Baby died after falling into sofa frame in Southampton
A four-month-old baby died after "rolling into the frame of a sofa in the gap between the cushion and the back", a serious case review has found.
Southampton Safeguarding Children Board said Billy had been sleeping with his mother on the sofa in their overcrowded council flat in February 2018.
She is thought to have pushed him into the sofa mechanism, the report said.
It criticised safeguarding processes and said there were "missed opportunities" to help the family.
However, the review said it was not possible to say whether anything done differently would have prevented Billy from dying the way he did.
Billy lived with his parents and five older siblings - all under the age of seven - in a three-bedroom first-floor flat provided by the city council.
The review found no agency appeared to have "examined the sleeping arrangements as the family grew nor questioned the parents about them".
"With eight people in a small three-bedroom flat, the suitability of the housing and the arrangements should have been assessed on an ongoing basis."
The authorities had previous concerns about neglect and abuse in the family, including "children running naked out of sight in the street, the floor being strewn with broken glass and a three-and-a-half-year-old injuring himself with a knife".
Southampton City councillor Darren Paffey said the death of Billy and other young children in such cases were "tragic and will have had significant consequences for their families".
He said there was "a dangerous gap in some people's understanding of the consequences of co-sleeping".
"While this is not unique to Southampton, we have a responsibility alongside other agencies in the city to do all we can so that parents are better supported to look after their children."