Resuscitation was attempted, but ambulance staff confirmed that Bohdi Rangi-Taylor had died.
Now Coroner Meenal Duggal is calling for the Ministry of Business, Innovation and Employment (MBIE) to work with the Ministry of Health to develop standards for infant sleep devices.
Coroner Duggal said that under the Fair Trading Act, there were mechanisms for Unsafe Goods Notices to be issued at the decision of the minister.
“I bring this matter to the attention of the MBIE, noting [expert] advice that sleeping pods are a danger to infants regardless of whether they are marketed for sleep or as a ‘lounger’.”
Tummy-sleeping, blankets and sleeping pods
Bohdi was born in April 2022 in Hawke’s Bay Hospital at 36 weeks and four days’ gestation, with his twin brother.
Bohdi’s parents were given two wahakura, a bassinet made from woven harakeke (flax) leaves with a flat bottom and reasonably firm sides, by the Safe Sleep Coordinator at Hawke’s Bay Hospital.
Wahakura are baby bassinets made from New Zealand flax. Photo / Whānau Ora Services
Bodhi’s mum purchased devices referred to as sleeping pods from a website called Taylorson.
From about 2½ to 4 months old, the twins had outgrown the wahakura and slept in the sleeping pods on their stomachs, usually on a bed.
From when the twins were about 4 months old, the sleeping pods were placed in their cots in their bedroom.
On the night of September 30, 2022, the twins’ usual evening routine was followed − they were given a bottle at around 6.30pm, and Bohdi was put to bed about 8pm.
He was placed on his stomach in his sleeping pod, which was in his cot on top of two innerspring mattresses.
The type of “sleeping pod” purchased by Bohdi’s parents.
A fleece blanket lined the sleeping pod. A woollen blanket and two fleece blankets were placed up to Bohdi’s shoulders and his arms were by his head.
A heater was on, but it was turned off when Bohdi’s twin was put to bed, about 30 minutes later.
The coroner noted the twins were placed on their stomachs to sleep as they settled more easily in that position.
At some point in the night, the twins were heard crying but Bohdi’s father said that was not unusual, and they stopped crying by themselves.
It was about 7am when Bohdi’s father went to get him and saw him “covered by blankets in the sleeping pod”.
On October 2, 2022 a post-mortem examination determined his cause of death was sudden unexpected death in infancy.
Pathologist Dr Judy Melinek advised this was likely due to suffocation or rebreathing of air due to Bohdi sleeping prone under a blanket inside a sleeping pod.
Babies of his age were unable to protect their airway or raise their head sufficiently to breathe.
Loose blankets could be a suffocation hazard, as could soft pillow structures, like the edges of the sleeping pod.
She said she “strongly recommended” reports were made to consumer product safety agencies to “cease the sale of these types of sleeping pods”.
She said there had been recalls of these types of devices in the United States as a result of reports of entrapment and sudden infant deaths.
SUDI risk factors
Dr Edwin Mitchell, Emeritus Professor of Paediatrics at the University of Auckland, has researched and published on sudden unexpected death in infancy (SUDI) for 40 years.
He told Coroner Duggal the major risk factors for Bodhi included his being placed on his stomach to sleep – this increases the risk of SUDI four to six times compared with a baby being put to sleep on their back.
The second risk factor was the blankets in Bohdi’s bed. Mitchell advised that a meta-analysis reported that around 25% of infants who died of SUDI were found with blankets covering their heads.
The final factor was the sleeping pod.
Sleeping pod or ‘lounger’?
The sleeping pod used for Bohdi was a soft mat surrounded by a soft pillow with cords at the bottom of the pillow to pull the ends of the pillow together to envelop the baby.
The pod was marketed in New Zealand and described by Taylorson’s website, as cited in the findings, as “ideal for overnight sleeping, aiding longer and more restful sleep … Our lightweight and cozy sleep pod is perfect for traveling and co-sleeping and can even be used as a crib insert.”
However, infant sleep devices such as sleeping pods are not considered safe by experts.
Mitchell advised that the American Academy of Pediatrics (AAP) discourages the use of sleeping pods.
In June 2022, the US introduced a federal rule to ensure that products marketed or intended for infant sleep provide a safe sleep environment for infants up to 5 months old.
Mitchell said that in March 2025, he went to a summit in the US addressing SUDI, where a leading American paediatrician advised him such devices are now being marketed as loungers and, in her opinion, they should be banned entirely.
Mitchell told the coroner that even when rebranded as “loungers”, they were still a danger to infants, as babies will fall asleep wherever they are placed, such as during tummy time.
“I would therefore recommend these sleeping pods and loungers are banned. In the first instance, I would suggest a voluntary recall while a mechanism is found to ban them permanently.”
The Ministry of Health guidelines say safe sleep devices are portable, low-sided, have rigid construction with firm sides that are not padded or soft, are compact, come with a mattress and bedding, and are supplied with rules of use.
Mitchell also advised that midwives and Well Child Tamariki Ora services should discourage the use of sleeping pods and loungers if they see them in use in households or are asked about such products by families.
MBIE and Standards New Zealand were consulted on the coroner’s proposed recommendations.
They confirmed products such as the sleeping pods used for Bohdi are not currently subject to any specific mandatory safety requirements in New Zealand.
MBIE advised that new standards are coming into effect in Australia this year that set out clear requirements for flat, rigid surfaces, restrictions on fabric or mesh sides, and prohibitions on entanglement hazards.
MBIE submitted that there may be value in putting in place similar standards suitable to the national context.
Standards New Zealand advised that any new standards would have to be commissioned by a government agency or industry group.
The coroner said a copy of her findings would be provided to the Child Youth Mortality Review Committee for it to consider how best to convey safe sleep education to new parents.
Coroner Duggal said considerable efforts are being made in New Zealand to promote the message that every sleep for a baby should be a safe sleep.
“That is, for every sleep, babies should be placed on their backs, in their own sleeping space (a firm, flat and level surface with no pillow), with their face clear.
“Parents are advised to have blankets firmly tucked, ideally under a mattress and have no extra blankets or soft toys in the bed.
“To this, I add that unapproved infant sleep devices should not be used.”
Taylorsons Responds
The owners of the company, Taylorsons, which sold the sleeping pod, said they accepted the findings but felt the findings placed too much emphasis on the product.
PC and Gin Tay told NZME they believed the use of blankets, and stomach sleeping, created an inherently unsafe sleep environment, regardless of whether a pod was also used.
The Taylorsons website now has updated advice, with the sleeping pods described as “loungers” and states they should only be used when the baby is being closely supervised.
The company said it would accept any standards that limited the sale of the product, if they were to come into effect.
Hannah Bartlett is a Tauranga-based Open Justice reporter at NZME. She previously covered court and local government for the Nelson Mail, and before that was a radio reporter at Newstalk ZB.