Inquest into the death of Ebony Thompson

1y · Female·hypoxic brain injury caused by pressure to the neck from entrapment on a loop-topped gate and accidental hanging

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.