A newborn's death could have been prevented if a pēpi-pod was delivered 24 hours earlier, a Coroner has found.
The death has led to a recommendation that funding is considered to give all mothers of newborn babies one of the safe sleeping pods at birth.
It's not the first time a coroner has recommended prioritising pēpi-pod use in infants, to stop parents from smothering their babies during co-sleeping, with as many as 12 recommendations dating back to 2008.
Coroners labelled the issue a "hidden epidemic" but a 2016 Weekend Herald investigation found a Ministry of Health contract to fund the bassinets was shelved, despite the death of about 50 babies a year from Sudden Unexpected Death in Infancy [Sudi].
In the latest tragedy, baby Eli Edwards-Te Rangi died in June last year in his mother's bed, the night before her midwife was supposed to bring a pēpi-pod for him to sleep in.
The mother woke in the night to find her 4-week-old baby face down and unresponsive.
Coroner Alexander Ho recommended the Ministry of Health consider automatically issuing all newborns with a pēpi-pod or wahakura, a woven flax bassinet, at birth.
"It is not sufficient that new parents are simply 'offered' such a device at birth," Coroner Ho said in his ruling on the baby's death.
"Many new mothers are tired and overwhelmed after giving birth. They do not want to make another decision.
"If there is a serious public health desire to reduce deaths of babies from Sudi, simple steps that will prevent deaths should be taken before they are needed."
Deputy Chief Coroner Anne Tutton said it was concerning that coroners continued to investigate deaths that may be preventable.
She endorsed the comments of former Chief Coroner, Judge Deborah Marshall, who said it was why coroners kept making the recommendations with the hope the message would get through.
"The evidence is quite clear of the dangers of co-sleeping without some protection for the baby," Marshall said in 2016.
"Babies are safest in a separate bassinet or cot, but if that was not possible, the pēpi-pod or wahakura was the 'next best option'."
Between September 2018 and June 2020, the number of Sudi-suspected deaths rose to 64.
In 2020, the Ministry commissioned research culminating in three reports released last month, to understand the reasons behind the number of babies dying from Sudi.
It found Māori babies were eight and a half times more likely to die from Sudi than non-Māori.
"The number of infants in New Zealand who die from Sudi each year is not declining and social inequities mean that the rate of Sudi is higher for babies who are Māori, or who live in areas of high deprivation," the Ministry's chief clinical adviser of child and youth health, Dr Tim Jellyman wrote.
In the tragic case of baby Eli, the birthing unit offered his mum a pēpi-pod but she declined, saying she already had a bassinet at home.
The coroner noted she was a smoker, and the midwife reminded her of the safe sleeping advice to prevent the risk of Sudi since baby Eli had been exposed to cigarette smoke during pregnancy.
Coroner Ho said the mother declined an antenatal referral to smoke-free services, but he was sympathetic to her decision to co-sleep with her baby.
"Motherhood is exhausting. I appreciate the circumstances in which a sleep-deprived mother, frequently woken during the night to breastfeed, might choose to have a baby in bed with her instead of placing him back in the bassinet."
New Zealand College of Midwives chief executive Alison Eddy said pēpi-pods needed to be available for anyone who wanted one, not only those who smoked during pregnancy.
"Pre-term birth and low birth weight are also risk factors. People seem to forget about this," Eddy said.
"Sudi is linked to health and social inequity and it is experienced more by those living in poverty.
"We need to address the root of the problem. This goes beyond us and the Ministry of Health. The whole sector and society need to be working on this to ensure all families with new babies have good housing."
Housing and poverty were among the issues identified in the Ministry of Health-commissioned reports released on May 31.
Other concerns were the need for engagement with whānau, smoking in pregnancy, infants who were sick and maternal mental health.
The need for a bicultural framework within a national Sudi prevention programme that recognised the significance and effectiveness of Māori leadership was recognised along with the need for culturally anchored programmes and safe sleep messages.
A Ministry of Health spokesperson told Open Justice any Sudi death was unacceptable but stopped short on the question of funding pēpi-pods for all newborns.
Instead, he said pēpi-pods could not be funded in isolation because they needed to be provided with appropriate safe sleep messaging for māmā and whānau.
This included stop-smoking programmes, of which there were 16 funded throughout the country.
The spokesperson said the Ministry was concerned at current rates of Sudi, and particularly the high rates for Māori and Pacific infants.
"We acknowledge current inequities are unacceptable and we are continuing to place considerable focus on the persistent rates of Sudi for Māori and how this might be better addressed into the future," he said.
He said funding from the Ministry, the National Sudi Prevention Service and Interim Health New Zealand, paid for the 8500 infant safe sleep beds provided to newborns each year since 2017.
"This will provide sleep-safe beds to 15 per cent of babies born each year nationally and is equivalent to the currently reported proportion of mothers who smoke during pregnancy."
The advice for safe sleeping continues to be avoiding all types of smoke, sleeping babies on their back, and on a flat surface with their faces clear.
Breastfeeding newborns was found to create stronger immune systems.