Molly died in October 2005
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Concerns had been raised about a nursery where a toddler choked to death on the strings of a cloth bag hung from her cot, an inquest has heard.
Staff at Gloucester's Tiddlywinks nursery were unable to resuscitate Molly Cunliffe after she tangled herself on rope tied to the cot's bars.
The 16-month-old died two weeks later in hospital.
An inquest heard how a child safety inspector had concerns about the nursery before the death in 2005.
'Well-recognised risk'
Linda Witts said: "Tiddlywinks have comprehensive procedures but they were not being implemented.
"My inspection revealed there had been cosmetic improvements. However some areas of procedure gave me concern.
"I did not see bags hanging on cots. If I had seen them I would have made them take them off.
"I am aware of cases where children have hung themselves - I consider this to be a well-recognised risk."
A jury at Shire Hall were also told child safety bodies and the cot's manufacturer give clear instructions warning of the hazards of hanging anything from or near to the equipment.
Nursery worker Clare Neal told the jury that sleeping children were checked every 10 minutes and that a bag had been tied to Molly's bed for as long as she could remember.
At the time of the accident, the nursery said Molly was in a fully-monitored cot room so staff were able to respond immediately.
The inquest is expected to last three days.