Inflicted pediatric head injury is a significant issue in New Zealand, fatal cases receiving extensive media attention. The primary aims of this article were to analyze injury patterns and reported mechanisms against both age and cause (accidental or inflicted). The secondary aims were to quantify these deaths and identify trends over time. We retrospectively reviewed pediatric deaths due to head injury in children younger than 15 years referred to the Coronial Service of Auckland, New Zealand, from January 1, 1991, to December 31, 2010. One hundred sixty-seven cases were identified. Overall incidence was stable over time; however, the rate of inflicted head injury increased significantly (from 0.1 to 0.4/100,000 per year). Evidence of impact was seen in 90% of cases. In children younger than 2 years, in the absence of motor vehicle or pedestrian trauma, subdural hemorrhage and diffuse axonal injury were both highly suggestive of inflicted injury. The absence of a history of trauma or a history of a fall less than 1 m was also highly suggestive of inflicted injury. Retinal hemorrhages in these fatal head injuries were severe in 77% of cases and moderate in the remainder.