Coroner Identifies Protocol Failures in Care Home Fall Death After Scripts 'Downplayed' Injury
A coroner's report has identified critical flaws in emergency call protocols after a 79-year-old care home resident died from a brain injury that was initially reported as a minor wound. The investigation found that biased information provided by staff led emergency operators to follow an incorrect
Key takeaways
- A 79-year-old woman died from a subdural haemorrhage after care home staff incorrectly described her fall to emergency services.
- The 111 emergency script used was for 'minor wounds' rather than 'head injuries' due to inaccurate information provided by a carer.
- The coroner has called for NHS Pathways to remove head injuries from the minor wounds protocol to ensure clinical input for all head traumas.
- Yorkshire Ambulance Service and NHS Pathways have received a prevention of future deaths report regarding these protocol failures.
What Happened
In June 2025, 79-year-old Christine Clegg sustained a fatal traumatic brain injury following a fall at Kesteven Grange Care Home in Hull, East Yorkshire. Mrs. Clegg was alone when she fell from her bed, but when a carer discovered her, the subsequent call to the 111 emergency service described the incident as the resident having 'put herself on the floor' with a 'bump' on her head.
Assistant coroner Sally Robinson concluded that the severity of the injury was downplayed by care home staff. This biased reporting caused call operators to utilize the 'scratches, grazes or minor wounds' protocol instead of the 'head, facial or neck injury' script. While the correct pathway would have mandated a consultation with a clinician regardless of specific answers, the minor wounds script ended with only basic first aid instructions and no clinical input. Mrs. Clegg's condition deteriorated over the following days, leading to her hospital admission and eventual death from a traumatic subdural haemorrhage.
Why It Matters
The incident exposes a vulnerability in the NHS Pathways system, where the accuracy of emergency responses is entirely dependent on the initial description provided by non-clinical staff. The coroner noted that the 'scratches, grazes and nicks' pathway currently includes certain head injuries, creating a risk that life-threatening trauma can be misclassified as minor. By following the wrong script, the system eliminated the possibility of immediate clinical oversight, which the coroner indicated would have been the likely outcome under the correct head injury protocol.
What Happens Next
A 'prevention of future deaths' report has been issued to the Yorkshire Ambulance Service NHS Trust and NHS Pathways. The coroner has formally advised these organizations to amend their protocols to exclude all injuries above the neck from the 'scratches, grazes and nicks' pathway. This change aims to ensure that any reported head injury automatically triggers a requirement for clinician advice, preventing basic first aid from being the sole recommendation in similar cases.
Key Facts
- The incident occurred at Kesteven Grange Care Home in Hull in June 2025.
- Christine Clegg died from a traumatic subdural haemorrhage after falling from her bed.
- Staff reported the fall to 111 as the resident 'putting herself on the floor' with a head 'bump.'
- The coroner found the information provided to the emergency operator was 'biased' and 'downplayed.'
- The wrong NHS script was followed, resulting in basic first aid advice instead of a clinical consultation.
Sources reviewed
Project Chintan independently synthesized and analyzed information cross-checked across the sources listed above.
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