Two-month-old baby girl Sapphire died with an alcohol level in her tiny body which was more than six times the legal blood alcohol limit for an adult driver.
A report into the baby's death on January 2, 2017, in Ahipara, has been released today with Coroner Debra Bell stressing the importance that breastfeeding mothers should not consume alcohol at any stage.
A toxicology report presented to the Coroner showed the amount of alcohol found in blood from Sapphire's heart was 308 milligrams per 100 millilitres of blood.
Because the reading was so high another test was carried out to confirm the accuracy and it was found the readings were the same.
For comparison the legal blood alcohol limit for a New Zealand driver aged 20 years and over is 50 milligrams per 100 millilitres.
Sapphire Rose Moengaroa Williams and her twin sister, Honey, were delivered by caesarean at North Shore Hospital on November 4, 2016. They were pre-term born at 33 weeks gestation with low birth weights and related medical issues.
Mother Janice Tua has seven children aged between 6 years and 1, together with the twins.
At the time of the death Tua and the twins' father Joe Williams were staying in Ahipara with family. She told police they were homeless and were waiting to be assigned a home by Housing New Zealand.
Tua would feed Sapphire every three or four hours with formula and occasionally breast milk.
Sapphire was supposed to be taking iron and vitamin C medication. However, Tua had left that behind in Kaeo two weeks earlier and had not returned to collect it.
Tua said on New Year's Day 2017 she had not noticed anything unusual about Sapphire's behaviour. She placed the twins in a cot where they usually slept.
Tua went to bed with Williams and two children sharing the same bed.
About 1am on January 2 Sapphire woke crying and while Tua waited for a bottle of formula to cool she gave her some breast milk.
When Honey woke crying Tua placed Sapphire on the bed to tend to Honey.
On her return Tua noticed Sapphire had blood coming from her nose and was unresponsive.
Williams told police he was woken by Tua and when he saw Sapphire unresponsive he placed her on the floor and started CPR. His sister called the ambulance at 3am but Sapphire could not be revived.
Pathologist Dr Simon Stables carried out a post-mortem examination which revealed the high level of alcohol in Sapphire's heart and a lesser amount in her liver.
He said the alcohol findings were difficult to explain as no alcohol was found in the stomach.
However one of the possibilities for such high levels was due to Sapphire drinking breast milk.
While Stables was uncertain about the cause of death, contributing factors included acute alcohol intoxication, dangerous sleeping environment, prematurity, possible septicaemia, and suffocation.
After receiving the post mortem report Coroner Bell asked police to get statements from Tua and Williams, seeking an explanation as to how Sapphire's blood alcohol levels could be so high.
Tua said the day before her baby's death she had been at her cousin's house and had drunk a box - 18 cans - of premix Bourbon and Cola.
Tua herself concluded the alcohol in Sapphire's blood would most likely have come from breastfeeding.
Coroner Bell said while there were a number of significant conditions contributing to Sapphire's death as well as the acute alcohol intoxication the case also highlighted the risks of bed sharing.
Coroner Bell said she had to consider whether Sapphire's death could have been prevented.
"Unfortunately, her mother chose to drink a large quantity of alcohol and subsequently at a later stage chose to breastfeed her," Bell said.
"Ms Tua accepts the alcohol in Sapphire's blood must have come from her consumption of alcohol. Sapphire's mother's actions highlight what has been well documented; alcohol can pass to a child via breast milk."
Police attended and were satisfied that there were no untoward or suspicious circumstances surrounding the death.
A copy of the finding would be sent to the Ministry of Health and Change for our Children.
Auckland paediatrician Dr Alison Leversha said the case was "very unusual".
"I haven't, in my professional experience, ever seen a case of alcohol poisoning through breast milk," she said.
However, she said: "The main advice, if you are pregnant or breastfeeding, is not to consume alcohol because alcohol passes very freely into the baby and that has lifelong effects on brain development."
Children's Commissioner Judge Andrew Becroft said the case was "perplexing" because the cause of death was unclear.
"The case does, however, point to the need for much more research and clarity as to the effect of breastfeeding mothers consuming alcohol and any potential dangers to the baby," he said.
"It is an important issue. It is impossible for me to go further than this given the state of the science as recorded in this finding."
A spokeswoman for Oranga Tamariki said her ministry assisted the Coroner with her investigation but the Coroner "did not make any recommendations or comments in relation to Oranga Tamariki".
"Our role when we receive a report of concern includes making sure any child involved is safe from harm, and working closely with police and other agencies. Police are responsible for any criminal investigation," the spokeswoman said.
"In responding to cases where an allegation of child abuse or neglect is made, we follow the established procedures which apply to all notifications of actual or suspected child abuse or neglect."
• Avoid alcohol while breastfeeding, especially during the first month.
• If you do drink, it is safest to: (a) drink no more than one to two units of alcohol once or twice a week; and (b) avoid breastfeeding for two to three hours afterwards for each standard drink you have.
• A standard drink is a 284ml glass of beer, a 125ml glass of wine or 25ml of spirits (single measure).
Source: Health Navigator NZ.