NHS 111 script “must exclude head injuries” after care home death
A coroner has called for NHS 111 to revise its head injury scripts after a woman died from a care home fall that staff ‘downplayed’.
Christine Clegg, 79, died after an unwitnessed fall led to a traumatic brain injury at Kesteven Grange Care Home in Hull in June 2025.
A staff member at the care home told NHS 111 that Clegg had “put herself on the floor” and had a “bump” on her head.
This led the call operator to follow a script for “scratches, grazes or minor wounds”, with “basic first aid advice” given.
In a report, assistant coroner Sally Robinson advised that all head injuries should be excluded from the script, meaning advice would instead be sought from a clinician.
Robinson said: “If injuries above the neck were excluded from the scratches, grazes and nicks pathway then the possibility of basic first aid advice being given is eliminated, as all head injuries answered, result in clinician advice being sought.”
Currently, the script for scratches, grazes or minor wounds can be used for head injuries and was used in Clegg’s case.
The call ended with basic first aid instructions being issued, but Clegg had suffered a traumatic subdural haemorrhage and later deteriorated and died in hospital, the coroner said.
In a prevention of future deaths report, Robinson said that if the head, facial or neck injury script had been followed instead, care home staff would have been directed to speak to a clinician.
In the report, Robinson said: “The situation appears to have been downplayed and information passed to the operator which was biased information, suggesting Mrs Clegg had placed herself on the floor when in fact she had fallen from a bed, and which caused the wrong script to be followed by the operator.
“The head injury was actively bleeding and the script which should have been followed was that of head injury, but instead, because of the information given by the care staff, the script which was followed was the scratches, grazes or minor wounds pathway.”
Robinson said this led to a “different outcome to the one the correct pathway was likely to recommend, which was to seek clinical input”.
The report has been sent to Yorkshire Ambulance Service NHS Trust and NHS Pathways, advising them to exclude all head injuries from the “scratches, grazes and nicks” script.
