A coroner has urged parents to make sure they follow safe sleeping advice after the tragic death of a Christchurch baby from cot death.
The 3-month-old died in 2019 and her case was referred to the Coroner.
Her name - along with her parents' names - have been suppressed to protect their privacy.
Coroner David Robinson's made no specific recommendations but did endorse the Ministry of Health's safe sleeping guidelines in a bid to prevent future Sudden Unexpected Death in Infancy (Sudi) fatalities.
He was quick to say the inquest process for the baby girl was not about "blame".
"Rather, it is about reaching a full understanding of the cause and circumstances of a loved one's death," he said.
"That can provide comfort and understanding to immediate family and can also benefit the wider community if the case allows for recommendations to be made which may reduce the chances of further deaths in similar circumstances."
He said the infant died in her cot at her family home.
She had a viral infection - likely respiratory - at the time and although that was not a direct cause of death it may have complicated her breathing and contributed.
Robinson said her official cause of death was Sudi "in the context of an unsafe sleeping position".
"My finding was that [she] was placed on the cot to sleep on her front, on a pillow with her head to the side," he said.
The baby was 89 days old (12 weeks) when she died.
There were no major health issues leading up to her death.
"[She] was clearly doing well," said Robinson.
"[Her mother] told of her being active, loving bath time and tummy time - she was strong and was able to hold her head up."
The day before she died she became "a little unwell".
She was unsettled and was not her "normal self" but she fed well.
That night her mother said she anticipated having to take her to the hospital.
Soon after the baby fell asleep in her mother's arms.
In the early hours of the next morning her father placed her in her cot on top of the pillow - in the same position she had been lying on her mother.
He used a blanket to prop the baby on her side slightly to "keep her from being face down".
After a short time he returned to check on her and found she was not breathing and he yelled to his wife to call an ambulance.
While the distressed couple waited for help the father performed CPR on the baby, assisted over the phone by a 111 operator.
"Unfortunately, notwithstanding the best efforts of [the father] and emergency services staff [the baby] could not be revived," said Robinson.
He said the father's decision to place the baby on the pillow made sense to him but was not ideal.
"He was right to try and settle her in her own cot. As a dad with plenty of experience of sleepless nights with grizzly unwell babies, I can fully understand his well-intentioned attempt to settle [the baby], emulating her sleeping position on [her mother]," he said.
"What we have learned through studying sudden infant deaths is that the best position is always for baby to sleep in a cot… lying on their backs without pillows.
"I don't criticise [the father] - he was doing his best to settle his baby.
"If one positive could be taken from this case it would be that the circumstances allow a timely reminder to mums and dads of the importance of putting babies to sleep in their cots on their backs."
Robinson agreed to suppress the names of the baby's parents in the interests of "justice, privacy and decency".
He said they were traumatised and having their names made public would no doubt cause "ongoing distress".
He added that although the coronial jurisdiction was "intended to be therapeutic in nature" he also had a duty to the public around the safety of children so he allowed the media to publish his findings.
"There is a legitimate public interest in the wellbeing of our children, particularly where there are steps that can be taken to reduce the potential for adverse outcomes," he said.
"The circumstances of [the baby's] death could potentially promote awareness of safe sleeping practices."
Make every sleep a safe sleep - advice for parents
Full advice for all babies can be found at the Ministry of Health website
Information about the use of pepi pods is on the same website.
Sudden unexpected death is a risk to babies until they are about 12 months old, but most deaths can be prevented.
There are things that we can do to protect our babies.
Although for some babies the cause of death is never found, most deaths happen when the babies are sleeping in an unsafe way.
Always follow these safe-sleep routines for your baby and your baby's bed.
To keep your baby safe while sleeping, make sure:
• They always sleep on their back to keep their airways clear
• They are in their own bassinet, cot or other baby bed (eg, a pēpi-pod or wahakura) – away from adults or children who might accidentally suffocate them
• They are put back in their own bed after feeding – don't fall asleep with them (to protect your back, feed your baby in a chair rather than in your bed)
• They have someone looking after them who is alert to their needs and free from alcohol or drugs
• They have clothing and bedding that keep them at a comfortable temperature – one more layer of clothing than you would wear is enough; too many layers can make your baby hot and upset them
• They are in a room where the temperature is kept at 20C.
Baby's bed is safe when:
• It has a firm and flat mattress to keep your baby's airways open
• There are no gaps between the bed frame and the mattress that could trap or wedge your baby
• Nothing in the bed might cover your baby's face, lift their head or choke them – no pillows, toys, loose bedding, bumper pads or necklaces (including amber beads and "teething" necklaces)
Where to get help:
If you are worried about your or someone else's mental health, the best place to get help is your GP or local mental health provider. However, if you or someone else is in danger or endangering others, call police immediately on 111.
OR IF YOU NEED TO TALK TO SOMEONE ELSE:
• LIFELINE: 0800 543 354 or 09 5222 999 within Auckland (available 24/7)
• SUICIDE CRISIS HELPLINE: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• YOUTHLINE: 0800 376 633 ,free text 234 or email firstname.lastname@example.org or online chat.
• NEED TO TALK? Free call or text 1737 (available 24/7)
• KIDSLINE: 0800 543 754 (available 24/7)
• WHATSUP: 0800 942 8787 (1pm to 11pm)
• DEPRESSION HELPLINE: 0800 111 757
• SAMARITANS – 0800 726 666.