Public health advice about safe infant care practices and safe sleeping environments must continue, the Otago-Southland coroner says.
Coroner David Crerar, in his formal findings, recommends that the director-general of health continue with public health advice following the death of a 2-month old Invercargill baby.
Rakaua Rawhira Rongen died of sudden infant cot death syndrome while sharing a bed with his parents in Invercargill on October 15.
There was no evidence to suggest Rakaua's death was caused by bed-sharing.
Mr Crerar said Rakaua was being looked after by his father Jorg on the evening of October 14.
He woke unsettled about 3am and Mr Rongen laid him in the bed on his back between himself and the baby's mother, he said.
About 7.45 the next morning it was discovered Rakaua was not breathing, Mr Crerar said.
Queensland state coroner Mark Johns said the risk of sudden unexplained death in infancy was greatly increased when a child slept in the same bed with one or more parents or other adults.
Mr Crerar recommended the Ministry of Health strengthen and broaden its public health advice in relation to safe infant care practices and safe sleeping environments.
This included bed-sharing by adults and siblings with infants under the age of six months, which exposed infants to an increased risk of death, and advice saying the safest place for babies to sleep during their first six months is in a cot beside the parental bed. The Moe Ora scheme to provide newborn infants with a self-contained sleeping cradle should also be encouraged, the coroner said.
The Ministry of Health should consider providing such a cradle to every new mother if she is unable to afford the purchase, he added.
"Steps should be taken by the Ministry of Health to ensure that this advice is given by public health educators and health professionals in those public health sectors over which the ministry have influence."
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