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

Published: 16:14, 13 July 2026 | Updated: 16:16, 13 July 2026 A health visitor expressed concerns about a four-year-old boy living in an ‘incredibly dirty’ home just days before he died after getting his head trapped between two stair gates, an inquest heard today. But the health visitor’s recommendation for the family of Draco Chapman to undergo a full social worker assessment was turned down by Norfolk County Council bosses, who decided there should be a lower level review instead. Draco was left unable to breathe and with irreversible brain damage after he tried to squeeze through a six-inch gap between one stairgate and another placed above it in a door frame, to keep him and his younger sibling in a living room. Norfolk Coroner’s Court heard how he was found unresponsive by his 16-year-old brother at the semi-detached home in Norwich, Norfolk, where he lived with his four siblings and their ‘helplessly disorganised’ mother, Rachel Chapman. Draco’s brother tried desperately to revive him before Mrs Chapman returned from a school parents’ evening for another of her children and joined in the resuscitation attempts before paramedics arrived on April 2, 2019. He was placed in an induced coma and treated at Addenbrooke’s Hospital, Cambridge, before his life support was withdrawn by doctors and he died on April 23 at Quidenham Children’s Hospice in Norwich. A coroner at an initial inquest in January 2022 recorded a conclusion that Draco’s death was accidental and due to catastrophic brain injury and asphyxiation, caused by hanging. But the finding was overturned after a serious case review by Norfolk Safeguarding Children Partnership found that concerns were raised by health visitor Helen Thompson and staff at Draco’s nursery in the months before his death. A health visitor’s recommendation for the family of Draco Chapman to undergo a full social worker assessment was turned down by Norfolk County Council bosses, who decided there should be a lower level review instead Giving evidence today on the first day of the second inquest, Ms Thompson said Draco’s family had previously been subject to a family support plan, giving them extra support from health visitors. She described how Draco had been diagnosed with a heart murmur and Noonan syndrome, a condition which can cause heart defects and developmental delays, meaning he had the mental age of a two-and-a-half-year-old. Ms Thompson recalled how she noted on earlier visits to the family home that Mrs Chapman, who was 20 weeks pregnant at the time of her son’s death, had been reluctant to claim full benefits she was entitled to. She recorded concerns in January 2016 about the low weight of Draco who was only able to eat pureed food, and noted in January 2017 that his mother was ‘ineffective in enforcing boundaries’. Ms Thompson also noted concerns about Draco still being in nappies in 2018 and discussed safeguarding supervision, but nothing more was done due to conditions in the house ‘fluctuating’ and him appearing to have ‘good days and bad days’. She had more concerns about the family’s ‘cluttered’ home in January 2019, while noting that Draco appeared clean and dressed, although his mother told of her difficulties looking after five children in her three bedroom semi-detached house. Draco attended accident and emergency ten days later with a head injury which was said to have been caused by him trying to lift a bed which then collapsed on his head. When Ms Thompson went on a routine visit to the house later in January, she saw Draco with a dirty face and feet but nothing suggested there should be a safeguarding referral, the inquest heard Draco was left unable to breathe and with irreversible brain damage after he tried to squeeze through a six-inch gap between one stairgate and another placed above it in a door frame But when she visited again on March 20, she found that home conditions were ‘deteriorating’ with three or four used nappies dumped in the overgrown front garden and food debris and rubbish scattered over the ‘dirty’ house. During the visit, she noted there was a large stair gate fitted on the living room door frame, and Draco was repeatedly moving a toybox up to it so he could try and climb over. Ms Thompson said she told Mrs Chapman that the stair gate did not serve any purpose as her children were climbing over it and that it did not replace the need for adequate supervision. She told the inquest that she felt the worsening conditions in the home meant there should be a full social worker assessment of the family, due in part to the children climbing over the stairgate and on the windowsill. Ms Thompson said that Mrs Chapman’s refusal to let her go upstairs, to check where her new baby would sleep after being born, also presented ‘a red flag’ to her. But she said that the threshold for a social worker review was judged not to have been reached - although there was a lower level referral to Norfolk County Council’s Children’s Advice and Duty Service (CADS) for ‘a less thorough assessment’. Ms Thompson said she did not choose to try and escalate a fuller assessment because she believed that CADS staff would do so if it was judged to be needed. Community midwife Kathryn Mitchell, who also visited the family with Ms Thompson on March 20, told in a statement read to the inquest how the house was ‘unclean and messy’ with scraps of food everywhere. The inquest is taking place at Norfolk Coroner's Court in Norwich and is expected to last until next week During the visit, she saw Draco repeatedly shoving his toybox to climb over the stair gate. He also smashed the box into the gate which dislodged it and made it more unstable. Mrs Chapman told in a statement how she had been ‘finding it very hard to manage the house’ during her pregnancy and accepted things ‘had got out of hand’ at her home. She claimed that she had placed the first stair gate on the living room entrance two years earlier and then added the second one shortly before Draco’s death to provide an extra barrier to stop him climbing over. When she returned home from her school meeting, she found her older son, referred to at the hearing as Child A, on the phone to ambulance and screaming that Draco had stopped breathing. Child A said in a statement that he had been upstairs playing video games when his mother had gone out without telling him to look after the children. He described conditions in the house as ‘squalid’. Draco’s father, David Chapman, who was divorced from the boy's mother but regularly visited his children, described him as a ‘very fun and mischievous boy’ who gave him ‘a lot of love and happiness’. He said in a statement that he was not aware that his former wife had installed the second stair gate in the doorway until he rushed to the house after being told of the accident. A statement from a police officer told how he found three paramedics working on Draco who was wearing a nappy and had blue lips. Another statement from a police officer who arrived at the scene described the house as ‘incredibly dirty’ and ‘full of bin bags overflowing with dirty nappies’. The officer added that ‘you could not even see the floor’. Helen Leverage, a nursery teacher at Tuckswood Academy, which Draco attended, said she had visited Draco’s home and described living conditions as ‘chaos’ with children appearing dishevelled and covered in food and a young girl eating grated cheese off the floor. Describing Ms Chapman, Norfolk area coroner Yvonne Blake, said: ‘I got the impression she was a helplessly disorganised but still able to take them (her children) to school. And was not very good at housework but was a bit overwhelmed.’ The inquest, which is due to last until next week, continues.