A head knock at preschool led to a toddler’s death
OPINION
June 12, 2025
Less than 12 hours after Lorenzo Miranda’s parents picked him up from what they’d thought had been an uneventful afternoon at Palmerston North’s Little Monkeys Preschool on November 8, 2017, the 20-month-old boy was dead.
His whānau would later discover that he’d had an apparently unobserved fall at the early childhood centre around 2.30pm and suffered a brain injury.
His parents rushed him to the Palmerston North ED when they noticed he had turned green and seemed very unwell on the drive home from preschool.
He died in hospital at 4am the next day after going into cardiac arrest during surgery.
Staff did not tell Lorenzo’s parents about his suspected fall when they arrived to collect him. In fact, it wasn’t until 10.30pm, when Lorenzo was in hospital receiving emergency medical care, that the centre told Lorenzo’s father his little boy might have fallen earlier in the day.
That meant that medical professionals did not know what was wrong with Lorenzo for several hours after he arrived at the ED, and were not able to give him treatment that probably would’ve saved his life, had it been administered more quickly.
Lorenzo’s family faced a long wait for answers; it took nearly seven years for the likely cause of Lorenzo’s death to be confirmed. Coroner Amelia Steel released her finding into the circumstances surrounding the toddler’s death in October 2024. However, the outcome of the coronial inquiry has only just been made public after media reporting about it.
Steel concluded that Lorenzo suffered an extradural haemorrhage from hitting his head after a short fall.
“This meant that blood was gradually bleeding into the space between the inner surface of the skull and the dura membrane that lines the skull.”
His chances of survival were very good had the doctors known earlier about the fall
Forensic Pathologist Dr Sage stated: “Had the fact of a significant fall onto his head been appreciated at the daycare centre (it was apparently unobserved), and had he then been brought for medical assessment immediately or soon (less than an hour) after the fall even though he did not initially appear to be 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.”
While WorkSafe concluded in its report into Lorenzo’s death that it would been unfair to expect staff at the ECE centre to recognise from Lorenzo’s symptoms and behaviours just how seriously he’d been hurt, in the Office of Early Childhood Education’s view there were several shortcomings in how the centre dealt with his injury.
- Lorenzo was in an inappropriate environment for his age – in the preschool room – with an adult-sized table and chair (Lorenzo was seen crying on the floor near the leg of an adult-sized chair – the facts outlined in the Coroner’s report point to Lorenzo having fallen from a chair that was an inappropriate height for him)
- Several staff, coming and going, were involved in Lorenzo’s care, with no one taking the lead (no primary caregiver)
- Lorenzo’s fall was never recorded
- Possible signs of a head injury were missed
Ministry of Education
The Ministry of Education did not immediately investigate and it would not have investigated had a complaint not been later made.
On March 7, 2018, the Ministry of Education received a complaint about how Lorenzo’s alleged fall was handled.
Ministry investigators concluded that there was no evidence that the teachers at Little Monkeys Preschool had failed to follow any health and safety procedures/practices in relation to Lorenzo’s suspected accident.
However, they did identify “a number of hazards” at the centre. While these had been resolved by April 9, 2018, a Ministry staffer in an email urged the centre owner to ensure she and her staff were “familiar with the Playground Safety Standards and the Premises and facility licensing criteria”.
The ministry raised issues about what active supervision was and the importance of implementing active supervision, and it raised the appropriateness of adult-sized furniture for young children in the group setting. But the concerns were considered by the ministry to represent breaches in compliance with regulations. But, it did not view the hazards to be related to Lorenzo’s alleged accident.
The changes we’d like to see
In the OECE’s view, the circumstances surrounding Lorenzo’s death show that health and safety regulations for ECE need to be strengthened, not pared back (which is what the Government is currently doing through its regulations reform).
Active supervision of children must become a requirement in all ECE settings – not a “nice to do” or optional.
Service providers must be required to ensure that every adult working with children has received an induction on what active supervision entails, and assessed the adult’s skills in supervision before allowing the adult to be responsible for children.
In centres, adult-sized furniture, chairs and couches in particular must not be in rooms that children can access if the furniture is too high for the child’s age or development to get on and off safely. As a rule of thumb, if the child’s feet can’t touch the ground when sitting, then the chair is too big for the child.
A primary caregiving system for all children under 2 years in centres must be introduced as a requirement for ECE centres. The problem at present is that centres with high staff turnover and multiple staff working on short shifts can lead to an infant having 5 or more different people caring for them in any single day, resulting in adults not having a close relationship with the child and not having intimate knowledge of the child (e.g. their personality, health and behaviour), and no one taking responsibility for the child.
We hope that the sector will learn from this tragedy, so that no other children die in similar circumstances.
Key lessons for all ECE services from this tragedy
In a specialised report for teachers and educators, the OECE has summarised what happened and what we believe the key lessons are for service providers, managers, and educators from this tragedy.
Login with your ECE service member details and go to the specialised report here: Learnings from Lorenzo Miranda’s tragic death.
