The death of a two-day-old girl has prompted hospital staff to change their care of mothers breast-feeding in bed, a coroner's inquest has heard.

The newborn, whose name is suppressed, was discovered lifeless in her bassinet by her mother last February at an Auckland postnatal unit.

A post-mortem examination showed she died of "possible accidental asphyxia during breast-feeding while lying in bed".

Speaking through tears at an inquest at Auckland District Court today, the baby's mother, who also has name suppression, described the pain of losing her daughter.


The baby girl was born on January 31, 2011 at Auckland City Hospital and about four hours later she and her mother were transferred to Auckland Birthcare, inquest officer Sergeant Heather Ruddell told the court.

Doctors who checked the baby found no health concerns, she said.

On the night of February 1, the mother began to feel unwell with a temperature, chills and trembling.

A nurse gave her blankets and a wheatbag to help keep her warm and helped to put the baby on the mother's breast to feed just after 1am.

The mother was very conscientious and she did not believe she would fall asleep while feeding the baby, the nurse told the court.

The nurse checked on her, and at 3.30am the mother called her back to the room to return the baby to her bassinet.

"She was pink and warm and I didn't notice anything that would cause me any concern," said the nurse, who has 40 years experience in postnatal care.

At 5.30am she carried out a routine check and used a torch to check the baby. Again, she noticed nothing of concern.

The mother told the court she had dozed between 1am and 3.30am "as I was breast-feeding and had had a restless sleep".

In the morning she took a shower and called her mother. When she went to pick up her baby at about 8.30am, she noticed her skin was darkened on her throat and called the nurse for help.

Staff found the baby mottled and lifeless and were unable to resuscitate her.

"It was obvious at that point that she was gone already and there was no chance to bring her back to life," said the mother.

The loss of her daughter was "an open wound" and it was difficult to discuss it again, she said.

When asked by Coroner Katherine Greig whether Birthcare staff had talked to her about bed sharing with her baby, she said "not that I can remember".

She was unsure whether she had received any information about the risks associated with it.

However, she knew about positioning when feeding, and making sure the baby could breathe and swallow safely.

Since the death of the two-day-old girl the nurse had changed her practice.

The nurse said there were practices that put mothers and babies close together in bed, such as to lift a baby's temperature.

She was more conscious about putting babies in beds with their mothers to feed and "I will really only do it as a last resort now", she said.

The nurse also now left information about sleep safe practices in babies' cots for new mothers.

A midwife who assisted the team that tried to resuscitate the baby, said she had also changed her practice since the newborn's death.

She was quicker to put babies back into their bassinets after feeding, and looked at babies more closely for signs of breathing during checks.

The general manger of Birthcare told the court that while mid-wives and nurses were now more vigilant in providing information to parents about the risks of bed sharing and breast-feeding, a national birthcare policy was needed to guide all health professionals and their patients through the information.

University of Auckland Faculty of Medicine professor Edward Mitchell also advocated for a national birthcare policy.

The child health expert told the court parents were currently unable to make an informed decision about bed sharing and breast feeding because they were not provided with the relevant information.

Prof Mitchell said people were being exposed to different messages about birthcare practises in New Zealand, making it difficult for parents and healthcare professionals to decide what to do.

"We have a situation in New Zealand where a message is not given [about breast-feeding and bed sharing] ... and then secondly, a contradictory message [is given] where there are groups saying if you want to breast-feed you have to bed share."

He said parents, in particular mothers, needed to be told there was little risk of breast-feeding and bed sharing if the mother was awake.

"My concern [is] in obstetric units at night time, when lights are low and the mother has gone through an exhausting labour.

"Then in that scenario, where the mother is likely to fall asleep, particularly if they are lying down ... the risk is particularly high."

Pathologist Dr Jane Zuccollo said the post-mortem examination revealed scarring on the baby's brain, possibly from reduced oxygen, and she had markings on the side of her body that indicated she had been in the same position for at least an hour before she died.