Inquest into the death of Baylen Pendergast

Contributing factors

• failure to diagnose subdural haematoma and occipital fracture on initial CT scan
• failure to pursue MRI imaging despite radiologist recommendation
• failure to escalate concerns about possible non-accidental injury to child protection authorities
• inadequate clinical reasoning regarding non-accidental injury indicators
• failure to consult child protection resources and guidelines (Mandatory Reporter Guide)
• lack of awareness of all household members and incomplete history taking
• delayed and undocumented follow-up after gate pass discharge
• no completion of discharge checklist
• absence of clear policy guidance for gate pass discharge in 2013
• unclear neurosurgical consultation regarding fracture confirmation
• second traumatic event on 28 November 2013

Coroner's recommendations

1. Urgent consideration to prioritise completion of Child Protection Training for paediatric medical staff and emergency department medical staff at Tamworth Base Hospital
2. Appropriate steps to be taken to confirm or ensure parents and caregivers of children presenting with head injury are provided with appropriate fact sheets or handouts explaining symptoms requiring further medical management upon discharge
3. Urgent consideration to prioritise completion of Paediatric Clinical Guidelines training for paediatric medical staff
4. Audit of completion of discharge summaries and provision of discharge summaries to general practitioners to ensure timely completion following discharge of a paediatric patient
5. Copy of findings forwarded to NSW Health for consideration by the Child Protection and Wellbeing Unit in development of NSW-specific guidelines regarding management of physical abuse and neglect cases in children