A four-year-old boy died after his neck became trapped between two stair gates that had been positioned one above the other, an inquest heard.

Draco Chapman was found unresponsive at his home in Norwich on 2 April 2019, and died three weeks later.

The inquest heard Draco's neck was trapped as he tried to climb between the stair gates, causing a cardiac arrest and irreversible brain damage.

Coroner Johanna Thompson concluded his death was accidental.

A serious case review by Norfolk Children Safeguarding Partnership has recommended that all stair gates should come with a mandatory warning for them not to fitted above another one.

The coroner's court in Norwich heard that Draco's mother, who was 20-weeks pregnant at the time, had been "finding it hard to manage" and the house had "got out of hand".

In a statement, she said she fitted a stair gate on top of another as the children would climb over if there was just one.

She said it was to "stop them from getting out of the lounge and on to the stairs", and to "stop them from hurting themselves".

She said the instructions did not suggest one could not go on top of the other, and she had "seen other people" do it.

On the day of the incident, she said the children had been to school and nursery, and then went to McDonald's as a "Tuesday tradition".

She said she had gone to a parents' evening and left her eldest child, who is now 19, to look after the younger ones.

When she arrived home, she said her eldest was on the phone to the ambulance service and was "screaming Draco isn't breathing".

The four-year-old was taken to the Norfolk and Norwich University Hospital before he was transferred to Addenbrooke's Hospital in Cambridge.

Draco had Noonan syndrome - a genetic condition that can cause a range of health problems. His mother's statement said he had heart abnormalities, was small for his age and had a mental age of a two-year-old.

He was later taken off life support and transferred to Quidenham Children's Hospice in Norfolk where he died on 23 April 2019.

In summing up, Norfolk's assistant coroner Ms Thompson said the serious case review referred to videos on YouTube about using double stair gates, adding that "there may well be an issue that needs to be addressed".

Speaking after the inquest, Draco's father said his son was "mischievous at times, but in a loveable way" and the family had been "destroyed" by his death.

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