The death of a 22-month-old girl who became trapped in looped-top fencing at a Darwin childcare centre was preventable, a Northern Territory coroner has ruled. Ebony Thompson was unsupervised in a playground blind spot at Humpty Doo Community and Child Care Centre for about 10 minutes on August 31, 2023, before staff found her blue and unresponsive at a chicken coop gate.
Coroner Elisabeth Armitage determined the toddler suffered irreversible brain damage from accidental hanging when she tried to peer over a 90cm-high gate, likely using a tricycle that slipped from under her. Ebony died two days later at Royal Darwin Hospital. The coroner noted that a taller, flat-topped gate was installed immediately after the incident, but said the simple fix came too late.
Armitage found a systemic failure by the centre and the regulatory authority, Quality Education and Care NT (QECNT), citing inadequate supervision and a failure to address a known blind spot. The blind spot behind a shed had been flagged as a high-risk area in 2022, yet no yard check was part of the centre’s active supervision strategy.
The coroner also highlighted that existing regulations only required fencing to prevent children from going through, over, or under, but were silent on entrapment risks. She called for an overhaul of safety standards, noting that the loop-topped gate was effectively authorized by minimal regulations.
QECNT director Katy Brennan told the inquest the regulator was ramping up safety activities, including supervision audits across all services. The centre had been compliant with the National Quality Framework at the time of the accident, and no issues with the gate were flagged during two regulatory visits in the year before Ebony’s death.
