The death of a 27-day-old baby was "unnecessary and preventable", a coroner has ruled.
Rotorua coroner Dr Wallace Bain released his findings today into the death of an infant who, due to suppression orders, can only be named as Baby X.
Baby X died on April 26 last year ata Rotorua address. The night before, the infant was fed and placed on the far side of a queen size bed, dressed in a onesie outfit. His sibling was later placed next to him and the mother slept between her two children before the father joined them in bed.
Throughout the night the child was rewrapped with his arms free and laid on his back, with the mother facing her baby. The following morning she woke and noticed the baby was pale, not breathing and cold to touch.
An ambulance was called and the father attempted to do CPR but the baby was confirmed dead by ambulance staff on arrival.
A postmortem found low levels of methamphetamine in his blood but not his liver and it was ruled this did not contribute significantly to his death. A scene examination was conducted and found the bedroom had a wall mounted heater turned on at a maximum setting.
The Coroner's report stated matters of deep concern were that the mother had been smoking methamphetamine during pregnancy, the father was smoking methamphetamine in the house the night the baby was put to bed and that two parents were sleeping in the bed with two young children.
"The death of Baby X in the circumstances explained is clearly a tragedy. It was unnecessary and preventable.
"It is disturbing to learn from the mother of Baby X that she was not aware of a number of safety factors that could have been applied to prevent this death, which in the Court's view is more likely than not, to be a result of unsafe sleeping arrangements," the Coroner stated.
Dr Bain recommended education be increased in respect of the benefits for safe sleeping environments for babies using the Whakahura and Pepe Pod infant beds.
