A 3-month-old baby with her face buried in a pillow. A 5-week-old lying on his tummy with cannabis in his system. A 4-month-old trapped down the side of a couch with his sibling partially on top of him. A 9-month-old with its neck caught in the band of a sleep tent.
These are just some of the tragic sudden deaths in babies (SUDI) that have come before the Coroner's office this year, most of which have been attributed to an unsafe sleeping environment.
Despite the well-documented risks of co-sleeping, putting babies down on their tummies and dangers of smoking around infants, key safety messages are still not reaching some families - or if they are, they are being ignored.
More than 900 children under the age of one have died in New Zealand from SUDI since 2002, 56 of them in 2020.
The numbers had plateaued in recent years, after dropping from an annual high of about 250 in the 1980s, but appear to be starting to rise again.
Selah Hart, chief executive of Hāpai Te Hauora, which delivers the SUDI Prevention Co-ordination Service, said there is a concern about a potential increase in some areas with high deprivation, like South Auckland.
This year coroners have already held 15 SUDI inquests - most of which occurred between 2017 and 2020. Other cases from the past few years have either already been heard or are still going through the system.
"It absolutely breaks our hearts to see these numbers because they are absolutely preventable," said Hart.
"From an overarching perspective, as the national co-ordination service, we don't feel frustrated, we feel broken-hearted. For each of those individual cases I'm pretty sure many of the parents hadn't set out the night before to lose their baby the next day."
Many of the inquests heard this year have involved the deaths of babies in homes where drugs, alcohol or smoking were common or where safe sleeping alternatives were available, but not used.
One Auckland baby boy, aged just three weeks and five days, died while co-sleeping with his parents in December 2017, a decision that may well have been by the fact that his mother was heavily intoxicated.
"This was unusual as he had his own cot and bassinet. (His) parents were not sure why he was co-sleeping with them, and his mother had consumed three bottles of wine that evening," said Coroner Tania Tetitaha.
"The effects of alcohol upon a person's ability to make safe choices is well known. I can infer from the amount of alcohol consumed that this may have impaired a parent's judgement about where (he) should have been placed to safely sleep.
"His death may have been prevented if this child had been placed to sleep in his cot. "
In another case, this time involving a family that smoked, an 8-month-old baby with bronchiolitis was placed face down on his parents' bed with his head facing the wall. His father woke up three hours later to find him pale and attempts at CPR failed to revive him.
The baby's mother smoked during pregnancy and after his birth. His father and others in the house also smoked.
"A New Zealand study published in 2017 showed that infants of mothers who smoked during pregnancy were at a six-fold increased risk of Sudden Infant Death compared to infants of non-smokers. Bed-sharing increased the risk five-fold, and for infants exposed to both these risks there was a 32-fold increase," said Chief Coroner Judge Deborah Marshall in her decision.
Marshall said the family had been educated about the risks of cot death and the safe sleep philosophy - no bed sharing and being put on their back to sleep - and urged people to follow these guidelines to "make every sleep a safe sleep".
Hart said smoking was a big risk factor in SUDI cases and she believed more needed to be done to raise awareness about the risks of it and helping mothers to stop.
"We know Māori women are the highest category of smokers, so until that is addressed we will continue to see these cases come through as one of the two main risk factors associated with SUDI."
She said cultural practices, like co-sleeping with a baby, have been passed down from generation to generation so changing that behaviour was a challenge.
"Some cultural norms are coming into play. It doesn't matter how many pamphlets they get, they aren't going to change those practices."
The key, she said, was to find a way a safer way for parents to continue with those practices - such as using Pēpi Pods for those who want babies in their beds.
Hart said another dangerous cultural trend that was seen in some Asian families was the use of sleep tents that go over the bed the baby is sleeping in.
In June, Coroner Alexandra Cunninghame held an inquest into the death of a 9-month-old baby who became caught in a sleeping tent.
When his mother checked on him he was hanging off the side of the bed with his neck caught in the band that held the tent to the mattress. He couldn't be revived.
"Tragically, (he) died as a result of a sleep accessory being used with the best intentions by loving parents, who were unaware of the risks inherent in the use of such items for infants and young children."
Cunninghame found most sleep tents were purchased overseas, which would limit the impact of any voluntary product recall, and they weren't common enough to develop mandatory product safety standards.
Instead, she felt the best way to try and prevent further deaths was through education.
She ordered SUDI Prevention Co-ordination Service to pass on a copy of the findings to the organisations it works with in the maternal and child health sector, so that awareness about the risk of sleeping tents can be passed on to families.
Hart said poverty, damp overcrowded homes and addictions often played a role too, with families simply not having a safe space to put their babies to bed.
She believed New Zealand needed a funded National awareness campaign that raised societal awareness that could then be the foundation for community leaders to have conversations with families that don't pay attention to advice being given in more traditional formats.
"We know that those that have mana or trust in the community can penetrate better with having those hard conversations."
-Put baby to sleep on their back with their feet at the end of their cot or basinet so they can't wriggle down under the blankets. Make sure their face is clear of bedding and don't use a pillow.
-Make sure babies have their own safe space to sleep.
-If you choose to share your bed with your baby, keep them safe by putting them beside you in their own baby bed, like a Pēpi-pod.
-Don't smoke during pregnancy or in the home around a baby.