A baby who was shaken and immersed in water died amid a 'lack of understanding' of domestic abuse by public agencies, a report found.
Four-month-old Ah'Kiell Walker died at the hands of his parents at their Gloucester home – where paramedics found him cold and soaking wet.
Ah'Kiell's father, Alistair Walker, was jailed for 10 years after being found guilty of manslaughter and cruelty to a person under 16 at Bristol Crown Court last year.
And the baby's mother, Hannah Henry, was jailed for four years for causing or allowing his death at the same trial.
Postmortem examinations found Ah'Kiell had healing fractures to his lower ribs suffered weeks before he died.
Despite his injuries, professionals working with Ah'Kiell did not identify any significant areas of concern prior to his death, the report said.
Ah'Kiell was admitted to Gloucestershire Royal Hospital on July 30, 2016 and later died as a result of a brain injury.
The Gloucestershire Safeguarding Children Board (GSCB) commissioned the independent report to understand the circumstances that led to Ah'Kiell's death.
The report's author, Joanna Nicolas, said there was a 'lack of professional curiosity' running through the case by agencies, including Gloucestershire County Council's Children Social Care team and Gloucestershire Hospitals NHS Foundation Trust.
The report said: "There is much work to be done in Gloucestershire to bring staff in all agencies to a point where they are confident and knowledgeable about domestic abuse."
Agencies knew the mother had lived with domestic abuse as a child, had a history of smoking cannabis and of drinking alcohol, the document said.
They also knew Henry had a conviction for possessing class A drugs, was found in possession of class A drugs and had been in at least two abusive relationships before meeting Walker.
The report said: "What was missing was an understanding of the risk indicators of physical harm to a child under one or an unborn baby, the risk of physical harm to the mother, both in pregnancy and with a child under one, the impact of the emotional harm to a child of living in a home where there is domestic abuse, the mother's age, substance misuse and concerns at times about the mother's mental and physical health.
"There is also some evidence of a lack of professional curiosity."
In the months before Ah'Kiell's death, a health visitor carrying out a new birth visit went to the mother's home in Gloucester, on March 14, 2016.
They found Ah'Kiell's dad, Walker, who did not live there but visited during the day.
The report said Walker was upstairs during the visit and did not appear but the home smelt of cannabis. The mother denied any use.
She told the health visitor she had no history of drug use, including alcohol, or of domestic abuse – 'none of which was true', the report said.
The health visitor found a lump on Ah'Kiell's head although it was not red or inflamed, the report said.
One month later in May, the health visitor attempted a planned home visit but Walker said Henry and Ah'Kiell were out.
On May 31 2016, the health visitor undertook a home visit for a six-eight week review and both parents were present.
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