Supervision issues flagged before Ebony Thompson was left alone for five-minutes at Humpty Doo childcare centre yard
WARNING: DISTRESSING. Staff and management at a Territory childcare centre were aware of issues around monitoring all kids in care in the months before a toddler’s death in a suspected accidental hanging.
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UPDATE, Thursday 6pm: A ‘damning indictment’ of a Humpty Doo child care centre’s ability to watch all of the kids in its care was exposed in an internal audit, the coroner has heard.
The barrister representing Ebony Thompson’s family, Luke Officer, said staff and management at the Humpty Doo Community and Child Care Centre were well aware of supervision issues at least a year before the unexpected death of the 22-month-old toddler.
Over the three day inquest, coroner Elisabeth Armitage has heard of at least three serious supervision breaches before Ebony’s death, including an injury near the bubblers, a little one who escaped, and a child who was found ‘stuck’ on a fence.
Ms Armitage said while supervision maps had been developed to show staff where they had to stand while watching the kids, there were simply not enough workers to cover all the ‘high risk areas’.
At the time of Ebony’s incident on August 31, 2023, there were three staff supervising 15 kids in a garden with six identified blind spots.
“There’s not enough staff usually in the playground to cover all areas, particularly if there are blind spots,” Ms Armitage said.
Centre director Rachel Marsh said while the policy said staff should attempt to position themselves to watch all the “high risk areas” and “blind spots” — in reality “you go to where the children are”.
Mr Officer suggested that by not diligently watching all these blind spots, staff missed the critical moment when Ebony wandered off from the group.
It was Ebony’s love of watching the centre’s pet chooks that likely enticed her behind the shed, and it is suspected while attempting to peek over the fence she slipped and accidentally hanged herself.
Nine minutes after the last headcount, Ebony was found unresponsive, unconscious but still ‘standing’ and gripping the metal bars.
No supervision audits were completed for the monitoring of the two and three-year-olds’ playgroup areas in either 2022 or 2023.
Mr Officer said the August 2022 audit of the centre’s monitoring of three to five-year-olds was a “pretty damning indictment … that supervision is an issue at the centre”.
Ms Marsh acknowledged her staff flagged there “wasn’t enough shared supervision”, there were issues with the “positioning” of staff, and complaints there was not “adequate supervision” of the children.
Ms Marsh said playground risk assessment was conducted that year, but it did not include the chicken coop area.
Following Ebony’s death the centre has installed a gate to block access to the blind spot where she was discovered, with Mr Officer questioning why this “simple step” was not taken before the tragedy.
“It was identified as a high risk area, and a potential hazard, why weren’t steps taken to eliminate that potential hazard as opposed to just simply saying ‘it needs to be supervised’?” Mr Officer said.
But Ms Marsh said before Ebony’s death there had been no incidents in that specific area, and the regulator, Quality Education and Care NT had not flagged any issues.
The coroner heard it was only after Ebony’s death the hip-height looped fence was identified as a potential “entrapment mechanism”, possibly resulting in an accidental hanging.
Two childcare centre workers told Ms Armitage despite their CPR First Aid training they were too panicked to attempt to revive her, and instead rushed to a medical clinic across the road.
Humpty Doo Family Practice medical centre doctor Salahuddin Khan said as soon as he saw her tiny body he knew “it was too late”.
Dr Khan said she was not breathing, there was no pulse, and even her arms and legs had turned “completely blue”.
Despite CCTV showing Ebony was alone in the yard for five minutes, Dr Khan said “she had been gone for at least 10 minutes, maybe more”.
Dr Khan said had CPR been started immediately it “definitely” would have made a difference to young Ebony’s survival prospects.
“If it’s done within 10 minutes then there was a good chance we could have revived the child,” he said.
He said he was not certain what caused the medical incident, as she was not showing signs of choking and there were no marks around her neck to indicate a hanging.
However, Dr Khan said it was possible a “slow” pressure on the neck area restricting blood flow would not have produced these marks, alternatively she could have suffered a rare genetic heart condition.
Toddler alone for five-minutes at childcare centre yard before suspected hanging
UPDATE, Wednesday 5pm: Her family trusted that their baby girl would be watched and cared for, yet for 300 seconds a Territory toddler was left alone and unsupervised before her suspected accidental hanging.
On the second day of the coronial inquest into her unexpected death, Ebony Thompson’s family heard it remained unclear exactly when their “little pudding” wandered into a known ‘blind spot’ at the Humpty Doo Community and Child Care Centre on August 31, 2023.
However Coroner Elisabeth Armitage was told there was a five-minute gap where the 22-month-old girl was left alone in the garden, while all other children were getting ready for lunch.
The staff member who discovered the toddler, Harpreet Kaur, started to weep as she remembered holding Ebony’s limp body and watching as her pale face turned blue.
Despite her CPR and First Aid training, Ms Kaur said she was too overwhelmed to try and revive Ebony herself.
Just 24 seconds after she was run into the office, Ebony was taken across the road to the Humpty Doo Family Practice medical clinic.
Two days later on September 2, Ebony died of a severe hypoxic brain injury, meaning not enough oxygen had reached her brain.
Counsel assisting the coroner Chrissy McConnell said the autopsy was unable to determine her immediate cause of death.
