Officials failed to act on health visitor’s concerns about ‘chaotic and squalid’ home where a four-year-old boy died days later after getting his head trapped between two baby gates, inquest hears

An inquest heard that officials did not carry out a full social work assessment after a health visitor raised concerns about the “incredibly dirty”, “chaotic and squalid” conditions in the home of four-year-old Draco Chapman. Days later, Draco died after his head became trapped between two stair gates in a doorway, leaving him unable to breathe and causing irreversible brain damage. The case matters because it raises questions about whether stronger intervention by local services might have identified risks in the home before the fatal incident.

The hearing was told that the health visitor had recommended a full assessment of the family, but Norfolk County Council instead opted for a lower-level review. Draco was reportedly trapped in a gap of about six inches between one stair gate and another placed above it to confine him and a younger sibling to the living room. The article says the concerns were raised only days before his death, and the inquest is examining the decisions made by agencies involved and the circumstances that led to the boy’s death.