Doctors believed 22-month-old Baylen Pendergast had suffered a “significant head injury” and further tests were needed after he first presented at hospital on November 22, 2013.

On Tuesday, the Tamworth Coroner’s Court heard medical staff did not follow the injury risk assessment screen which requires mandatory reporting to authorities like Family and Community Services, or police, if the patient answers yes to at least one of eight questions.

The young child died in a Sydney hospital about a week later after his life support was turned off.

An autopsy found he suffered a lack of oxygen and blood flow to the brain, and had been in cardiac arrest, after he was found unconscious in his mother’s Gosse Street, Westdale home on November 28. 

On the first day of the inquest, the court heard Baylen was a “smart, loveable” character who loved dinosaurs, eating and could walk and run “often at full pelt”.

The court heard Baylen’s mother thought he might have fallen and hit his face on his racing car bed about 3am on November 17, 2013. She saw him sitting up in his bed, with vomit and blood on him.

His mother noted that her son, who usually wasn’t clumsy, had another two falls on November 21 – including one where he hit his head on his mother’s bedhead.

The following night her concerns for his health heightened and she took him to Tamworth hospital.

Counsel assisting the coroner Hamant Dhanji told the inquest the doctor had concerns for the child’s health and facial bruising that may have been “non-accidental”.

A CT scan was ordered, but whether or not a fracture in the young child’s skull was determined is one of the issues being investigated by the Deputy State Coroner Derek Lee. 

“Baylen's death unfortunately does raise a number of difficult questions,” Mr Dhanji said.

Baylen left Tamworth hospital with family on a “gate-pass” on November 24.

On the night of November 28, he was found unconscious and was rushed to hospital.

“By 10.15pm Baylen had been in cardiac arrest for 30 minutes, which is a significant time,” Mr Dhanji told the inquest.

He was airlifted to Randwick Children’s Hospital and arrived in Sydney about 7am the following day.

Doctors found a fracture in the rear of his head and multiple hemorrhages in a CT scan.

"He had suffered severe brain damage, leading to brain death … life support was sadly withdrawn,” Mr Dhanji said.

The coroner is examining the cause of, and nature of, the injuries to Baylen, and how he suffered them and “was the care and treatment appropriate”, and whether there was a “failure to properly diagnose head injuries” on the prior hospital visit.

Coroner Lee will also look at whether clinical staff took appropriate measures including notification to authorities, as well as what caused Baylen to lose consciousness on November 24.

The inquest continues.