A police investigation suggested a possible cause of her death was “pressure on the neck by hanging”, but Ms Kaur maintained Ebony appeared to be standing at the fence line.
“She was looking like she was watching the chooks,” Ms Kaur said.
Ms Kaur said she did not remember where the child’s feet were — whether they were on the ground or on the bar — but said she did not have the impression she was “hanging”.
The Thompson’s barrister Luke Officer suggested that in her panic, Ms Kaur may have missed that Ebony’s head was lodged between the loops of the fence.
“No. Her face was down, like leaning over her shoulder towards the shed,” she said.
Ms Armitage has repeatedly heard the shed where Ebony was discovered was a known “blind spot” in the garden.
A casual staff member Kaitlyn Maloney said the supervision maps were prominent around the centre, clearly identifying ‘high risk areas’ that needed to be closely watched at all times while children were present.
Ms Kaur, a room leader, said she did not recall ever seeing a supervision plan and said she received no induction or formal guidance when she joined the centre.
But she said ‘common sense’ meant staff had worked out that the shed near the chickens needed extra vigilance — not only because of the low visibility but also because of the snake risk.
Despite the formal guidelines, Ms Kaur said in practice educators moved to the locations where children were playing.
At the time of the final headcount at 11.32am, Ms Kaur remembered seeing Ebony in the sandpit.
Five minutes later the room leader started taking the first group of kids inside to wash their hands before lunch.
She told police she trusted her staff to watch the yard, yet CCTV showed the two other workers followed her inside 30 seconds later — critically without a final check around the yard.
Ms Armitage heard that for five minutes childcare centre workers were preoccupied with herding 14 “chaotic” toddlers into the bathroom, before Ebony’s absence was realised.
The coroner heard this was not the first major safety breach at the centre that year, with a child escaping from the centre in February.
Mr Officer suggested there was a lack of accountability from the centre’s management to ensure staff were fully across the current policies and procedures.
He said while staff were told to read and sign off on these documents, there was no one enforcing they were studied closely.
The coroner heard staff meetings were held after hours at 6pm, and workers who were unable to attend were expected to use their 40-minute lunch breaks to read through the agenda minutes.
Unresponsive toddler discovered in childcare centre’s ‘blind spot’
INITIAL, Tuesday 5pm: Medical experts were unable to fully determine how a Northern Territory toddler was discovered clinging to a childcare centre fence, standing yet unconscious as she rapidly turned “blue”.
Her grieving family watched through tears as coroner Elisabeth Armitage opened the coronial inquest into the unexpected death of 22-month-old Ebony Thompson on Tuesday.
Over four days, Ebony’s grieving family will hear from 14 witnesses including the childcare centre staff, police, medical experts and education regulators, to explore how she suffered a medical incident at the Humpty Doo Community and Child Care Centre in 2023.
Counsel assisting the coroner Chrissy McConnell said the morning Ebony’s mother Jade dropped her off was like every other Thursday.
Ebony was one of 15 kids in the Green Ants room on August 31 for a morning of playing, frolicking in the sand pit and watching the chickens.
The coroner heard there was a critical 10 minute window around 11.30am where the toddler wandered away from the group.
It was only when staff called the roll before lunch that they noticed a child was missing.
Staff member Harprett Kaur discovered the little one in a known “blind spot” behind a shed in the yard at 11.41am — unconscious and unresponsive.
Ms Kaur said she found Ebony “turning blue” but still standing and gripping onto the fence line.
In body cam footage Ms Kaur told police she immediately picked Ebony up, but did not find any signs of bite marks or anything in her mouth.
“She didn’t scream or cry or anything,” Ms Kaur said.
NT Police Sergeant Wayne Roomes told the coroner it was an “odd scenario” for a person to be discovered blue in the face but still standing.
“The only logical conclusion I could come to was that she tried to get over the fence, got a bit higher and lost her footing for whatever reason,” he said.
“And the hoops got under her jaw, and she couldn’t get herself off.”
Coronial investigator NT Police Detective senior Constable Chris Wheeler also suggested a possible cause of her death was “pressure on the neck by hanging”.
Under cross examination from the child care centre’s barrister Adam Mason, Mr Wheeler confirmed Ms Kaur had not indicated Ebony’s head was “stuck” or over the fence, or that her feet were off the ground.
The coroner heard after staff tried desperately to revive her, Ebony was rushed to the Humpty Doo Family Practice medical clinic across the road.
Ebony’s mother, Jade, was at the clinic, with the first police officer on scene describing her as “very distraught”.
His body-camera captured the sounds of her sobs, over the rhythmical beeping of medical equipment as they attempted to save the little girl.
The coroner heard the ambulance arrived within 24 minutes and Ebony was taken to Royal Darwin Hospital in a critical condition.
She was treated in the Intensive Care Unit, and died two days later from a severe hypoxic brain injury on September 2.
“The immediate cause of death … was recorded as undetermined,” Ms McConnell said.
Ms McConnell said the inquest would seek to find answers to questions that have haunted Ebony’s family since her death: How long was their child unsupervised and unaccounted for? Were there enough staff? How was she able to wander off? And could earlier medical intervention have helped saved her life?
Ms Armitage told Ebony’s loved ones the coronial was not just to recognise the “precious” life that Ebony lived, but provide answers to her family and the wider Territory community who needed assurance their children would be safe while at daycare.
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