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A toddler who suffered a fatal but “invisible” head injury after a short fall at preschool might have survived if he had received treatment sooner.

A report following his death noted it could be considered “an impossible task” for the preschool staff to have realised the significance of his symptoms, particularly as he had been dancing and playing with his friends after the suspected fall.

Lorenzo Miranda was 20 months old when he died in late 2017 at Palmerston North Hospital, where health professionals had been working to understand what was wrong with him - none aware he had taken a seemingly harmless tumble from a chair earlier that day.

The tragic circumstances surrounding his death were outlined in a coroner’s report, which explained there was no reason for childcare staff to have realised he had suffered such a serious injury, but had Lorenzo’s parents been informed of the fall, which nobody witnessed, they might have been able to seek more timely and targeted treatment for him.

Lorenzo’s parents, Beaudene and Ricardo, described him to the coroner as a “happy and energetic boy”, who loved animals, singing and dancing.

“He was the type of child ‘that was always up to something’,” the coroner wrote in the report.

Lorenzo Miranda died after a fall at preschool.

Lorenzo was dropped off at preschool in the afternoon the day before his death.

A WorkSafe investigation noted a teacher heard Lorenzo crying and found him lying on his back on the ground near a chair. Teachers comforted Lorenzo but found no evidence of external injury.

Another teacher noted that before she left the centre for the day, she saw Lorenzo heading off to play with his friends, waving goodbye to her as he went.

Through the afternoon, he was seen playing with rabbits and otherwise playing normally.

His condition began to turn around the time other parents started showing up to collect their own children. Lorenzo started crying, but this was not considered unusual as he often cried when he saw other children being picked up, the report said.

A staff member held him and noticed he seemed hot and clammy, and thought there might be a bug going around. His temperature was taken, but was found to be within a normal range. Another staff member thought the issue might have been that he skipped his afternoon nap.

One staff member cuddled him against her shoulder as he fell asleep. She explained to his father when he arrived that Lorenzo had been sweaty and upset.

The coroner said Lorenzo cried when his father began putting him into the car, and during the drive home, the parents decided to take him to the hospital as he did not appear to be breathing properly.

Neither parent had been told about the suspected fall from the chair, so health staff did not know initially what to focus on for his treatment, instead suspecting he had sepsis.

It wasn’t until 7pm, hours after the fall, which happened about 2.30pm, that a surgeon was informed a CT scan showed Lorenzo had a brain bleed.

“At this time Lorenzo was critically unwell with a massive extradural haematoma,” the coroner said.

Lorenzo Miranda, pictured with his dad Ricardo Miranda and mum Beaudene Wi, died in his parents' arms after a brain bleed in 2017.

The surgeon made a burr hole to relieve the pressure on Lorenzo’s brain, and preparations were made to transfer the toddler to Wellington Hospital for specialist treatment, but before the transfer could happen, Lorenzo suffered a cardiac arrest in the operating theatre.

He was put on life support in the ICU. “Sadly, it became apparent that Lorenzo had an unsurvivable head injury, and he died in the ICU at about 4am on 9 November 2017.”

The surgeon told the coroner the cause of death was from a build-up of intracranial pressure that had been developing from the moment of trauma.

A forensic pathologist said if the fact of a significant fall on to his head had been appreciated at the preschool and he had been brought for medical assessment immediately or within less than an hour, despite the fact he did not appear significantly injured, “there is a very significant possibility that he would have survived this injury”.

“He did eventually receive entirely appropriate neurosurgical treatment but had this been conducted earlier his chances of survival were very good,” the pathologist said.

The WorkSafe investigation had noted the staff dealt with minor slips, trips and falls regularly and there was nothing about this one to place the staff on alert.

“There were small and unremarkable changes in Lorenzo that went unnoticed by staff. This was compounded by several staff being involved after the incident, meaning that no one person was able to notice changes in him following the incident,” the report said.

Lorenzo was taken to Palmerston North Hospital where health staff discovered he had a brain bleed.

“It is unfair to expect such staff to recognise the symptoms and behaviours demonstrated by Lorenzo that day – the whole incident lasted only two and a half hours, which was a short period in which to recognise the significance of changes in him and reach a sound conclusion; ‘It could be said that it was an impossible task.’"

However, Lorenzo’s parents were best placed to recognise unusual changes in him, and had they been told about the suspected fall, they could have advised hospital staff accordingly.

The Early Childhood Council advised WorkSafe that there had previously been calls to install CCTV technology in centres.

“Those calls were unfavourably received, due to initial set-up costs and confusion over the operation of the technology.”

It was noted that some centres have the technology installed and find it works perfectly well, and that costs have significantly dropped.

Lorenzo Miranda died in November 2017 after suffering a fatal head injury in a fall at daycare.

“There is no question that had there been video footage of this incident, the management of, and care of Lorenzo might well have been different.”

The coroner said the incident highlighted the importance of informing parents about suspected or seemingly harmless injuries, though recognised there was nothing to suggest to staff that they needed to record or communicate what had happened.

“Although preschool staff suspected that Lorenzo had experienced an unwitnessed fall; due to a combination of factors including a lack of obvious injury, Lorenzo’s continued participation in usual play activity, his short time at day care, his involvement with a number of staff throughout the afternoon and exhibiting predictable late Wednesday afternoon tiredness - the significance of this fall was understandably not appreciated.

“The subsequent guidelines developed by the Early Childhood Council following Lorenzo’s death addresses the gap identified. That is the risk associated with the ‘invisibility’ of head injuries and the inability of nonverbal children to communicate the reason for their distress.

“The management of these situations requires a vigilant and uncompromising approach in early childhood settings.”

The coroner did not make any recommendations.