Inquest into the death of Baylen Pendergast

21y · Male·Complications of blunt head injury resulting from at least two separate acts of trauma (on 17 and 28 November 2013). The traumatic event on 28 November 2013 alone was sufficient to cause death and involved the application of significant non-accidental force.

Baylen Pendergast, 21 months old, died from complications of blunt head injury sustained in two separate traumatic incidents (17 and 28 November 2013). The coroner found injuries were non-accidental and resulted from significant force. Critical failures occurred during his first hospital admission on 22-24 November 2013: a subdural haematoma and occipital fracture visible on CT imaging were not diagnosed; the radiologist's recommendation for MRI was not pursued despite suspicion of non-accidental injury being raised; mandatory child protection reporting procedures were not followed; and discharge on a 'gate pass' occurred without clear documentation of medical decision-making or appropriate follow-up. The coroner identified inadequate clinical reasoning regarding non-accidental injury assessment, failure to consult child protection resources, reliance on a potentially inconsistent history, and poor inter-departmental communication as key contributing factors. Systemic improvements have since been implemented including child protection training, MRI availability, social work staffing, and clearer discharge procedures.