To examine publicly available coronial findings and recommendations relating to SUDI cases to identify recurring modifiable risks, social determinants of health, and system-level failures that might inform prevention strategies.
Approach:
Method: label
Method: text
Key Findings:
583 SUDI cases were closed from 2012 to 2025, with a rate of approximately 0.82/1000 live births.
Recommendations were made in 21.8% of closed cases, totaling 127 cases.
22 distinct types of specific, system-directed recommendations were identified.
Interpretation:
The findings reveal recurring modifiable risks associated with SUDI.
Limitations:
The dataset only includes closed cases, potentially omitting ongoing investigations.
Data is limited to the timeframe of January 2012 to June 2025.
Conclusion:
The study underscores the importance of addressing modifiable risks and systemic failures to reduce SUDI rates in New Zealand.
