Norfolk County Council officials opted for a lower-level review instead of a full social worker assessment for a family whose four-year-old son died after his head became trapped between two stair gates, an inquest has been told.

Health visitor Helen Thompson had expressed concerns about the home environment of Draco Chapman, describing it as 'incredibly dirty' and 'chaotic' in the weeks leading up to his death. Despite her recommendation for a comprehensive social worker assessment, the council's bosses decided against it, opting for a less thorough review.

Draco died on April 23, 2019, after an incident in which he tried to squeeze through a six-inch gap between two stair gates in a doorway. He was found unresponsive by his 16-year-old brother and later died in a children's hospice after life support was withdrawn. An initial inquest in January 2022 concluded his death was accidental, caused by catastrophic brain injury and asphyxiation.

However, this finding was overturned following a serious case review that highlighted concerns raised by Ms. Thompson and staff at Draco's nursery in the months prior to his death. At the reopened inquest, Ms. Thompson testified that Draco had been diagnosed with Noonan syndrome, which affected his development, giving him the mental age of a two-and-a-half-year-old. She also noted earlier concerns about the mother's reluctance to claim full benefits and her difficulties enforcing boundaries.

Ms. Thompson described a deterioration in home conditions during visits in January and March 2019. By March 20, she observed used nappies in the garden and rubbish scattered throughout the house. During this visit, she saw Draco repeatedly trying to climb over a stair gate, which she noted was ineffective and did not replace the need for adequate supervision. She also viewed the mother's refusal to allow her to inspect the nursery for a new baby as a 'red flag'.

Despite these concerns, the threshold for a social worker review was not met, and a referral was made instead to the council's Children's Advice and Duty Service for a less thorough assessment. Ms. Thompson stated she did not escalate the request further, believing CADS would do so if deemed necessary.

Community midwife Kathryn Mitchell, who accompanied Ms. Thompson on the March 20 visit, also described the house as 'unclean and messy.' Draco's mother, Rachel Chapman, who was 20 weeks pregnant at the time of her son's death, acknowledged in a statement that managing the household had become difficult and things 'had got out of hand.' She stated she had installed the second stair gate shortly before Draco's death to create an additional barrier.

Draco's father, David Chapman, who was divorced from Rachel Chapman but visited his children regularly, described his son as 'very fun and mischievous.' He was unaware of the second stair gate until after the incident.

An officer at the scene described the house as 'incredibly dirty' with overflowing bin bags of nappies, making the floor barely visible. A nursery teacher who had visited the home described the living conditions as 'chaos.'

The inquest, being held at Norfolk Coroner's Court, is expected to last until the following week.