Preschool centre staff wondered whether a child had fallen when they found him crying on the floor, but they did not report the incident, the Ministry of Education says.
He died that night.
Seven documents recording the ministry's investigation into the death of 20-month-old Lorenzo Miranda, who attended Little Monkeys Preschool in Palmerston North, show that staff found the boy "lying on the floor crying" next to an adult-sized table and chairs on November 8 last year.
"They did wonder if he had fallen, but checked him and found no sign of any injury or that he had been unconscious, and while he was upset, they felt he was fine," the ministry said in the first report on November 9, a few hours after Lorenzo died at 4am that day.
But a second report on November 14 said a pathologist believed the brain bleed that killed the child could have been caused by an earlier fall at home.
"Pathologist has said he believes a brain clot caused by an earlier injury (two to three weeks ago) may have caused a clot to form and subsequently burst," the report said.
"The slightest thing could have caused this, e.g. a tumble or a small jolt in a braking car.
"The child did have a minor accident at home three weeks ago when he fell off a fence and grazed his face."
But Lorenzo's mother Beaudene Wi told the Herald he did not fall from a fence three weeks earlier and that she told police the mark on his face was an eczema spot.
The documents, released to the Herald under the Official Information Act, showed the November 14 report said police had interviewed the centre manager and four other staff and found "no need for a criminal investigation".
WorkSafe also interviewed staff and decided not to hold a full investigation.
However both agencies told the Herald last week that they were still investigating Lorenzo's death.
Lorenzo's father Ricardo Miranda told Māori Television's Native Affairs this week that when he arrived to pick his son up, staff did not tell him the boy might have fallen and said they "thought Lorenzo had a fever and took his temperature but found nothing wrong with him".
His condition worsened almost immediately and his parents rushed him to the hospital.
A report on March 14 said Ministry of Education staff visited the centre on March 9 and found five "health and safety and teaching practice concerns" including a child being put on an adult chair then not supervised and potential hazards appeared to not be managed or mitigated.
The centre was placed on a provisional licence from March 15 but ministry officials visited again the next day, March 16, and found no issues so the full licence was restored.
However a follow-up letter on April 9 from regional education adviser Nicole Hobbs asked centre owner Jenny Hall to "review the use of the adult table and chairs in the over-2-year-old environment."
"I would like the teachers to consider the appropriateness of this for smaller children, especially those under-2-year-olds when they come into the environment from the under-2-year-old space."
On the same day, the ministry's regional education manager Rae Karipa wrote to Lorenzo's family saying all relevant centre staff had first aid certificates and "basic full body first aid checks" were completed when they found him on the floor.
"At this point the signs being exhibited by [Lorenzo] did not specifically indicate concussion, his temperature was in the normal range and he often showed signs of being tired towards the end of the day," she wrote.
"He was seen lying on his back beside the large table at approximately 2.30pm crying and [he] was picked up and cuddled for two to three minutes until he stopped crying and went off to play, this was not seen as anything requiring to be documented."