The death of a toddler who became trapped on a fence at a childcare centre outside Darwin last year after being unaccounted-for for up to 10 minutes was preventable, a coroner has found.
Ebony Thompson was found by a staff member hanging from the 900mm high loop-top fence in a “blind spot” behind a shed at the Humpty Doo Community & Child Care Centre on August 31 and could not be revived.
In handing down her findings into the 22-month-old’s death, Coroner Elisabeth Armitage ruled Ebony had been trapped in the fence for at least four minutes after trying to lean over it to see into the centre’s chicken coop.
Judge Armitage said the lack of a “yard check” in the centre’s “active supervision strategy” represented a “systemic failure” by the centre and childcare regulator Quality Education and Care Northern Territory (QECNT).
The Humpty Doo Community & Child Care Centre is about 37 kilometres south-east of Darwin. (ABC News: Hamish Harty)
She said the centre’s response to an earlier incident in which a child wandered through an open gate into the centre’s car park had failed to address shortcomings in the strategy.
“There was clearly a lapse of supervision, during which time this escape occurred, and the outcome could have been far more serious if the child had not been located and promptly returned to the centre,” she said.
“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.”
Judge Armitage found that while it would be “impossible to eliminate all supervision lapses” QECNT had also failed to appreciate or adequately manage the risk posed by the fence.
The gate to the chicken coop was secured behind a taller flat-topped gate after Ebony’s death and has since been removed. (Supplied: NT Courts)
“Immediately after the incident involving Ebony, a new blue gate was fitted minimising the possibility of children accessing the blind spot or the chicken coop gate,” she said.
“And later, the island shed and chicken coop gate were removed, thereby eliminating both environmental hazards.
“Tragically, this simple fix was too late for Ebony.”
Judge Armitage acknowledged that childcare centres were regulated nationally but urged the NT government to advocate for upgraded fencing requirements and conduct a public awareness campaign about the dangers of loop-top fencing.
She also recommended the government conduct “a supervision audit across all childcare centres in the NT” and impose penalties on any that failed to rectify identified issues in a timely manner.
Ebony’s family say childcare centres found in breach of their supervision obligations should be forced to rectify the issues. (Supplied)
Ebony’s family called on the government to ban loop-top fencing under the banner of “Ebony’s Law” and introduce a “three strikes rule” that would see centres in breach of their supervision obligations “immediately temporarily closed pending assessment and rectification”.
“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,” Judge Armitage said.