Sudden Unexpected Death in Infancy in New Zealand: A Review of Coronial Recommendations

Sudden Unexpected Death in Infancy (SUDI) remains a leading cause of post-neonatal mortality in Aotearoa New Zealand. We analysed New Zealand coronial findings and recommendations to identify recurring modifiable risks, social determinants of health, and system-level failures that might inform prevention strategies.

A structured thematic synthesis was conducted on 127 New Zealand coronial findings and recommendations released between 2012 and 2025. Data were abstracted on infant demographics, sleep environments, caregiver factors, socioeconomic determinants, and the nature of specific coronial recommendations.

Bed sharing was present in 81% (n = 103) of cases. Maternal smoking was documented in 34 cases. Deaths clustered in early infancy, with 50% occurring before 3 months of age. Social complexities, including overcrowding, damp housing, and financial hardship, contributed to the sleep environment in 60% of cases (n = 76). Coroners issued 22 distinct types of recommendations targeting systems-level rather than just individual change.

Findings show that sudden infant deaths are complex, with contributing factors operating at many levels and not simply due to parent's failure to follow prevention advice. SUDI prevention must shift from parental messaging to include multi-level interventions that address structural poverty, prioritised provision of in-bed sleepers, agency accountability, and mandatory workforce training.