Recurring concern

Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuries

First to latest report 31 Oct 2013 — 26 Jun 2026

Reports that mention this concern
28
Times this concern has been raised
33
Stated actions linked to this concern
46

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.

What is 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 and published responses 28 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West London

    AI-generated summary

    Nihad Ousta · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Nihad Ousta was admitted to a mental health ward and suffered visible head trauma on two occasions before deteriorating and undergoing neurosurgical treatment. He was later transferred to a nursing home and then admitted to St George’s Hospital, where he died several months later. The report identified the absence of written guidance or a protocol for managing head injuries, including the frequency and range of general and neurological observations.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of written guidance or policy for management of head injury

    Wider context from the report

    “There was not and currently is not a protocol or other written guidance or policy for the management of head injury (to include frequency and range of general and neuro observations) ”

    Source location

    Nihad Ousta · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Portsmouth and South East Hampshire

    AI-generated summary

    Thelma Doris Clarkson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Thelma Doris Clarkson fell at home on 10 February 2015, sustained head injuries, and died in hospital the following day after her condition deteriorated and an inoperable head injury was identified. The concern was that the NICE Head Injury Pathway did not treat Clopidogrel use as a trigger for a CT scan in the same way as Warfarin, despite the risk of increased bleeding from head trauma.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the head injury pathway to include Clopidogrel as a CT scan trigger

    Wider context from the report

    “Prior to her fall, Mrs Clarkson has for some time been prescribed and was taking the drug Clopidogrel for long-standing heart disease. The British National Formulary warns that patients taking Clopidogrel are at risk of increased bleeding from trauma. However, I was told in evidence at the Inquest that under the NICE Head Injury Pathway which was in use at the time at Gosport War Memorial Hospital, had Mrs Clarkson been taking Warfarin she would have been sent to a larger hospital to have a CT scan of her head but the Pathway did not include Clopidogrel as a similar trigger for a CT scan - notwithstanding the risk of increased bleeding from head trauma. I was also told that, had Mrs Clarkson been sent from Gosport War Memorial Hospital for a CT scan, there is a strong possibility it would have revealed the extent of her head injury and her treatment - and its potential outcome - may have been different. I am therefore concerned that the NICE should consider whether its Head Injury Pathway should be amended to include taking Clopidogrel as a trigger for a CT scan in the same way as Warfarin presently does. ”

    Source location

    Thelma Doris Clarkson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Manchester North

    AI-generated summary

    Toni Piel · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Toni Piel suffered a head injury in a fall at home on 10 December 2014 and was treated at hospital before being discharged. He was found dead at home on 23 December 2014, with the inquest concluding that he died from a head injury caused by a fall, although it was not established whether this was linked to the earlier injury. Concerns included that his home circumstances and the absence of anyone able to observe him were apparently not considered at discharge, and that risk factors were not documented.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to assess home circumstances and available observation when discharging patients following head injury

    Wider context from the report

    “i) At the time the deceased was discharged home following the head injury on 10 December 2014 the deceased’s home circumstances were apparently not taken into account. Had such an assessment been made it would have been noted that there was no-one able to observe the deceased at home. The NICE clinical guideline 175 issued January 2014 recommends that this should be taken into account. ii) No assessment of the risk factors in discharging the deceased was documented in the deceased’s records. ”

    Source location

    Toni Piel · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operational improvements to head injury assessment and discharge are the responsibility of the involved NHS trust.

    Verbatim wording from the response

    “These are both operational matters for the trust involved. I note that your report has been sent to the Pennine Acute Hospitals NHS Trust. I understand that Pennine Acute has undertaken a review of this case which has resulted in actions to improve the management, supervision, assessment and discharge of head injury patients in their care. The Trust will provide you with full details in its response.”

    Source location

    2015-0263-Response-by-Department-of-Health
    Page 1 · response
    Published 9 July 2015

    Open published response

  4. Manchester South

    AI-generated summary

    Kathleen Eaton · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kathleen Eaton fell in her bedroom on 26 January 2015 and was lifted using a blow-up ‘hoist’ before being left awaiting her regular carers. She was later taken to hospital, where she was found to have damage to and around her brain; the inquest recorded subdural and subarachnoid haemorrhage, recurrent falls, and other medical conditions. Concerns included inadequate training and procedures for assessing head injuries and uncertainty about when to summon an ambulance, as well as the distance between the care service base and the deceased’s home.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of policies and procedures for assessing and dealing with head injuries

    Wider context from the report

    “2. She stated that she was unaware of any set policies or procedures in place for assessing and dealing with head injury cases. There was nothing in writing advising as to when it is appropriate and/or necessary to summon an ambulance. ”

    Source location

    Kathleen Eaton · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce mandatory first-aid training before Responder attendance and require certificates to remain current.

