Her kaumātua then went to sleep on an air mattress in the lounge at around 10pm before Korowai-Aroha awoke at 2am and was bottle-fed before being put back to sleep on the chair.
However, at 7am the next day, March 21, Korowai-Aroha's aunt, who also lived on the property, entered the lounge and saw the dog asleep on top of her niece.
"The dog was pulled off Korowai-Aroha, who was unresponsive. Despite resuscitation
efforts, Korowai-Aroha could not be revived," Bates said.
Bates said coroners have made multiple recommendations in the past about safe sleeping practices for babies to ensure health workers provide consistent messages to parents.
"It is an important message because it is effective in preventing infant deaths," he said.
Although it is not clear that the safe sleep message was given to Korowai-Aroha's whānau, it is clear that Korowai-Aroha had only recently begun sleeping on a recliner chair at her kaumātua's home when she stayed, Bates said.
He called the baby girl's death a tragic reminder "that every sleep should be a safe sleep".
A Ministry of Health prevention programme launched in 2017 aimed at reducing the number of baby deaths had a key focus on two preventable causes, involving exposure to tobacco smoke during pregnancy and unsafe bed-sharing.
Korowai-Aroha's mum had "very responsibly stopped smoking immediately when she found out she was pregnant" and did not share her bed with her daughter, Bates said.
However, putting Korowai-Aroha to sleep on a chair known to be used by the family dog did represent a smothering risk akin to co-sleeping with a baby.
Despite that, Bates said he wished "to emphasise that Korowai-Aroha was clearly loved and well cared for by her whānau".
And as a result of work by previous coroners, he did not make any new recommendations.
