The deaths of three Wellington babies while sleeping beside adults has prompted yet another warning from the coroner.
Wellington coroner Garry Evans called on the Ministry of Health to strengthen guidelines on safe sleeping practices for newborns in May and again in August after investigating the sudden deaths of eight infants.
Another warning has now been issued by fellow Wellington coroner Ian Smith after findings were issued on three more deaths.
Hope Kuti was 10 weeks old and living with her family in Wainuiomata on September 19 last year.
Hope was one of four young children, but at the time of her death only one other - a three-year-old - remained at the house due to "an extensive need for Child, Youth and Family Service (CYFS) to become involved", Mr Smith said.
He said there had been issues with the parent's continual domestic violence and neglect and CYFS had not yet been informed of Hope's birth.
Her mother came home around midnight, going to bed an hour later having drunk upwards of 10 pre-mixed bourbon and colas.
The next morning she discovered Hope lying face down and not breathing.
The three-year-old had since been removed from the house and placed in the care of extended family, Mr Smith said.
A month later, in Cannons Creek, Porirua, Dante Tahuri-Uren died while sleeping on a couch beside his mother.
His mother admitted "spotting" cannabis oil and said they had stopped sleeping in her bed as she did not like the "vibes" upstairs.
They went to sleep at 8.30pm and the mother was woken around 11pm by Dante crying. She woke again at 12.30am and went to change Dante's nappy but Dante was no longer breathing.
On January 26, 2009, Summer Lamsam was less than three weeks-old, having been born prematurely, when put to bed with her parents in their Porirua home.
She had been sharing the queen-sized bed after refusing to settle in her cot.
When her mother awoke at 4.30am she saw Summer's father had moved and his back was on the child's face.
An ambulance was called but Summer could not be revived.
In all three deaths the subsequent coroners' investigations found the sleeping arrangements were unsafe and likely led to accidental asphyxia.
Mr Smith issued a letter to the Director General of Health, Stephen McKernan, urging that "the public health advice in relation to safe infant care practices and safe sleeping environments be strengthened and broadened".
He said it should be made clear that bed sharing by adults with infants under six months exposed the child to the risk of death and the safest place for babies to sleep during this period was in a cot beside the parental bed.
The coroners' warnings followed similar statements from child health experts in December.
Paediatrician Dawn Elder, who studied the last 10 years of unexplained baby deaths in the Wellington region, said work needed to be done on getting information to parents.
Auckland University professor of child health research Evan Mitchell said about half the cases of sudden infant death syndrome occurred in "bed sharing situations".
South Australian deputy Coroner Tony Schapel also voiced concerns last year, warning against bed sharing as well as placing infants on overly soft mattresses and the use of V-shaped pillows.