Recurring concern
Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuries
Pin
Get email alerts
Request correctionFirst reported 31 Oct 2013•Latest report 26 Jun 2026
What this concern includes
Includes deficiencies in dedicated head injury assessment or treatment pathways and their controls, including clinical decision support, triage, referral, escalation, admission, guidance, policy alignment and discharge arrangements, when they affect recognition or management of head injuries.
Not included
- Excludes generic staffing, training, documentation or communication deficiencies not explicitly tied to the head injury assessment or treatment pathway.
- Excludes unrelated injury, falls, anticoagulation, emergency transport or clinical governance concerns unless they specifically concern recognition or management of a head injury.
- Excludes deficiencies in pathways for other conditions, even where the failure mechanism is similar.
- Reports
- 28
- Individual concerns
- 33
- Date range
- 2013–2026
- Stated actions
- 46
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
-
Concerns raised1
Failure to follow the falls policy for suspected head, neck, back or hip injury
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
-
Action
Deliver additional training on assessing, managing, escalating and documenting witnessed and unwitnessed falls and injuries.
Stated by Westfield Residential Home -
Action
Hold the scheduled staff meeting and practical workshop on falls assessment, observation, escalation and documentation.
Stated by Westfield Residential Home -
Action
Provide all staff with guidance notes on post-fall assessment, safe movement, emergency escalation, monitoring, documentation and reporting.
Stated by Westfield Residential Home
-
Action
Circulate the updated Falls policy to existing and new staff through the policies-of-the-month programme.
Stated by Westfield Residential Home -
Action
Conduct an unannounced inspection assessing record keeping, falls management and staff handover processes.
Stated by Care Quality Commission
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
No regulatory action is currently required because inspection found no ongoing risk issues relating to the concerns.
Stated by Care Quality Commission
-
Position
Inspection evidence identified no concerns with the home's management of falls for current service users.
Stated by Care Quality Commission
-
Concerns raised1
Failure of the NHS 111 scratches, grazes and nicks pathway to exclude injuries above the neck
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Lack of national guidance on when to recommence anticoagulation after traumatic head injury
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Action
Assess the issue through the guidelines surveillance process to determine whether guidance recommendations should be updated or newly issued.
Stated by National Institute for Health and Care Excellence -
Action
Discuss with relevant specialist societies the possibility of developing a consensus statement on restarting anticoagulants after traumatic intracranial haemorrhage.
Stated by National Institute for Health and Care Excellence -
Action
Review NICE’s response and consider whether NHS England must take resultant action.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
NICE, as the provider of relevant clinical guidance, is the appropriate organisation to respond to concerns about anticoagulation guidance.
Stated by NHS England
-
Position
Individualised risk-benefit decisions may make it challenging to produce specific guidance on restarting anticoagulation after traumatic head injury.
Stated by NHS England
-
Concerns raised1
Failure of CT scan guidance to identify patients with non-anticoagulant blood-clotting conditions
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Action
Finalise the update of the head injury guideline, incorporating the updated review of serious-outcome risks for people with head injuries and coagulopathies.
Stated by National Institute for Health and Care Excellence -
Action
Make a research recommendation on the risks associated with a history of bleeding or clotting disorders.
Stated by National Institute for Health and Care Excellence -
Action
Keep the risks associated with bleeding or clotting disorders under review to identify the need for further guidance updates.
Stated by National Institute for Health and Care Excellence
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
Insufficient convincing evidence prevented adding bleeding or clotting disorders as a standalone indication for head CT.
Stated by National Institute for Health and Care Excellence
-
Position
Existing guidance requires assessing head-injury patients for any history of bleeding or clotting disorders.
Stated by National Institute for Health and Care Excellence
-
Concerns raised1
Failure to distinguish persistent vomiting from initial post-injury vomiting
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to continue neurological observations following head injury
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
-
Action
Maintain a NICE-compliant Falls Policy specifying neurological-observation frequency and continuation until medical review.
