A Story

A four-year-old boy died after his neck became trapped between two stairgates that had been positioned one above The Other , an inquest heard.

Draco Chapman was found unresponsive at His Family 's home in Norwich on 2 April 2019, and died three weeks later in a children's hospice.

The inquest heard His Mother had installed The Second stairgate to stop her children " from hurting themselves".

Assistant coroner Johanna Thompson concluded Draco's death was accidental.

A serious case review by Norfolk Children Safeguarding Partnership has recommended for all stairgates to come with a mandatory warning for them not to be used together.

The Coroner 's court in Norwich heard that Draco's mother, who was 20-weeks pregnant at The Time , had been " finding it hard to manage" and The House had " got out of hand".

In a statement, She Said she fitted a stairgate on top of another as The Children would climb over if there was just one.

She Said it was to " stop them from Getting Out of the lounge and on to the stairs" and to " stop them from hurting themselves".

She Said the instructions did not suggest one could not Go On top of The Other , and she had " seen other people" do it.

On The Day of The Incident , She Said The Children had been to school and nursery, And Then went to McDonald's as a " Tuesday tradition".

She Said she had gone to a parents' evening and left her eldest child, who is now 19, to look after the younger ones.

When she arrived home, She Said her eldest was on The Phone to The Ambulance service and was " screaming Draco isn't breathing".

The inquest heard Draco had got trapped by his neck by the upper stairgate while trying to climb over the lower stairgate, causing a Cardiac Arrest and irreversible Brain Damage .

Draco, who had Noonan syndrome, was taken to the Norfolk and Norwich University Hospital before he was transferred to Addenbrooke's Hospital in Cambridge.

He was later taken off Life Support and transferred to Quidenham Children's Hospice where he died on 23 April 2019.