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Coroner rules on toddler found at Humpty Doo early learning service
Freya Lucas
Mar 25, 2025
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The Northern Territory coroner has ruled on the case of a child who lost consciousness at a long day care centre outside Darwin, passing away two days later.
Before continuing to engage with this piece readers of The Sector should be aware that it discusses the death of a child, and consider their own wellbeing before proceeding.The incident took place at the Humpty Doo Community and Childcare Centre in August 2023, and was the focus of a four-day inquest in Darwin last week.
Ultimately the coronial inquest found that the toddler’s death was most likely her becoming trapped in a common pool fence which was used to keep chickens enclosed. The inquest is expected to receive submissions in the coming weeks before the coroner makes formal findings and recommendations.
The child was two months away from turning two years of age when the incident occurred, resulting in her death two days later in the Royal Darwin Hospital when her family elected to turn off her life support.
Evidence supports fence theory
During the inquest Northern Territory Coroner Elisabeth Armitage heard evidence from staff at the service, first responders and medical experts.
Two doctors testified that the toddler's death was likely the result of a hanging, after her neck became trapped between the circular loops of the pool fence.
At the time of the incident the police ruled her death as "non-suspicious", with officers commenting on the ‘extremely unusual’ circumstance of the toddler being unconscious and upright against the fence.
An autopsy was unable to determine the cause of death, however during the inquest former NT chief forensic pathologist Marianne Tiemensma said a review of the autopsy results and other evidence found infection, sickness, poison or congenital abnormality were unlikely.
"Because we can exclude those, the only reasonable explanation we are left with is pressure to the neck," she told the inquest.
The educator who found the child testified that she was standing upright at the time, and that no part of her body was stuck or trapped in the fence, however emergency paediatrician and Kidsafe Queensland president Ruth Barker said the worker may have been mistaken, given the traumatic circumstances.
"Once unconscious, you're telling me that she could not be bearing her own weight, [so] how does she remain vertical?" Judge Armitage asked.
"The only way I can see that she would remain vertical is if she was suspended with her head caught between the loops," Dr Barker replied.
Policies and actions scrutinized
The centre director noted that neither KidSafe NT nor the NT Regulatory Authority (Quality Education and Care NT) had identified the chicken coop fence as a hazard.
CCTV footage from the day of the incident showed three educators leading children in from the playground for lunch about 11:40am, when they realised the child was missing.
Judge Armitage said it was her belief that by that point, the child had lost consciousness against the fence, in a blind spot in the playground of the service.
Two of the educators on duty at the time told the inquest they could not remember if they had been told that the blind spot had been identified in the centre's supervision policies as a "high-risk" area in 2022.
At the time of the incident the staff chose to lift the child and take her across the road to a doctor’s clinic, despite all having CPR training, a decision which was critiqued by staff in the doctor’s office.
"I knew the child had been gone for a while," one of the GPs testified.
“"What confused me was that [if] all the staff were trained in CPR, why wasn't it initiated where she was found? And then later on I could've been called. Why was the child carried here all the way, wasting time?"
The coroner, however, said that she understood why the educators had taken the actions they did.
"I probably would've scooped her up and run into the office as well, rather than immediately do CPR there," she said.
"You can do all the CPR training in the world, but at the moment when you're confronted with that situation, you might not have the capacity to do it."
The inquest is expected to receive formal submissions in the coming weeks before the coroner hands down findings and recommendations.
This piece draws on coverage compiled by the ABC. Access that coverage here.
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