Coronial
NTother

Inquest into the death of Ebony Thompson

Deceased

Ebony Jules Thompson

Demographics

1y, female

Date of death

2023-09-02

Finding date

2025-10-24

Cause of death

hypoxic brain injury caused by pressure to the neck from entrapment on a loop-topped gate and accidental hanging

AI-generated summary

Ebony Thompson, aged 22 months, died from hypoxic brain injury caused by neck entrapment in a loop-topped chickencoop gate at a childcare centre. She became trapped while standing on a tricycle attempting to view chickens, the tricycle rolled away, and she became suspended by her neck in the gate loops for approximately 4-10 minutes before being found unconscious. Key preventable factors included: the presence of a hazardous loop-topped gate in a supervision blind spot behind an island shed; failure to identify and manage entrapment/strangulation risks despite Kidsafe public warnings; inadequate supervision allowing a 10-minute gap in accountability; missing departure/yard checks when children transitioned to lunch; and the centre's failure to notify regulators of a 2022 fence reconfiguration that enlarged the blind spot. While regulations permitted the gate design, expert evidence confirmed entrapment risks were not appreciated by centre staff or the NT regulator (QECNT). Immediate CPR would not have saved Ebony given the catastrophic hypoxic injury sustained.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

paediatricsemergency medicineintensive careforensic medicineoccupational and environmental health

Error types

systemcommunicationdiagnosticdelay

Clinical conditions

hypoxic brain injuryneck compression injuryairway compressioncarotid compressioncardiac arrestunconsciousnessirreversible neurological damage

Procedures

CPRintubationendotracheal tube insertioninterosseous infusiondefibrillationemergency resuscitation

Contributing factors

  • presence of low loop-topped chickencoop gate creating entrapment and strangulation hazard
  • gate located in supervision blind spot behind island shed
  • inadequate active supervision of children in playground
  • unaccounted child for approximately 10 minutes
  • no departure/yard check when children transitioned from playground to lunch
  • absence of procedural requirement for final sweep of spaces being exited
  • inadequate risk assessment and management of gate hazard by centre staff
  • failure of centre to notify regulator (QECNT) of 2022 fence reconfiguration
  • failure of QECNT to identify entrapment risk during assessments and compliance visits
  • insufficient awareness of entrapment and strangulation risks from loop-topped fencing among early childhood providers and regulatory officers
  • inadequacy of National Regulation 104 regarding fencing standards in childcare centres
  • child's height (90cm) matched gate height (90cm) enabling head entrapment

Coroner's recommendations

  1. NT Department of Education and Training with QECNT to advocate for strengthening of fencing standard in National Quality Framework to reflect Kidsafe recommendations for child-safe fencing including entrapment and strangulation risks
  2. Ensure authorised officers are aware of entrapment and strangulation risks from fencing and playground equipment and require them to actively identify and address such risks during inspections
  3. Put in place processes to obtain and consider all Kidsafe Fact Sheets and notifications, ensure authorised officers are aware of such notifications, and share with all childcare service providers
  4. Ensure site visit documentation includes requirement to conduct fencing/barrier and blind spot inspections at regular intervals with current photos maintained by QECNT
  5. Educate providers on benefits of engaging Kidsafe or similarly expert playground inspections and service risk assessments; where safety concerns identified, require appropriate expert inspection
  6. Develop and conduct supervision audit across all NT childcare centres with specified penalties for non-participation and failure to rectify identified issues in timely manner; conduct similar audits at appropriate frequency
  7. NT Government undertake public awareness campaign alerting general public to entrapment and strangulation risks of loop and rod-topped fencing, potentially called 'Ebony's Message' with family consent
Full text
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Source and disclaimer

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