Coroner Urges NHS 111 Script Reforms Following Fatal Head Injury Misdiagnosis
Assistant coroner Sally Robinson has issued a prevention of future deaths report following the death of 79-year-old Christine Clegg. The investigation revealed that a care home fall was incorrectly processed through NHS 111 scripts designed for minor grazes rather than head trauma.
Key takeaways
- A 79-year-old woman died from a brain injury after an NHS 111 call miscategorized her fall as a minor scratch or graze.
- The coroner found that the care home staff's description of the fall influenced the operator to use the wrong clinical script.
- Proposed reforms would mandate that all injuries above the neck be excluded from minor injury pathways to ensure clinician involvement.
What Happened
In June 2025, 79-year-old Christine Clegg suffered an unwitnessed fall from her bed at the Kesteven Grange Care Home in Hull, East Yorkshire. Although the fall resulted in a traumatic subdural haemorrhage, care home staff described the incident to NHS 111 operators as the patient having "put herself on the floor" with a "bump" on her head. This description led the call handler to utilize a script intended for scratches, grazes, or minor wounds rather than the protocol for head injuries.
Because the operator followed the minor wound pathway, the call concluded with basic first aid instructions rather than a clinical referral. Mrs. Clegg’s health declined in the following days, and she eventually died in the hospital from a traumatic brain injury. The inquest concluded that the initial assessment downplayed the severity of the injury, preventing immediate medical intervention.
Why It Matters
The case highlights a procedural vulnerability in the NHS Pathways system, where the initial categorization of an injury by a non-clinical caller can bypass life-saving protocols. The assistant coroner noted that if the "head, facial or neck injury" script had been activated, the system would have mandated a conversation with a clinician regardless of the specific answers provided by the caller. The failure to trigger this pathway meant a serious internal bleed was managed as a superficial graze.
What Happens Next
Assistant coroner Sally Robinson has submitted a prevention of future deaths report to the Yorkshire Ambulance Service NHS Trust and NHS Pathways. The report recommends a structural change to the software: excluding all injuries located above the neck from the "scratches, grazes and nicks" script. This proposed update aims to ensure that any reported head injury automatically triggers a requirement for clinician input, removing the risk of operator or caller bias leading to inadequate care instructions.
Key Facts
- Christine Clegg died in June 2025 following a fall at Kesteven Grange Care Home in Hull.
- The official cause of death was a traumatic brain injury (subdural haemorrhage).
- NHS 111 handlers used a "scratches, grazes or minor wounds" script instead of the "head injury" pathway.
- The correct pathway for head injuries mandates a consultation with a clinician.
- Coroner Sally Robinson has called for the removal of head injuries from minor wound scripts to prevent future deaths.
Sources reviewed
Project Chintan independently synthesized and analyzed information cross-checked across the sources listed above.
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