A coroner is warning parents to make sure cots are well-constructed after a 1-year-old girl died when she became trapped by loose cot railings.
Ashburton girl Liiana Ato Mamapomisa died in Christchurch Hospital's intensive care unit on her first birthday - March 26, 2012, after the accident at her home two days earlier.
Coroner Richard McElrea found Liiana had died of a global ischaemic brain injury as a result of positional asphyxia.
Her standard wooden cot was loosely assembled, and a gap had formed between the side rails on the frame and the mattress.
Liiana had partly fallen over the side of the mattress and through the gap in a standing position, her head remaining trapped against the mattress by the loose railings.