"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.