A four-year-boy died after his neck became trapped between two stair gates that were fitted one above the other in a door frame by his mother, an inquest has heard.
An injured Draco Chapman was found by an older sister at home in April 2019, then taken to Norwich and Norfolk University Hospital, placed in an induced coma, transferred to another hospital, and died later that month in a hospice.
The child’s head had become stuck in a six-inch gap between the stair gates leading to the living room in the Norwich property as he tried to climb over, Norfolk Coroner’s Court was told.
His mother Rachel Chapman said she had put the stair gates on top of one another to keep her children safe and to stop them climbing over the lower one and on to the stairs.
Draco suffered neurotic asphyxiation from accidental hanging, and a cardiac respiratory arrest, according to a medic.
Dr Roddy O’Donnell, clinical director of the Paediatric Intensive Care Unit at Addenbrooke’s Hospital in Cambridge – the second medical facility where he was treated – said: “It was clear he had suffered serious and irreversible neurological injury.”
The court was told 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.
Boy’s mother was at a parents’ evening
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 she was at a parents’ evening on 2 April 2019.
Sergeant Graham Green, of Norfolk Constabulary, told the court that after Draco was found injured he was taken upstairs by an older brother who carried out CPR on him and called the emergency services before his mother arrived home.
Mrs Chapman said in a statement: “I returned home and expected it to be normal. My oldest child was on the phone to the ambulance screaming that he (Draco) had stopped breathing. I went upstairs to do CPR and the ambulance staff arrived and took over.”
She said she had fitted the stair gates on top of one another to stop the children climbing over the bottom one.
‘The two stair gates were to keep children safe in the lounge’
She 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 2 April, 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.”
Draco died on 23 April 2019 and the court heard that his mother was no longer caring for her other children.
His death was recorded as accidental by the coroner, Johanna Thompson, 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.”