By Laura Banks
An incorrect diagnosis at a NSW regional hospital led to a vulnerable toddler being discharged with a skull fracture and a brain bleed, only for the boy to die eight days later.
Deputy Coroner Derek Lee this week released damning findings into the suspicious death of 21-month-old Baylen Pendergast, who presented at Tamworth Hospital on November 22, 2013.
Baylen Pendergast, who was 21 months old, died after sustaining “non-accidental” head injuries in 2013.
Hospital staff missed the toddler’s head injuries on a CT scan, failed to follow up with an MRI, did not recognise his injuries and report them and discharged him with inadequate follow-up.
“The cause of Baylen’s death was complications of blunt head injury resulting from at least two separate acts of trauma. It is most likely that these acts of trauma occurred on 17 and 28 November, 2013,” Lee wrote in his findings. “The injuries were the result of the application of significant force by another person or persons.”
In response, the hospital this week admitted it had let Baylen down.
“We did not provide him with the care he deserved,” Tamworth Hospital general manager Yvonne Patricks said in a statement.
Baylen died eight days after being discharged from Tamworth Hospital.
“We accept the coroner’s recommendations and continue to work on ways we can further improve our standards of care.”
Baylen’s paternal grandmother Ruth Pendergast said the family found little comfort in the findings for the boy they called “Little Snowy”.
“It’s been a very long nearly 10 years, whoever did it, they need to have a conscience and come forward, nothing will bring Baylen back, he will never be forgotten, but he deserves justice,” Pendergast told this masthead.
Baylen first presented to Tamworth Hospital on November 22, 2013, with bruising to his face, shins, forearms and chest, and a cut near his right eye. His mother, Zoe Merlin, told doctors he had fallen from his bed four days earlier and had been vomiting.
A CT scan was sent to an overseas radiologist for review. The radiologist initially found no fractures or haemorrhages, but an MRI was suggested after consultation with Tamworth doctors.
Baylen’s father Luke Pendergast has not lost hope that justice will be realised.
Consultation between the teams at Tamworth and a John Hunter Hospital neurosurgical registrar found there could be a more serious injury. However, no further investigations were ordered and Baylen was discharged on November 24.
The treating doctor contacted his mother on November 28 after she failed to update his condition. He was told the child had seen a GP the day before and was improving.
Hours later, NSW Ambulance would be called after Baylen was found “lying in bed, unconscious”. He was rushed back to Tamworth Hospital, then flown to the Sydney Children’s Hospital in Randwick, where he died on November 30.
His mother would later tell friends she heard “a loud thump” in Baylen’s bedroom that night and that her boyfriend claimed the noise occurred when he “kicked his toe” while putting Baylen back to bed.
A post-mortem found fresh skull fractures and brain bleeds, as well as evidence of previous serious head trauma.
The coroner found that none of the doctors at Tamworth followed child protection policy and that even the “slightest” suspicion of child abuse should have been reported.
Following Baylen’s death, additional guidelines were introduced at Tamworth Hospital, and changes were made in 2018 to child protection training at the hospital. But as of April last year, only 37 per cent of emergency department and 24 per cent of paediatric medical staff had completed the mandatory training.
The coroner recommended staff at Tamworth urgently complete the training, asked for fact sheets to be given to parents of children with head injuries, advised that an audit be carried out on paediatric discharge summaries to ensure they are completed and forwarded to GPs and asked that Baylen’s inquest be sent to the state’s child protection and wellbeing unit to be used in the creation of future policy.
Despite no criminal charges being laid over the child’s death, Baylen’s father Luke has not lost hope that justice will be realised.
“You didn’t deserve this mate. You should be here with us. I love you,” he said.
Baylen’s inquest was halted five years ago and referred to the Director of Public Prosecutions as the coroner believed there was enough evidence for a jury to convict a “known person” over Baylen’s death. But in 2020, the DPP handed the case back. A spokesperson said there were no plans to reopen it.
A NSW Police spokesperson said detectives continued to investigate Baylen’s death.
Health Minister Ryan Park said the coroner’s recommendations would be considered thoroughly, “to enable lessons to be learned and acted upon”.
“I know that since then, a number of improvements have been instituted in Hunter New England Local Health District hospitals,” he said.
“But of course, we can always do better, and I will continue to work closely with the broader health system to do so.”
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