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A baby died while sleeping between parents who had been drinking before they took the infant to bed with them.
Midwives had warned the mother - who has not been named - about the risks of sleeping beside her baby - but she admitted she repeatedly ignored their advice.
The details of the tragic case were revealed in a report to Coventry City Council.
The baby - named only as Child W - was born healthy in May 2011.
However, the mother ignored the 'safe sleeping' advice she was given before she left hospital and regularly slept with the baby between her and her partner.
she woke to find the baby had stopped breathing and called an ambulance, but paramedics could not save the child.
Officials launched a full investigation as the parents were known to social services.
The child had not been taken into care but staff decided to carry out a further family assessment.
Last week the city's safeguarding children board published its report, which found the tragedy could not have been prevented.
But health chiefs say this was not an isolated tragedy and are warning parents against putting their babies to bed next to them.
Across Coventry and Warwickshire 27 babies have died in their parents' beds since 2008.
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