The death of a baby suffocated by her mother who was suffering from postnatal depression may have been avoided if she had received better care, an inquiry has found.

Key information about Erin Sutherland, including a history of postnatal depression from having her older children, was "lost" in the GP system, the Mental Welfare Commission said.

The 37-year-old pleaded guilty on the grounds of diminished responsibility to culpable homicide following the death of her nine-month-old baby Chloe on February 3, 2015.

She was sentenced to three years in prison pending inpatient psychiatric treatment in June last year.

The High Court in Edinburgh heard she had "severe" postnatal depression when she killed Chloe at her home in Parkhead View, Edinburgh, but was turned down for support by a perinatal mental health team because her daughter was older than six months.

The Scottish Government instructed the body to carry out an investigation into her care before her baby's death.

In a report published on Thursday, which refers to Sutherland as Miss OP, the three-strong board found there were "missed opportunities for referral to postnatal and adult mental health services", and criticised the "very limited communication" between the organisations involved in her treatment.

MWC executive director Alison Thomson said: "Everything is indicating that if she had received that care and treatment at an earlier available opportunity, then it would have significantly reduced the likelihood of what occurred.

"We have not found any single failing or omission which caused or directly contributed to the death. However, during the course of our investigation we found several aspects of Miss OP's care and treatment that should have been better.

"There were a number of factors which, if addressed, would have increased the likelihood of Miss OP receiving appropriate care and treatment for her depression at an earlier stage."

She urged the care providers involved to "learn lessons" from the death to prevent similar incidents in the future.

Ms Thomson added: "Miss OP often presented with a good facade and did not express to any care professionals any thoughts of harm to herself or her children.

"This gave unfounded reassurance to those who were in contact with her.

"The combination of a previous history of thoughts of infanticide in the first postnatal year and deteriorating mental health during a time of stressful life events should have alerted those involved to the need for increased vigilance and support.

"Considering the number of people, agencies and services involved, there was very little communication between them and it is unlikely that anyone really had an overview of what was going on."

A pre-birth planning meeting would have highlighted the history, risks and appropriate management plan to all involved and might have reduced the risk of this information being "lost" within the GP system, the inquiry stated.

Sutherland had been offered postnatal depression scale screening at six weeks and six months after Chloe's birth but she declined it.

"Given her previous history of postnatal depression, we think this should have been pursued further and enquiry made about depressive symptoms at each contact - this was not done," the report said.

The review also found after a brief assessment in November 2013, following a referral from a midwife because of her history of postnatal depression, there was no further contact with a psychiatrist.

A letter with details about her history, early warning signs and future management was only sent to Sutherland's GP practice three months after the meeting, described in the report as an "unacceptable delay".

The following August, Sutherland was discharged from the postnatal mental health service by a community psychiatric nurse, a move which was not discussed with anyone else in the team in advance.

The letter was not sent to the GP practice until that December.

The report said: "The community psychiatric nurse gave no clear reason for this other than it was an oversight."

It outlined that on February 2, 2015 - a day before Chloe died - her mother took her to the GP with an ear infection. The doctor later told the committee Sutherland's behaviour did not cause concern.

The following day, she called the postnatal depression support service because she was stressed after a disagreement with Chloe's father about access.

She "calmed" during the call and reassured the counsellor she and the children were safe but a few hours later she called 999 to report she had smothered Chloe.

The review team interviewed Sutherland, who said she had wondered why symptoms including weight loss and complaints of low mood had not been "picked up and acted upon" at a number of GP appointments.

While the health visitor was aware of Sutherland's history of postnatal depression, she was not aware of the psychiatrist's assessment and her previous history of thoughts of harming herself and her children when unwell.

A letter from psychiatrist stated it had been copied to the health visitor but the review found no evidence of this in the health visitor notes.

The committee also found there had been no system in place to follow up on referrals made by the GPs to the health visitor or other services, while there was a "high number of different GP contacts" which made continuity of care difficult.

The commission has made 14 recommendations to ensure similar cases do not slip through the net, three for NHS Lothian, one for the Scottish Government, one for the Royal College of General Practitioners Scotland and nine for all Scottish health and social care bodies.

They will be asked to establish a clear system for access to perinatal mental health experts and urgent assessment by mental health teams where needed.

A further recommendation is that areas with perinatal mental health services should ensure women with histories of postnatal depression can be referred until their child is one.

This is also among the three recommendations for NHS Lothian, which dealt with Sutherland's case.

Mental health minister Maureen Watt said: "The Scottish Government accepts and welcomes the report's recommendation to establish a managed clinical network for perinatal mental health.

"Work has already been progressing on the creation of a new network and it is currently progressing through the approval process at NHS National Services Scotland. We are clear that we want it to be approved and implemented as soon as possible.

"I fully expect that health boards and health and social care partnerships will give very careful consideration to the lessons highlighted in this report that apply to the quality and provision of the mental health services they provide, including perinatal mental health. I expect them all to ensure that all women are given access to the support they need."

Professor Alex McMahon, nurse director at NHS Lothian, said: "Our sincere condolences and sympathies are with the family of baby A. This was a tragic case and one that prompted us to take immediate action.

"NHS Lothian completed a robust investigation at the end of last year and we created a detailed action plan to address inconsistencies and discrepancies in care and improve the service for women overall.

"These actions have now all been implemented and I would also like to reassure patients and their relatives that lessons have been learned."

He added: "Work was also carried out to strengthen communications between the team and other healthcare workers, including GPs, to ensure they are aware of the full range of services available in Lothian."

If you are suffering from postnatal depression, or are seeking support in relation to issues highlighted in this article, you can contact the Association for Postnatal Illness for more information.