A baby died while sleeping between parents who had been drinking before they took the infant to bed with them.
Midwives had warned the mother - who has not been named - about the risks of sleeping beside her baby - but she admitted she repeatedly ignored their advice.
The details of the tragic case were revealed in a report to Coventry City Council.
The baby - named only as Child W - was born healthy in May 2011.
However, the mother ignored the 'safe sleeping' advice she was given before she left hospital and regularly slept with the baby between her and her partner.
In July last year she woke to find the baby had stopped breathing and called an ambulance, but paramedics could not save the child.
Officials launched a full investigation as the parents were known to social services.
The child had not been taken into care but staff decided to carry out a further family assessment.
Last week the city's safeguarding children board published its report, which found the tragedy could not have been prevented.
But health chiefs say this was not an isolated tragedy and are warning parents against putting their babies to bed next to them.
Across Coventry and Warwickshire 27 babies have died in their parents' beds since 2008.
Carmel McCalmont, head of midwifery at University Hospital, Walsgrave, said all pregnant women and new mothers were advised against co-sleeping.
However, she said some parents continued to do so, often because they were tired or had been given poor advice by relatives.
She said: 'Babies should sleep on their back with their feet to the bottom of the Moses basket or cot.
'No matter how tired parents are they should never be tempted to bring their baby to bed with them.'
Jim O'Boyle, cabinet member for children at Coventry City Council, said: 'This was a tragedy and we wish it could have been avoided.
'Parents need to realise no matter how much they love their children or think they are doing the right thing, once they are asleep and unconscious they are not in control.'
Babies who sleep beside their parents are at greater risk of suffocating and harmfully overheating.
There are also some risk factors that make it even more dangerous.
They include co-sleeping when parents are very tired, or after drinking, taking drugs, or even some prescription medications. Smoking is another major risk factor.
Ms MacCalmont said: 'Drinking alcohol and being very tired are significant risk factors because parents can sleep so deeply that they roll over and can suffocate their baby.
'Also, a lot of parents think they are doing the right thing by going outside to smoke. They don't realise the toxins remain on their clothes. We advise to avoid smoking.'
Despite the dangers, some charities continue to promote the benefits of co-sleeping, such as making it easier for mums to breastfeed.