A UK coroner has warned of the dangers of a bedside cot after the death of a newborn baby who choked to death this month.
Seven-week-old Grace Joy Roseman was sleeping in a Bednest cot when she managed to manoeuvre her head over the edge of the cot, which led to the 'safety ridge' cutting off the oxygen to her brain.
The Bednest cot is designed to be placed next to a parent's bed and has a panel which can be folded down to leave a ridge 7cm high on one side.
Grace died after her mother Esther put her down for a nap in the cot about 8.30am on April 9. When the mother returned about 90 minutes later the baby girl was lying with her head over the edge of the cot and was unresponsive.
Investigations into Grace's death are continuing, but in a provisional statement the cause has been listed as asphyxia resulting from the 'safety ridge' cutting off the oxygen supply from her windpipe.
The cot is endorsed by UK's National Children's Trust but, according to a Daily Mail report, West Sussex coroner Penelope Schofield has said she was concerned about further injuries from Bednest cots.
"In my opinion urgent action should be taken to prevent future deaths ... should another baby be placed in the prone position and left with the side incompletely lowered again in one of these cots, another death could occur," Ms Schofield wrote in her report on baby Grace's death.
"If the cot's side is not safe to be incompletely lowered or for the cot to be tilted more than 5cm then it should be questioned as to whether these should be options available at all."
The National Children's Trust has suspended sale of the Bednest cots until the coroner's investigations into Grace's death are complete.
The UK manufacturers of Bednest posted a statement on their website following the release of Ms Schofield's report expressing their sadness and expressing their condolences to Grace's family.
"We are doubly upset to hear this news, since the concept behind Bednest's design is first and foremost about baby health and safety and came originally from highly experienced neo-natal nurses," the statement reads.
"The coroner has highlighted that all safety guidelines for the correct use of the crib are laid out in the instruction manual, but due to a growing second-hand market for our Bednest cribs, these instruction manuals may not be passed on. This may be, sadly, what happened with Grace's crib.
"We are now considering displaying basic instructions on the side of the crib itself.
"We advise all parents purchasing a second-hand crib to first of all visit our website where they will find out how to obtain a full instruction manual for use with their Bednest.
"These instructions will include: do not leave the baby unattended if crib sides are not both up and secured (and) do not tilt the crib by more than five centimetres."
Grace's father Gideon told the Daily Mail were "no words" to describe the loss of "beautiful little Gracie".
"She was just starting to develop her own little personality and was always smiling," he said. "We would not wish any parent to have to go through such a devastating loss."
The Bednest cot is sold in Australia by Danish by Design for $599.95. The company has not announced any plans to suspend sales of the cot here.