Inquest into the death of Baylen Pendergast

Case Number: 2013/361922

Findings Date: 23 June 2023

Magistrate: Derek Lee

CORONIAL LAW | suspicious death of a child; cause and nature of paediatric head injuries; whether head injuries were non-accidental; care provided at Tamworth Base Hospital; management of paediatric head injuries; management of paediatric patients with suspected non-accidental injuries; whether report to child protection authorities should have been made; management of paediatric patients by way of a “gate pass”; provision of discharge summaries

Responses

Recommendations

The Chief Executive Officer Hunter New England Local Health District

1. Urgent consideration be given to prioritising completion of Child Protection Training for firstly, paediatric medical staff and secondly, for emergency department medical staff at Tamworth Base Hospital.

2. Appropriate steps are taken to confirm or ensure that parents and caregivers of children presenting with head injury are being provided with appropriate fact sheets or handouts explaining what symptoms they should be particularly alert for upon discharge and what to do if such symptoms arise.

3. Urgent consideration be given to prioritising the completion of Paediatric Clinical Guidelines training for paediatric medical staff, if same has not already completed.

4. An audit be conducted of the completion of discharge summaries, and the provision of discharge summaries to general practitioners, to ensure that such summaries are being completed and provided in a timely manner following discharge of a paediatric patient.

Circulation of findings

That a copy of the findings in the Inquest into the death of Baylen Pendergast be forwarded to NSW Health for consideration by the Child Protection and Wellbeing Unit in the development of any NSW specific guidelines regarding management of physical abuse and neglect cases involving children and young people.