A newborn baby died after being placed in a car seat on a hotel room bunk bed overnight, it has emerged.
The 10-week-old twin was found unresponsive at the accommodation in Wigan in July 2016.
Investigations found the infants had been left on the bottom bunk while their parents drank in the hotel bar
However, a serious case review said the adults were not "excessively intoxicated" and the child had been alive upon their return to the room.
No criminal charges were brought and a coroner was unable to ascertain the cause of death.
An independent report, published by Wigan Safeguarding Children Board (WSCB), said the baby, referred to as Child M, had been born prematurely.
The infant was of low birth weight, needed consistent feeding and was consequently at "high risk" of sudden and unexpected death, it said.
'Significant risk factors'
The family was on a four-day break when the the twins were left in their upright car seats at about 19:00 BST.
Child M's parents then drank in the downstairs hotel bar until 01:00, and the mother gave the baby 3oz of infant formula at 02:30.
At about 10:00 the baby was found to be unresponsive, and carried down to the hotel reception by the father.
Despite resuscitation attempts, the child was later pronounced dead in hospital.
The report said hotel CCTV showed the parents had checked on the twins and another young sibling every 30 minutes.
Both adults voluntarily underwent forensic tests which showed their blood alcohol levels were "within an acceptable range".
In the 24 hours prior to death, the report said, Child M only had three feeds - which is not thought to have been in line with expert advice given.
There was evidence health professionals regularly gave the parents guidance on safe sleeping and prevention of sudden infant death.
While the report found areas of practice by the authorities could be strengthened, no serious omission in practice contributed to the death, the report concluded.
It added as parents could not ensure Child M could sleep safely in the hotel, they chose to place the baby in a car seat, which was "one of the most significant risk factors in sudden infant death".
Dr Paul Kingston, chair of WSCB, said it was a "truly sad loss of a child".
"The findings highlight 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 encourage the government to act as regulators for safety warnings on car seats.