In both cases the mothers fell asleep while breastfeeding their babies in bed.
In the first case, Meleana Haukinima gave birth to twin boys at almost 30 weeks on November 14, 2009 at Auckland City Hospital.
Following eight weeks of neonatal care Mrs Haukinima, her husband, Stanley, and the twins were moved into a parent room - used to provide a place for parents to care for their children with assistance close by.
On the night the twins were moved into the facility, Mrs Haukinima woke to feed one twin, Pauliasi, but then fell asleep. She awoke two hours later to find Pauliasi not breathing.
At the time of Pauliasi's death Auckland City Hospital's neonatal unit did not have a written policy about bed-sharing, but information about safe sleeping practices was given to families in handouts and verbally "on many occasions".
"I am also satisfied that before the twins were transferred to the parent room no information was given to Mr and Mrs Haukinima about the expectation that bed-sharing should not occur in the parent room," Coroner Greig said.
There was no explicit policy for staff and no written material highlighting the issues of co-sleeping for parents, she found.
In a separate case, a 2-day-old girl and her mother were staying at Birthcare Auckland for postnatal care following the birth at Auckland City Hospital on January 31 last year.
On the second night the baby girl woke for a feed, so the mother, with the support of a nurse, fed her in bed.
The mother dozed while she fed, and the baby was moved back to her own bed by a nurse about two hours later. It was not until the morning that it was noticed the baby was not breathing, and she was pronounced dead.
Birthcare's breastfeeding policy, which was in place in February 2011, said that breastfeeding could be initiated with the mother sitting upright or lying. At the time of the baby's death Birthcare did not have a safe sleeping policy, but a safe sleep policy was implemented later in 2011.
Birthcare general manager Ann Hanson yesterday said staff at that time were reluctant to tell parents of the risks of bed-sharing in case it frightened them.
"It was a hard message to deliver, but now with our training, I think we've got that under our belts."
The coroner's findings into both deaths made a series of recommendations to the Ministry of Health, all District Health Boards, the Auckland District Health Board and Birthcare Auckland.
The Ministry of Health said recommendations made by the coroner were already "well advanced".
Auckland District Health Board's director of child health, Richard Aickin, said the hospital accepted all of the coroner's findings.
