the Coroner showed the amount of alcohol found in blood from Sapphire's heart was 308 milligrams per 100 millilitres of blood.
For comparison the legal blood alcohol limit for a New Zealand driver aged 20 years and over is 50 milligrams per 100 millilitres.
Pathologist Dr Simon Stables carried out a post-mortem examination which revealed the high level of alcohol in Sapphire's heart and a lesser amount in her liver.
He said the alcohol findings were difficult to explain as no alcohol was found in the stomach.
However, one of the possibilities for such high levels was due to Sapphire drinking breast milk.
While Stables was uncertain about the cause of death, contributing factors included acute alcohol intoxication, dangerous sleeping environment, prematurity, possible septicaemia, and suffocation.
After receiving the post mortem report, Coroner Bell asked police to get statements from Tua and Williams, seeking an explanation as to how Sapphire's blood alcohol levels could be so high.
Tua said the day before her baby's death she had been at her cousin's house and had drunk a box - 18 cans - of premix Bourbon and Cola.
Tua herself concluded the alcohol in Sapphire's blood would most likely have come from breastfeeding.
Coroner Bell said while there were a number of significant conditions contributing to Sapphire's death as well as the acute alcohol intoxication the case also highlighted the risks of bed sharing.
Coroner Bell said she had to consider whether Sapphire's death could have been prevented.
"Unfortunately, her mother chose to drink a large quantity of alcohol and subsequently at a later stage chose to breastfeed her," Bell said.
Breastfeeding advice:
• Avoid alcohol while breastfeeding, especially during the first month.
• If you do drink, it is safest to: (a) drink no more than one to two units of alcohol once or twice a week; and (b) avoid breastfeeding for two to three hours afterwards for each standard drink you have.
• A standard drink is a 300ml glass of beer, a 125ml glass of wine or 25ml of spirits (single measure).
Source: Health Navigator NZ.
