Northern Territory Coroner Elisabeth Armitage examined the deaths of children who were referred to as Baby B, Baby K, and Baby S, delivering her findings in Darwin on Thursday.Â
"Each baby was young and small and the environment in which they co-slept was risky and likely caused their deaths," she found, noting the dangers posed by soft blankets, as well as alcohol and drug intoxication.
Judge Armitage said the cases were only three among many such baby deaths across Australia, listing nine other cases in the NT alone.
"These were all tragic and potentially avoidable deaths. These were loved babies who left behind devastated families."
From 2017 to 2024, the judge said co-sleeping was found to be a factor in about 40 per cent of infant deaths, the majority of them Aboriginal.
She said co-sleeping on mattresses continues considered to be the norm in Aboriginal communities.
Expert evidence to the inquest suggested "minky", or ultra soft blankets, and intoxication by alcohol or drugs were "perilous for infants" co-sleeping.
Sleeping conditions that increased the risk of suffocation included beds with soft surfaces such as compressible mattresses, bean bags, sofas and pillows, the inquest was told.
"We must do more to educate all parents, but particularly Aboriginal parents, on how to create and ensure consistently safer sleeping environments for babies," Judge Armitage said.
According to national advice, it is safest for a baby to sleep on a separate surface to its parents, such as inside a cot.
The coroner noted proper beds and firm mattresses were often economically beyond the reach of many Aboriginal families, who were often transient, sleeping on mattresses on the floor in substandard housing.
In the case of Baby B, the inquest was told his mother and father were drinking and smoking late before going to bed with the baby between them.
The father slept in late and when the mother came to check on the baby she found him cold to touch and not breathing. Her screams woke the father.
An autopsy found no other factors contributed to the baby's death other than the unsafe sleeping environment.
Baby K and Baby S also died after sleeping beside parents, the inquest was told.
Judge Armitage recommended the NT government consult with Aboriginal agencies and services to assess the need for better alcohol rehabilitation for pregnant and new mothers.
She also recommended NT Health and the Department of Children and Families consult with Aboriginal agencies to develop culturally sensitive educational materials about safer co-sleeping.
Such materials should meet the needs of parents with low literacy, or those who spoke local languages, and there should be an educational awareness campaign for Aboriginal community groups, the judge said.
Relevant agencies should also identify infants exposed to unsafe sleeping and provide guidance to staff to remedy that, including by providing firm mattresses, lightweight blankets and baby sleeping pods.