Kiwi parents are "unwittingly killing'' up to 60 babies each year, and government agencies are failing to prevent the needless deaths, a coroner warns.
Rotorua coroner Wallace Bain says critical messages about safe sleeping messages are still not getting through to parents and dozens of New Zealand babies are dying unnecessarily as a result.
Releasing his findings into the death of Rotorua baby Tahi Elvis Edwards, Dr Bain found the infant died as a result of accidental asphyxia due to an unsafe sleeping environment with his mother.
Dr Bain has hit out at government agencies for failing to educate parents and wants his findings forwarded to the Minister of Social Development to help prevent further deaths.
The baby's mother, Ngaire Kura Tukiwaho, who previously lost a child to SIDS, was jailed for the death of baby Tahi.
Dr Bain said Tahi, who was two months old, was sleeping cuddled into his mother's shoulder in the back seat of a car while she was heavily intoxicated on January 5, 2011. He slipped under her arm and suffocated. She was charged with manslaughter, pleaded guilty and was jailed for two years and one month in May last year. The Government ordered an investigation on the family.
Tukiwaho's three other children are in the care of Child Youth and Family.
Dr Bain said he has reviewed several findings in relation to unsafe sleeping practices.
"The chilling facts from a review of all these findings relating to baby deaths from unsafe sleeping practices, include co-sleeping or bed sharing, make sobering reading.''
Parents were "unwittingly killing'' their children, he said.
"This is a very very sad state of affairs and it seems to me, can only be rectified by education and on the ground assistance for mothers,'' he said.
"The court sadly has to repeat the chilling message that keeps coming out from these very sad inquests.''
All of these deaths were preventable, Dr Bain said.
"In my view the message is simply not getting out there to the level and extent it should. Babies in this country are dying unnecessarily. Latest figures suggest it could be as many as 55 to 60 babies dying each year from unsafe sleeping arrangements who might otherwise be alive.
"It can be corrected very simply by education and on the ground assistance to families with new babies. Whilst tragically it seems there will always be SUDI deaths with young babies, it is clear that if unsafe sleeping arrangements were eliminated then a very significant number of babies and young New Zealanders would survive.''
Dr Bain said it needed to be made clear to parents that bed-sharing by adults and siblings with infants under six months exposed the infant to the risk of death and should be avoided.
The safest place for babies to sleep for the first six months of life, was a cot next to the parents' bed.
"The court sadly refers to a number of detailed findings that this court has given in this region in terms of unsafe sleeping practices and entirely preventable deaths,'' he said.
"That steps be taken by the [Social Development] Ministry to ensure that the same advice is given by public health educators and health professionals in those public heath sectors over which the Ministry has influence.''
Dr Bain said he wanted his findings to be forwarded to the Minister of Social Development so further deaths were prevented.
"It is even more of a tragedy that we do not appear to be putting the necessary resources in place so that these preventable deaths are in fact prevented.''