Stated by Kent and Medway Mental Health NHS Trust -
Action
Monitor compliance with neurological-observation standards through the Falls Care Pathway, incident reporting and quality governance reviews.
Stated by Kent and Medway Mental Health NHS Trust -
Action
Include clinically indicated neurological observations in shift handovers and patient status boards, with ongoing quality assurance audits.
Stated by Kent and Medway Mental Health NHS Trust
-
Action
Use electronic NEWS2 observations to identify consciousness changes, trigger neurological observations when indicated, issue missed-observation alerts and support remote clinical review.
Stated by Kent and Medway Mental Health NHS Trust -
Action
Train staff in electronic observations and neurological-observation competencies, with ongoing training for newly appointed nursing and medical staff.
Stated by Kent and Medway Mental Health NHS Trust -
Action
Employ a specialist Physical Health Nurse on each ward to teach, support and supervise physical healthcare.
Stated by Kent and Medway Mental Health NHS Trust -
Action
Deliver Trust-wide train-the-trainer education on neurological observations and the Glasgow Coma Scale to physical health nurses, with refresher sessions and online access.
Stated by Kent and Medway Mental Health NHS Trust -
Action
Develop and disseminate a learning bulletin reminding staff to complete Glasgow Coma Scale observations after incidents, possible strokes, head injuries and medical emergencies.
Stated by Kent and Medway Mental Health NHS Trust
-
Concerns raised1
Lack of clear direction in the post-falls process on when to call 999/111 for possible or suspected head injury
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Action
Review and update the falls protocol in line with current NICE guidance, directing staff to contact 999 or 111.
Stated by Hampshire County Council
-
Concerns raised3
Failure to maintain awareness of revised National Institute for Health and Care Excellence guidance on head-injury scanning
Failure of the head-injury policy to include patients receiving low-dose anticoagulants within the 8-hour computerised tomography scan criterion
Failure of the head-injury policy to reflect revised National Institute for Health and Care Excellence guidance
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Action
Amend and launch the head-injury policy to require CT scanning within eight hours for patients receiving therapeutic anticoagulants, including DOACs.
Stated by University Hospital Southampton NHS Foundation Trust -
Action
Disseminate the updated head-injury policy and key NICE changes to clinical teams and publish it on the staff intranet.
Stated by University Hospital Southampton NHS Foundation Trust -
Action
Continue ensuring CT scanning within eight hours for patients receiving prophylactic enoxaparin who develop clinical signs or symptoms after a fall, and for patients receiving therapeutic anticoagulants.
Stated by University Hospital Southampton NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
Position
NICE is expected to clarify whether prophylactic anticoagulants should trigger the same scanning requirements as therapeutic anticoagulants.
Stated by University Hospital Southampton NHS Foundation Trust
-
Position
Patients receiving prophylactic enoxaparin are not routinely scanned after falls without clinical signs suggesting bleeding.
Stated by University Hospital Southampton NHS Foundation Trust -
Position
Universal CT scanning for patients receiving prophylactic enoxaparin could overwhelm scanning capacity and delay scans for patients who require them.
Stated by University Hospital Southampton NHS Foundation Trust
-
Concerns raised2
Falls form failing to direct doctors to relevant head injury guidance
Head injury treatment policies failing to align with NICE Guidelines
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Lack of a system to fast track CT scans for patients on warfarin with suspected head injury
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Action
Use the updated Emergency Department adult head injury pathway to guide assessment, CT scanning, neurosurgical referral and clinical documentation.
Stated by Manchester University NHS Foundation Trust -
Action
Embed the Clinical Decision Support Tool in the Emergency Department Electronic Patient Record to guide adult head injury management and CT requirements.
Stated by Manchester University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
The CT scan reporting delay was one hour beyond target but did not appear to have significantly contributed to the adverse outcome.
Stated by Manchester University NHS Foundation Trust
-
Position
The local head injury pathway and electronic decision-support tool provide existing guidance for timely CT scanning and neurosurgical referral.
Stated by Manchester University NHS Foundation Trust
Data last updated 7 September 2026