She said the doctor did not ask the questions a medically qualified practitioner should ask.
Coroner Bell said her finding did not mean that - had Taitoko been adequately assessed - the outcome would have been different.
She said transporting Taitoko to an emergency department may have been difficult, but it was clear had the doctor known Taitoko suffered from head strikes, he would have had him hospitalised.
The Coroner said there was no certainty he would have survived, but it should have been recognised that Taitoko required a full medical workup and advanced medical treatment - which would be worth any perceived or real risk to him.