‘Tragic accident’ - four-year-old child died after being trapped between stairgates
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The death of a four-year-old child who died after being trapped between two stairgates was a “tragic accident”, a serious case review has found.
The child, who is known as AH, died in a hospice in April 2019 following a cardiac arrest three weeks after the accident at their Norfolk home.
The incident prompted a criminal investigation which has since been concluded.
A review into the child’s death has called for agencies protecting children to evaluate guidance on the safe usage of stairgates, but said that “used in the right circumstances, there is no doubt that stairgates save lives”.
The report, by the Norfolk Safeguarding Children Partnership (NSCP) said the accident, on April 3, took place while AH and three of their five siblings were at home.
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It stated: “Child AH was found trapped in the gap between the original stairgate and one added to prevent the children climbing over the lower one.”
The family’s other children have now gone into foster care or are being looked after by the council.
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The report found a number of “concerns about neglect” were known about by agencies during Child AH and their siblings’ lives.
The police who responded to the 999 call said the home, which was in a “socially deprived area” was in “absolute squalor”.
And the report found the house, which was cleaned following the accident, was described as “cluttered with an unpleasant odour from the stained carpets and piles of unwashed clothing”.
It also said: “Forty-five bags of dirty washing were removed by the cleaning company.”
However, the children had never been subject to child protection or children in need plans - but shortly before the accident the family had been referred to family support services, after issues were raised by a health visitor.
The report found that the home, which was said to be “cluttered” had “deteriorated” between January and April 2019.
It stated: “AH was reported to have worn the same clothes all week... they were not toilet trained and not always cleaned after soiling their nappy.” A stairgate was installed due to concerns about a child climbing on upstairs windowsills, but this was described as “unsafe”, with “the children climbing over it” and “trying to force it open”.
In March, the health visitor raised several concerns, including “the filthy condition of the home and garden, the safety of the children, and the risks presented by the stairgate”, which led to the referral for family support - just days before the accident and Child AH’s subsequent death.
But it was found the family did not meet the threshold for a social work assessment.
The report found there were indicators of neglect, including there being “often no food in the house”, children being left in soiled nappies and “sore”, and the accident ahead of Child AH’s death occurring when the children were unsupervised by a parent or appropriate adult.
However, the children were said to be “happy, lively and resilient” with a “warm relationship with their mother who clearly loved them very much and took a pride in their achievements”.
Professionals felt AH’s mother was “overwhelmed by demands of a big family, a low income and no friends or family support”.
Chris Robson, NSCP chairman, said: “This was a tragic accident and the thoughts of the whole partnership are with AH’s family and friends.
“AH’s mother was seeking to protect him by installing these gates and there is no doubt that she loved her children very much.
“The review recommends multi-agency work to review the published risks of using stairgates so that parents and carers know when and how to use them safely.
“However, despite the absolute tragedy of AH’s death, I would not want to deter anyone from installing a gate to stop small children from accessing the stairs.
“Used in the right circumstances, there is no doubt that stairgates save lives.”
The review, which was published on Wednesday, August 5, was commissioned last year to look at how well agencies worked together and to identify any learning that could lead to improving safeguarding practice.
Six recommendations were made, including promoting training on isolation and links to depression, and reviewing neglect risk assessment tools.
Mr Robson added: “There are always things we can learn from any tragedy and, in this case, more could have been done to look at the wider family network. As a partnership, we welcome the recommendations of the review.”