The sleeping arrangements of a six-week-old infant were dangerous, but a coroner has been unable to pinpoint exactly what caused her death.
Coroner Garry Evans today released his findings into the death of Majesty Toki, who could not be revived after falling asleep while breastfeeding on her mother in their Porirua home last October.
Majesty's mother Tewinia Toki often breastfed the baby about 6am before the pair fell asleep on her bed for another two hours, Coroner Evans heard.
In the days before Majesty's death she developed a cough and was taken to her family doctor, but the doctor concluded she was well.
On the morning on October 25 Majesty woke about 4am or 5am and Ms Toki breastfed her for about half an hour.
Ms Toki fell asleep while Majesty was feeding but woke when she finished. She then latched Majesty back on to her breast before falling asleep again.
At 7.30am Ms Toki woke and let her sister into the house, with Majesty still in the position she had fallen asleep in.
The electric blanket was on and Majesty was wrapped in her own fleece blanket, with Ms Toki's own two duvets also covering her, Coroner Evans said.
Ms Toki woke and left the room again. When she returned five minutes she noticed Majesty was still in the same position.
Ms Toki picked her up and was unable to revive her.
A post-mortem examination by Jane Zuccollo found Majesty's cause of death was sudden and unexpected. Factors included possible thermal stress associated with flu, sleeping with an adult and having the electric blanket turned on, and mild dehydration.
"As stated by Dr Zuccollo this is a complex case," Coroner Evans found. "It is not possible to be exact in causal terms."
Coroner Evans said Majesty's sleeping environment was unsafe but noted she was well loved and very well cared for and her parents were not neglectful.
"They were simply unaware of the risks in the environment in which majesty was put down to sleep before she died."
Last week a coroner's report into the death of 10-week-old Rakaua Rawhira Rongen concluded that he died of sudden infant death syndrome while sharing his parents' bed last October.
Rakaua was put to sleep in his parents' bed, but was unable to be revived the next morning.
Coroner David Crerar recommended the Ministry of Health should "strengthen and broaden" advice around infant care practices and safe sleeping environments. He hoped publicity about the risks would help reduce similar deaths.
Coroner Evans did not make any specific recommendations in today's report.
In late August Chief Coroner Neil Maclean issued a report into sudden infant deaths and found there had been 163 cases in five years.
In another 30 cases a coroner found that babies died from asphyxiation while sleeping on their stomach or in bed with someone else.
