Ah'Kiell Walker death: Authorities' 'lack of understanding' of abusive homes
Authorities in Gloucestershire showed a "lack of understanding" of homes where domestic abuse takes place, a serious case review into a baby's death said.
Ah'Kiell Walker died aged three months from a brain injury in July 2016.
The report said his mother Hannah Henry was a victim of abuse, and the risk to Ah'Kiell should have been recognised.
Gloucestershire Children's Services and Gloucestershire Police, which were both criticised, said they had accepted the report's findings.
Henry was jailed for four years, while the boy's father Alistair Walker, was jailed for 10 years.
Walker, 27, was found guilty of manslaughter and cruelty to a person under 16, at Bristol Crown Court.
Henry, 22, was convicted of causing or allowing death, and cruelty to a person under 16.
Healthcare professionals had not identified any significant areas of concern prior to Ah'Kiell's death, the report said.
Kevin Crompton, the independent chair of the Gloucestershire Safeguarding Children's Board, said it was difficult to say whether it could have been prevented.
Water in mouth
He said: "When mother had a broken jaw and gave several different versions of events, the professionals should have got together and said, 'Hang about a minute, this doesn't add up - something's happening here, we should have more of a look at'."
Paramedics had to tip water out of the baby's mouth when he was found.
A post-mortem examination revealed the cause of Ah'Kiell's death as an injury to the brain through lack of oxygen, possibly resulting from submersion in water.
The director of Gloucestershire Children's Services, Chris Spencer, said: "We fully accept that there were things that we and our partners could have done better.
"We have taken significant action to improve services and the way we protect vulnerable young people in the county."
A spokesman for Gloucestershire Police said: "We're confident the positive steps we've taken with training and changes made have vastly reduced the risk of the same mistakes being able to happen again."