An inquest has heard that officials failed to act on a health visitor's concerns about a 'chaotic and squalid' home where a four-year-old boy died after getting his head trapped between two stair gates.

Draco Chapman was found unresponsive by his 16-year-old brother at the family's semi-detached home in Norwich, Norfolk, on April 2, 2019. He had attempted to squeeze through a six-inch gap between two stair gates placed one above the other in a door frame, which trapped his head. Draco was left with irreversible brain damage and was unable to breathe.

Paramedics were called, and Draco was placed in an induced coma. His life support was withdrawn on April 23, 2019, at Quidenham Children’s Hospice, and he died. An initial inquest in January 2022 recorded a verdict of accidental death, citing catastrophic brain injury and asphyxiation due to hanging.

However, this finding was overturned following a serious case review by the Norfolk Safeguarding Children Partnership, which highlighted concerns raised by health visitor Helen Thompson and staff at Draco's nursery in the months leading up to his death.

Health Visitor's Concerns

During the second inquest, Ms. Thompson testified that Draco's family had previously been under a family support plan, receiving additional assistance from health visitors. Draco had been diagnosed with Noonan syndrome, a condition that can cause heart defects and developmental delays, and had the mental age of a two-and-a-half-year-old. Ms. Thompson noted in earlier visits that Draco's mother, Rachel Chapman, was reluctant to claim full benefits she was entitled to. She also recorded concerns about Draco's low weight in January 2016 and noted in January 2017 that his mother was "ineffective in enforcing boundaries." Ms. Thompson also observed Draco still in nappies in 2018 and discussed safeguarding supervision, but no further action was taken because the home conditions were described as 'fluctuating' and the child seemed to have 'good days and bad days'.

Deteriorating Home Conditions

Ms. Thompson visited the family home again in January 2019 and noted concerns about the 'cluttered' state of the house, although Draco appeared clean and dressed. His mother had expressed difficulties managing five children in their three-bedroom home. Draco attended accident and emergency ten days later with a head injury, reportedly caused by a bed collapsing on him.

On a subsequent routine visit on March 20, 2019, Ms. Thompson observed that the home conditions had "deteriorated." Used nappies were found dumped in the front garden, and food debris and rubbish were scattered throughout the house. During this visit, she noticed a large stair gate on the living room door frame, with Draco repeatedly using a toybox to try and climb over it. Ms. Thompson informed Mrs. Chapman that the stair gate was ineffective as the children were climbing over it and it did not substitute for adequate supervision.

Ms. Thompson told the inquest that the worsening conditions, including the children climbing over the stair gate and on the windowsill, led her to believe a full social worker assessment of the family was necessary. She also noted Mrs. Chapman's refusal to allow her upstairs to check where the new baby would sleep as a "red flag." Despite these concerns, the threshold for a social worker review was deemed not to have been met. Instead, a lower-level referral was made to Norfolk County Council's Children's Advice and Duty Service (CADS) for a less thorough assessment. Ms. Thompson stated she did not escalate the assessment further, believing CADS staff would do so if they deemed it necessary.

Community midwife Kathryn Mitchell, who accompanied Ms. Thompson on March 20, reported in a statement that the house was "unclean and messy" with food scraps everywhere. She observed Draco repeatedly shoving his toybox against the stair gate, dislodging it and making it more unstable.

Family Statements

Mrs. Chapman stated in a written statement that she had been "finding it very hard to manage the house" during her pregnancy and accepted that things "had got out of hand." She claimed she had installed the first stair gate two years prior and added the second shortly before Draco's death to prevent him from climbing over.

Draco's father, David Chapman, described him as a "very fun and mischievous boy." He was unaware of the second stair gate until he arrived at the house after being notified of the accident.

A police officer at the scene found paramedics working on Draco, who was wearing a nappy and had blue lips. Another officer described the house as "incredibly dirty" and "full of bin bags overflowing with dirty nappies," with the floor obscured by rubbish.

Nursery teacher Helen Leverage from Tuckswood Academy, where Draco attended, described the living conditions as "chaos," with children appearing dishevelled and a young girl eating cheese off the floor. Norfolk area coroner Yvonne Blake described Mrs. Chapman as "helplessly disorganised but still able to take them (her children) to school. And was not very good at housework but was a bit overwhelmed."

The inquest is expected to continue for the rest of the week.