Coroner Wallace Bain says it's a tragedy that the necessary resources don't appear to be in place to stop the preventable deaths of young babies.
Dr Bain has released his findings on the death of Tahi Edwards, aged two months, who suffocated in his mother's arms while she was drunk and asleep in Rotorua in 2011.
Ngaire Tukiwaho was sentenced to prison last year for his manslaughter.
Dr Bain said latest figures suggest that as many as 55 to 60 babies could be dying each year from unsafe sleeping arrangements.
He recommends that the advice in relation to safe sleeping environments be strengthened and broadened so it is clear that bed-sharing by adults with infants under six months should be avoided.
Dr Bain said coroners sadly have to deliver findings in that area repeatedly.
A summary of a review of Child, Youth and Family's involvement with the baby's mother was released last year, stating that there were no gaps found in its policy and procedure.
