Report reveals professionals' concerns over home life of tragic Draco
- Credit: David Chapman
Concerns over the state of a four-year-old's home were raised by teachers and a health visitor three months before he died after getting stuck between two stair gates.
The findings were revealed in a serious case review published by Norfolk Safeguarding Children Partnership (NSCP) after the death of four-year-old Draco Chapman, from Norwich, on April 23, 2019.
He died a few weeks after the accident which happened in his home on April 2, 2019, while being cared for by his older siblings, according to an inquest at Norfolk Coroner's Court on January 25, 2022.
His mother, who had five children at the time, was out at a parents' evening when the accident happened and was separated from their father.
Assistant coroner Johanna Thompson concluded Draco died from accidental death and the medical cause of death was catastrophic brain injury due to asphyxiation due to hanging.
No criminal proceedings were brought but the children were put into the care system after the accident.
The report written by NSCP, made up of Norfolk County Council, police and health providers, said: "The three months before the incident were of significance and marked an increase in the level of concerns by the health visitor, the pre-school and the primary school.
"Draco continued to be happy but in mid-March school raised concerns with the mother about him wearing the same dirty clothing all week and having no socks.
"The house deteriorated and was clearly indicative of the mother being increasingly unable to cope and properly supervise the children.
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"These issues were raised with the mother by the health visitor and the mother agreed and said she needed help."
The report, published in June 2020, revealed the family received regular support from the children's centre since 2012 but did not reach the threshold for social services help.
It added: "The children were loved by their mother and professionals felt that she did her best but was overwhelmed by the demands of a big family, a low income and having no friends or family support, but these were not explored to gain a fuller understanding of the causes."
There was no evidence of abuse.
The report recommended professionals should explore the impact of issues of isolation due to depression and better assess and share views about children's living conditions.