The accident happened in Dorotea last spring.
A relative of the child called 112 when the accident occurred.
The child had fallen down a flight of stairs while being strapped into a car seat.
An ambulance was called to the scene and paramedics decided to wait without taking action.
Later, the baby started vomiting and feeling increasingly worse.
Was sent home again by helicopter - without x-rays
The child was then taken to the emergency room by ambulance helicopter.
There, the emergency personnel assessed that the baby had suffered a mild concussion and the baby was sent home again by helicopter.
No further examination or X-ray was done.
- The mistake was that they misjudged the whole thing from the beginning.
It meant that the right action and care was delayed, says Nino Bracin, chief physician Region Västerbotten.
A few hours after the child came home, the condition worsened further.
Relatives called 1177 and ended up in a long telephone queue, which meant that help was delayed.
Had emergency surgery: Busy for the family
The baby then had to be flown in urgently by helicopter to hospital - again.
There, a new assessment and investigation was carried out, which showed that the baby had suffered a brain haemorrhage.
The baby was then operated urgently.
- It is clearly a problem that the baby had to be flown by ambulance helicopter twice, and difficult for the family.
It is a long transport between Umeå and Dorotea.
It's a shame that it turned out the way it did, says Nino Bracin.
- We had to report this.
We will review the routines at each unit, how we can prevent it from happening again.
It's about patient safety.
How is the baby today?
- From what I have heard, the child did well after the operation, no secondary damage or anything like that, says Bracin and continues:
- Iron bleeding is serious.
There is a great risk that the baby could have suffered serious injuries afterwards.