Boy, four, died when his neck became trapped in six-inch gap between two stair gates fitted one above the other after his mother left him in care of his teenage brother, inquest hears
- Draco Chapman died after his neck became stuck in two stair gates in April 2019
- He was taken to hospital but died in a hospice three weeks later on April 23, 2019
- Draco got stuck in a gap between stair gates on top of each other, inquest heard
- Coroner Johanna Thompson said the four-year-old boy’s death was accidental
A four-year-old boy died after his neck became trapped in between two stair gates that had been stacked on top of each other, an inquest has heard.
Draco Chapman was found unresponsive at his home by one of his older siblings in Norwich, Norfolk, on April 2, 2019, and died three weeks later on April 23.
His head had become trapped in a six-inch gap between two stair gates that had been fitted one above the other in a door frame, Norfolk Coroner’s Court heard on Tuesday.
Draco, who was one of six children, all of whom lived with his mother, was being looked after by an older sibling at the time of the incident while his mother was at a parents’ evening.
Coroner Johanna Thompson concluded the four-year-old boy’s death was accidental after he suffered a cardiac arrest and irreversible brain damage.
Draco’s mother Rachel Chapman, who was 20-weeks pregnant at the time of the accident, said she had fitted the stair gates on top of one another to stop her children from climbing over it.
Draco Chapman (pictured) was found unresponsive at his home by one of his older siblings in Norwich, Norfolk, on April 2, 2019, and died three weeks later on April 23
A case review by Norfolk Children Safeguarding Partnership recommended that all stair gates should have a mandatory warning saying they should not be used on top of one another.
In a statement, Mrs Chapman said: ‘I was pregnant and agreed with the health visitor that I needed help and she made a referral to social services.
‘I struggled but knew I needed help. My oldest would help with the children but I had to accept it had got out of hand.
‘On April 2, I fitted the second stair gate to stop them (the children) from getting out of the lounge and on to the stairs. I thought it would act as a door and keep them safe in the lounge.
‘The bottom one didn’t work as Draco used to climb over it.’
Mrs Chapman said she had arrived home from a parents’ evening to find her eldest child on the phone to the ambulance screaming that Draco ‘had stopped breathing’.
She said she performed CPR on Draco until the ambulance arrived, when Draco was rushed to Norwich and Norfolk Hospital, the inquest heard.
Draco was placed in an induced coma before being transferred to Addenbrooke’s Hospital, in Cambridge, and then to a hospice, where he died on April 23.
His head had become trapped in a six-inch gap between two stair gates (pictured) that had been fitted one above the other in a door frame, the inquest heard on Tuesday
Dr Roddy O’Donnell, clinical director of the paediatric intensive care unit at Addenbrooke’s, said Draco died after suffering neurotic asphyxiation from accidental hanging, and a cardiac respiratory arrest.
Dr O’Donnell added: ‘It was clear he had suffered serious and irreversible neurological injury.’
The court heard that before his death, Draco had been diagnosed with a heart murmur and Noonan syndrome, a condition which can cause heart defects and developmental delays.
Sergeant Graham Green, of Norfolk Constabulary, told the court in a statement that Draco was found injured by his sister and was taken upstairs by an older brother who carried out CPR on him and called the emergency services before his mother arrived home.
The sergeant said that when he spoke to the oldest boy about the incident, he described Draco as ‘lifeless, peaceful and a sweet little boy’.
Sgt Green added that as he spoke to the child in the living room, he noticed ‘Fruit Shoots and McDonald’s’ on the living room floor.
Health visitor Helen Thompson told the court in a statement that she had visited the family in March 2019 and noted Draco using a toy box to climb over the stair gate.
She said: ‘The house had a lot of dirty nappies outside the front door and in the living room there were scraps of bread on the floor.
‘Draco dragged a bit of plastic to the gate and she said it was a piece of dismantled table which she took apart because the children were using it to climb over the stair gate.
‘When we discussed the safety of the stair gate, I said the children need to be supervised to keep them safe.’
At Norfolk Coroner’s Court (pictured), coroner Johanna Thompson concluded the four-year-old boy’s death was accidental after he suffered a cardiac arrest and irreversible brain damage
A member of staff at the nursery Draco attended told the court in a statement they had offered to help Mrs Chapman after noticing his clothing was dirty, and replacements given to him had not been returned.
She said: ‘She said she had a huge pile of washing and couldn’t get on top of it.
‘I had a sense she was very tired and overwhelmed and offered her to bring bags into nursery so we could do it and it would be handled discreetly.
‘She never took us up on that. I never had any doubt that she loved her children.’
The court heard that Mrs Chapman was no longer caring for her other children, and the nursery staff member said that when she visited her after his death, Mrs Chapman said she would do anything to turn back time.
Draco’s death was recorded as accidental by the coroner, who said: ‘The medical cause of death is catastrophic brain injury and asphyxiation by hanging.
‘Draco became trapped by his neck while trying to climb over the lower stair gate and as a consequence of becoming trapped between this and the higher stair gate, this caused him to become asphyxiated and caused cardiac arrest.’
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