A one-month-old baby boy died after his mother fell asleep with him on a sofa, a serious case review has found.
The death in June last year was the subject of the review as both he and his half-brother were under a child protection plan at the time.
A report recommended safer sleeping advice is given to parents during pregnancy and reinforced during the child’s early years.
There were no criminal proceedings over the baby’s death.
The names of the family were not released and they were only referred to by the pseudonyms Liam and Nicole in the Gloucestershire Safeguarding Children’s Board serious case review.
The report said on the evening prior to the baby’s death he was put in his cot by his mother who “had smoked some cannabis”.
“During the night Nicole awoke to feed Liam although she could not remember the details surrounding this,” it added.
“She awoke the following morning as usual and was lying on the sofa, as was Liam, who was not breathing.”
The report said the cause of his death was “unascertained”.
‘Repeated and reinforced’
At the time of the death, the family was in contact with a number of agencies including children’s social care, education providers and health workers.
The baby’s mother was known to the police as a victim of domestic abuse and alleged sexual violence.
Kevin Crompton, from Gloucestershire Safeguarding Children’s Board, said: “Liam’s mother fell asleep leaving him on the sofa which can be dangerous and stresses the importance of safe sleeping guidance.
“Although it would have been difficult to predict or prevent Liam’s death, there is learning to be had from this case.”
The report said safer sleeping advice should be “given, repeated and reinforced by professionals” during pregnancy and infancy.
It also highlighted records taken by the agencies involved were not of sufficient quality to know what was happening to the family, what risks were identified or actions that were taken.
The serious case review also identified the need and importance of a “robust and timely” pre-birth assessment and an “inconsistent application of thresholds and child protection processes”.