As many as 60 babies a year are dying from unsafe sleeping arrangements and there needs to be stronger public advice against parents sleeping with babies, says Rotorua coroner Wallace Bain.
He was commenting on the death of a two-month-old Tahi Elvis Edwards who died while sleeping in the back seat of a car with his drunk mother in January 2011.
Ngaire Tukiwaho, or Ngaire Edwards, was found guilty of manslaughter in the High Court in Rotorua in May and sentenced to two years and one month in jail.
Tahi was her fifth child and two years earlier another two month old son died of sudden infant death syndrome.
From that experience she knew that children were vulnerable and she had been advised of safe sleeping practices.
On the day before Tahi died, she drank heavily and told police that on a scale of 1-10, with 10 being heavily intoxicated, she was at 8 or 9.
After a fight with her partner she put her son in the back of the car with her as she thought the night was cold.
She fell asleep with the baby in her arms and when she woke he had slipped down with his face against her body and arm.
Tahi was likely to have died from accidental asphyxia.
When spoken to by police she accepted that she knew about sleeping risks and could not explain why she did not leave Tahi asleep in his pram or place in in the garage or carport.
She said she was generally not thinking straight at the time.
The High Court noted she accepted his death was entirely preventable.
The chilling facts of this case raised concerns about the previous loss of her son, advice on safe sleeping practices, the mother's continued use of alcohol and whether there was a level of dysfunction that Child Youth and Family were not aware of.
This was clearly a matter for Social Development Minister Paula Bennett who ordered an investigation into this case.
''In my view the message is simply not getting out there...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.
The vast majority are Maori and Pacific Island babies.
''This is an indictment on our society and needs to be corrected urgently.''
''It can be corrected very simply be education and on the ground assistance to families with new babies,'' the coroner said.
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