A review, prompted by the death of a 14-week-old baby girl, has uncovered a series of failings by child protection services (CPC) in Glasgow.
The baby, identified only as Child A, died in hospital in March 2015 after being found in a home strewn with dirty nappies and drug paraphernalia.
A significant case review said failures of communication led to deficiencies in the care of child protection services.
Glasgow CPC said they were developing a plan in response to the review.
Despite prior involvement from social services in the city, when police officers arrived at the family home on the day of Child A's death, they found her siblings living in conditions described as "uninhabitable".
The review said: "They reported the home being in a state of disarray, dirty soiled clothing and nappies observed in rooms throughout the home, the bedroom occupied by two of the older siblings was stated to be uninhabitable with broken beds, no mattresses or bed clothes.
"Police further noted evidence of drug misuse within the property: scorched tinfoil on the floor and remnants of a plastic wrap believed to have contained heroin."
CCTV footage of the area also showed Child A's siblings roaming freely at midnight without adult supervision.
A post-mortem examination of the child later concluded that she had died as a result of sudden and unexplained death in infancy.
The review said that it was important to acknowledge that the outcome may have been the same, even if the intervention of care services had been diffierent.
However, in its findings, the significant case review said there had been deficits in information sharing within and across agencies, which impacted on assessment, decision making, care planning and intervention with Child A and her family.
The review also highlighted changes of social service personnel at key times, staff absences that reduced the opportunities to re-assess the child and her family's circumstances and an "inconsistent and fragmented" approach to assessing the risks faced.
'Sad and difficult'
A spokesman for the Glasgow Child Protection Committee said it was unable to publish the full report for legal reasons.
He added: "The significant case review process is clearly intended to give professionals the opportunity to learn from serious incidents and how best to improve services to protect children and young people.
"It is not an inquiry into culpability, which is a matter for criminal investigation or disciplinary procedures.
"Throughout the review process, the committee has welcomed the readiness of staff to reflect on this complex case and to identify shortcomings as well as good practice.
"The agencies involved are developing a plan in response to the findings of this review and this work will be subject to further scrutiny by the Child Protection Committee."
A spokesman for the Glasgow Health and Social Care Partnership added that the case had been "extremely sad and difficult".
He said: "We are addressing concerns raised in the findings of this review as a matter of priority."