The death of a toddler who became trapped in looped-top fencing at an Australian childcare centre was “preventable”, a coroner has determined.
Ebony Thompson was unsupervised in a playground “blind spot” at Humpty Doo Community and Child Care Centre near Darwin for about 10 minutes on August 31, 2023.
By the time she was found by staff at the gate to a chicken coop, the 22-month-old was blue and unresponsive.
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She was rushed to a nearby medical centre but sadly never regained consciousness and died at Royal Darwin Hospital two days later in a tragedy that has sparked calls for an overhaul of safety standards.
Northern Territory Coroner Elisabeth Armitage determined the little girl had suffered irreversible brain damage caused by accidental hanging when she tried to peer at chickens over the 90cm-high gate.
Armitage agreed with Officer in Charge Wayne Roomes that it was likely that Ebony had been standing on a red, yellow and blue tricycle when it slipped out from under her, trapping her between the loops of the fence.
The death of Ebony, who would have turned four on Wednesday, need not have happened, Armitage said.
“Parents entrust their children to childcare services every day and expect to collect them healthy and well every evening,” she said in inquest findings handed down on Friday.
“Ebony’s unexpected death invokes fear in all parents of young children and is a tragedy and source of anguish for her family, friends and the wider community.”
‘Systemic failure’ Staff went looking for Ebony, one of 15 children in the Green Ants room for kids aged between two and three, when they realised during a head count she had not left the playground with the others to prepare for lunch.
The chicken coop gate, constructed in the style of many loop-topped pool fences but only about waist-high to most adults, was at the end of a pathway behind a shed in a known “supervision blind spot”.
Armitage said it was difficult to understand how a yard check was not part of the centre’s active supervision strategy, calling it a “systemic failure on the part of the centre and Quality Education and Care NT (QECNT)“, the regulatory authority in the Territory.
“Ebony was entrapped for four minutes or more,” she said.
“Accepting the expert evidence … concerning the speed at which a child would become unconscious due to compression of the neck and thereafter suffer irreversible brain injury, I am satisfied that when she was found her injury was catastrophic and unsurvivable.”
Ebony Thompson was just 22-months when she died. She would have turned four this week. Credit: NT Coroner’s Office The blind spot behind the centre’s shed had been highlighted to staff during a 2022 meeting as a “high risk area”, meaning “supervision is always required”.
But the centre was up to scratch in all areas of the National Quality Framework (NQF) at the time of Ebony’s accident, and there was “nothing” in a 2020 assessment to indicate that the regulator had any concern about the blind spot.
No issue with the gate was picked up either during two regulatory visits in the 12 months before she died, when one child tripped over and another walked through an open gate and into the carpark — although improved safety checks of the outdoor area were required after the latter incident.
“Whilst this incident required a response from the centre, which included an education session with staff regarding supervision and a revised supervision procedure, the fact that Ebony was not positively accounted for over a 10-minute period demonstrates that in spite of those efforts, there was another occasion of inadequate supervision, this time with tragic results,” Armitage said.
Ruth Barker, a veteran paediatrician and director of the Queensland Injury Surveillance Unit, said the best approach to safety involves removing hazards because it is impossible to eliminate all supervision lapses.
A taller, flat-topped gate was installed immediately after Ebony’s emergency to prevent children accessing the original chicken coop gate, which along with the shed has since been removed.
“Tragically, this simple fix was too late for Ebony,” Armitage said.
QECNT director Katy Brennan told the inquest the regulator was ramping up activities around safety, with supervision audits across all services.
The gate where Ebony was found unconscious. Credit: NT Coroner’s Office When she died, the only regulation around fencing and barriers in childcare centres was that preschool-age kids and younger “cannot go through, over or under” it.
“The regulation is silent on the risks of entrapment and its minimal terms effectively authorised the presence of the lethal loop-topped chicken coop gate,” Armitage said.
Brennan had explained that because the standards are regulated by the national framework, any change “would have to be adopted nationally” and the NT “could not act unilaterally”.
Armitage has put forward several recommendations, including that NT authorities push for standards in the national framework that address entrapment risks, and for the territory’s government to undertake a public awareness campaign around the dangers of loop and rod-topped fencing.
Ebony’s family have also proposed a number of changes. The first, which would be known as “Ebony’s law”, is for loop-style pool fencing to be banned, and another is a “three strike rule” that would force the closure of centres that breach supervision obligations until they are corrected.
“While my recommendations are not as comprehensive as those submitted by the family, each of the family’s recommendations is worthy of close consideration by the NT Government, and I have repeated all of them in full so that can occur,” Armitage said.