Report by Wigan authorities reveals baby girl died after being strapped into a car seat for 15 hours in a hotel room
The 10-week old baby - referred to as Child M - died in July 2016.
A report by authorities in Wigan has revealed how a baby girl died after being strapped into a car seat for 15 hours in a hotel room.
The 10 week old baby - who's named as Child M for legal reasons - was left in the seat overnight on a bunk bed.
Details of the death of the infant, emerged in the findings of a serious case review ordered by authorities in Wigan, Greater Manchester, because of suspected neglect - although previously no charges were brought following a criminal investigation and a coroner found it was not possible to ascertain the cause of death.
The independent report, published by Wigan Safeguarding Children Board, outlined that Child M, a twin, was a premature baby of low birth weight who needed a consistent feeding routine and consequently was at high risk'' of sudden and unexpected death.
Child M died in July 2016 while the family were on a four-day holiday in the UK with their six children.
The twin infants were placed by their parents to sleep in their car seats, which were upright on the bottom bunk bed, between 7pm and 7.30pm.
Child M's parents then drank alcohol in the downstairs hotel bar during the evening but reportedly checked on the twins and another young sibling every 30 minutes. Some of these checks were verified by a review of the hotel's CCTV system and police conversations with the hotelier, the report said.
The hotel owner also told police the parents were not excessively intoxicated'' at the bar.
The parents returned to their bedroom at 1am and the mother fed Child M with a feed of 3oz of infant formula at 2.30am.
Child M was discovered unresponsive in the car seat at about 10am and was pronounced dead the same morning shortly after arrival at hospital.
The parents voluntarily consented to forensic tests to determine their blood alcohol levels and the results were within an acceptable range'', the report said.
The hotel room was secured as a possible crime scene where it was noted there were empty cans of lager and beer bottles and it also emerged in the 24 hours prior to Child M's death, the infant had only had three feeds - a feeding pattern not thought to be line with expert advice given.
Child M remained under the care of a neo-natal outreach team after discharge from hospital following birth and there was evidence that health professionals regularly gave advice to the parents over safe sleeping and prevention of sudden infant death.
The review concluded: Whilst the review has identified areas of multi-agency practice that could be strengthened, it has not identified any serious omission in practice that contributed to the death of Child M.
The parents could not follow through on the plans to ensure Child M could sleep safely in the hotel and made the choice to place Child M to sleep in a car seat. This is one of the most significant risk factors in sudden infant death.''
Following publication, Dr Paul Kingston, independent chair of Wigan Safeguarding Children Board, said: This is a truly sad loss of a child and we send our continuing deepest condolences to the family.
The findings highlight the difficulties faced by families in sustaining safe sleep arrangements amidst gaps in cohesive professional advice from many sources, not least in relation to sleeping in car carry seats which is not a unique issue to Wigan.''
Among the review's recommendations was one to influence nationally'' to encourage the Government to act as regulators for the safety hazards warnings on car seat equipment.