NT Government accepts sweeping reforms after preventable childcare tragedy

This article contains detailed information about the death of a child and the findings of a coronial inquest. Reader discretion is advised. Support services are listed at the end of this article.

The Northern Territory Department of Education has accepted all seven recommendations handed down following the coronial inquest into the death of 22-month-old Ebony Thompson, who died after becoming trapped in loop-top fencing at the Humpty Doo Community & Child Care Centre in August 2023.

Coroner Elisabeth Armitage’s findings were unequivocal and deeply confronting: Ebony’s death was preventable. The inquest identified failures in supervision, environmental risk assessment and regulatory oversight, creating the conditions in which a known hazard went unaddressed and a child remained unaccounted for for approximately 10 minutes. 

During outdoor play, Ebony entered a known supervision blind spot behind a shed. The area contained a 900mm loop-top gate forming part of the chicken coop enclosure. The Coroner found Ebony likely attempted to look over the gate using a tricycle for height. When the tricycle shifted, she fell forward and became suspended by the neck between the loops. 

Medical evidence indicated Ebony had been entrapped for at least four minutes. By the time she was located, her injuries were catastrophic and unsurvivable. 

Coroner Armitage identified three primary factors contributing to Ebony’s death.

The first was the presence of the low loop-top gate in the childcare playground. Although this style of fencing was permitted under existing requirements, Kidsafe had identified loop-top fencing as posing entrapment and strangulation risks. The Coroner found the risk posed by the gate had not been identified by the centre, educators on duty or Quality Education and Care Northern Territory before the tragedy. 

The second was the location of the gate in a known supervision blind spot. The gate could only be seen by educators standing reasonably close to it and was otherwise not visible from most of the playground. While the centre had recognised some level of risk associated with the blind spot, the combined risk created by the gate and its location was not adequately understood or managed. 

The third was the failure of active supervision strategies. Ebony was unaccounted for for about 10 minutes, giving her the opportunity to enter and remain in the blind spot unnoticed. When children transitioned from the playground to lunch, no yard, playground or departure check was conducted to ensure no child had been left behind. The Coroner described this as a systemic failure by both the centre and QECNT. 

Seven recommendations accepted

The NT Department of Education has accepted all seven recommendations, which require changes across regulation, supervision, environmental safety and public awareness.

The recommendations require the Department and QECNT to advocate for stronger fencing standards under the National Quality Framework so that fencing throughout childcare centres, not only perimeter fencing, reflects Kidsafe recommendations for child-safe fencing, including entrapment and strangulation risks. 

They also require authorised officers to be trained to identify entrapment and strangulation risks arising from fencing and playground equipment, and to ensure those risks are addressed during regulatory functions.

QECNT must also strengthen processes for obtaining, considering and sharing Kidsafe fact sheets and other safety notifications relevant to early childhood safety with authorised officers and providers.

Site visit documentation must include regular fencing, barrier and blind spot inspections, supported by current photographs to track changes over time.

The recommendations also require QECNT to educate providers about the benefits of engaging Kidsafe or similarly qualified experts to conduct playground inspections and service risk assessments. Where safety concerns are identified, QECNT may require a service to engage an expert to undertake a playground or risk assessment inspection.

A supervision audit will also be developed and conducted across all childcare centres in the Northern Territory, with penalties to apply where services fail to fully participate or fail to rectify identified issues in a timely way.

The final recommendation calls for a public awareness campaign to alert the broader community to the entrapment and strangulation risks associated with loop and rod-top fencing. Subject to the family’s consent, the campaign may be called “Ebony’s Message” or similar. 

Ebony’s family has also called for broader reforms under the banner of “Ebony’s Law”.

Their proposals include a ban on loop-style fencing, stronger supervision audits, clearer requirements for identifying and reporting blind spots and high-risk hazards, and a three-strikes model for repeated supervision breaches.

While the Coroner did not adopt all of the family’s proposals in full, she said each was worthy of close consideration by the NT Government. 

The implications extend far beyond one service or jurisdiction.

For approved providers, nominated supervisors and service leaders, the inquest reinforces that supervision is a system, not a moment.

Headcounts alone are not enough. Transition points, outdoor play, blind spots and environmental hazards require layered supervision strategies, including final yard, playground or departure checks when children move between spaces.

The findings also challenge services to reassess outdoor environments with fresh eyes. Fencing, gates, sheds, animal enclosures, fixed and movable equipment, pathways and areas with limited visibility should be reviewed through the lens of child behaviour, curiosity, climbability, entrapment risk and visibility.

Importantly, the Coroner’s findings show that compliance with existing standards does not necessarily mean a risk has been eliminated. Professional judgement, expert advice and proactive risk management remain essential.

For regulators, the inquest underscores the need to identify environmental hazards during monitoring and assessment activity, not simply review policies and documentation.

Ebony’s death is a devastating reminder that child safety relies on strong systems, active supervision, safe environments, responsive regulation and a culture in which risks are identified, escalated and addressed before harm occurs.

The official coronial findings can be accessed here.

Support services

Readers impacted by this article can access support through:

Lifeline — 13 11 14
Beyond Blue — 1300 22 4636
Parentline NT — 1300 30 1300
Kids Helpline — 1800 55 1800