People left in charge of vulnerable infants were told to "exercise their duties responsibly" after an inquest for an Invercargill infant who died in 2010.
Southern region coroner David Crerar made the statement in his formal written findings into the death of Joseph James Batchelor-Smith, 9 months. He was found dead 17-18 hours after he was put to bed by his caregiver, Honey Samson, on September 25, 2010.
Pathologist Noelyn Hung attributed Joseph's death to an acute episode of septicaemia with an associated fever, compounded by the heat in the house.
The inquest put the spotlight on the possible role of heat pumps in contributing to infant deaths.
Mr Crerar said he was unable to state the death was caused by overheating because the temperature of a heat pump was too high.
But a high temperature in a living situation, particularly in a sleeping environment, was a risk factor in the deaths of vulnerable children, he said.
It was "of concern" Ms Samson did not check Joseph for up to 18 hours, Mr Crerar said.
"Whilst I have no evidence which could satisfy me that if baby Joseph had been checked on earlier in the night or in the morning by his caregiver, his distress, and probable high temperature, would have been noted and action ought to have been taken to address any such problem."
Mr Crerar recommended a copy of the findings be forwarded to the child and youth mortality review committee so the circumstances of Joseph's death could be used to prevent similar deaths.
- © Fairfax NZ News
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