    Verbatim wording from the response

    “ACTION TAKEN: Following the inquest into Mrs Eaton's death, PPHT and the Council have had discussions about amending the terms of the contract and making it a requirement that: (a) first aid training is provided before any Responder can attend; and (b) first aid certificates are obtained and must not be permitted to expire.”

    Source location

    2015-0236-Peaks-and-Plains-Housing-Trust
    Page 3 · response
    Published 22 June 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Validate the Responder assessment procedure with the ambulance service and obtain its customer-assessment checklist for future use.

    Verbatim wording from the response

    “ACTION TAKEN: PPHT invited the ambulance service to visit PPHT to ensure that the assessment procedure Responders follow is fit for purpose. The ambulance service confirmed that it is similar to theirs and acceptable. They also provided their checklist document for assessing customers for us to use in the future. Both this and the written procedure (Appendix 1) have been updated and shared with staff. Managers will be checking this is embedded during discussions with staff at team meetings and in one-to-ones and will also be carrying out spot checks.”

    Source location

    2015-0236-Peaks-and-Plains-Housing-Trust
    Page 3 · response
    Published 22 June 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update and share the ambulance checklist and written assessment procedure with staff.

    Verbatim wording from the response

    “ACTION TAKEN: PPHT invited the ambulance service to visit PPHT to ensure that the assessment procedure Responders follow is fit for purpose. The ambulance service confirmed that it is similar to theirs and acceptable. They also provided their checklist document for assessing customers for us to use in the future. Both this and the written procedure (Appendix 1) have been updated and shared with staff. Managers will be checking this is embedded during discussions with staff at team meetings and in one-to-ones and will also be carrying out spot checks.”

    Source location

    2015-0236-Peaks-and-Plains-Housing-Trust
    Page 3 · response
    Published 22 June 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Check that the assessment procedure is embedded through team discussions, one-to-ones and spot checks.

    Verbatim wording from the response

    “ACTION TAKEN: PPHT invited the ambulance service to visit PPHT to ensure that the assessment procedure Responders follow is fit for purpose. The ambulance service confirmed that it is similar to theirs and acceptable. They also provided their checklist document for assessing customers for us to use in the future. Both this and the written procedure (Appendix 1) have been updated and shared with staff. Managers will be checking this is embedded during discussions with staff at team meetings and in one-to-ones and will also be carrying out spot checks.”

    Source location

    2015-0236-Peaks-and-Plains-Housing-Trust
    Page 3 · response
    Published 22 June 2015

    Open published response

  5. Cardiff & Vale of Glamorgan

    AI-generated summary

    Phyllis Eleanor Barlow · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Phyllis Eleanor Barlow, who was taking warfarin, fell and struck her head in a GP surgery car park on 29 September 2014 but was not admitted to hospital. She fell again at home the following day, sustaining a subdural haemorrhage and hip fracture, and died on 8 November 2014; the concern was that GP surgeries were not sufficiently aware of NICE guidance requiring hospital admission and CT scanning after a head injury in a person taking warfarin.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of GP awareness of NICE head-injury guidelines for patients treated with warfarin

    Wider context from the report

    “(1) At the time of her fall in the GP car park on 29th September 2014 NICE guidelines (on head injuries) were in place to the effect that anyone suffering a head injury who was on warfarin should be admitted to hospital forthwith and undergo a CT scan. ████████ who appeared at the inquest on behalf of the GP practice testified that these NICE guidelines were not known or appreciated by her GP practice at the time even though they were in force. Mrs Barlow was not admitted to hospital as she should have been on 29th September 2014. ████████ subsequent enquiries have revealed that there is widespread ignorance of these NICE guidelines among GP colleagues, although they are appreciated by the ambulance service, and A&E departments. The Coroner is concerned that steps should be taken to make GP surgeries in Wales aware of the importance of these NICE guidelines, and that anyone who suffers a head injury while being treated with Warfarin should be admitted to hospital forthwith and a CT scan undertaken on them.. ”

    Source location

    Phyllis Eleanor Barlow · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to admit patients with head injuries treated with warfarin to hospital forthwith

    Wider context from the report

    “(1) At the time of her fall in the GP car park on 29th September 2014 NICE guidelines (on head injuries) were in place to the effect that anyone suffering a head injury who was on warfarin should be admitted to hospital forthwith and undergo a CT scan. ████████ who appeared at the inquest on behalf of the GP practice testified that these NICE guidelines were not known or appreciated by her GP practice at the time even though they were in force. Mrs Barlow was not admitted to hospital as she should have been on 29th September 2014. ████████ subsequent enquiries have revealed that there is widespread ignorance of these NICE guidelines among GP colleagues, although they are appreciated by the ambulance service, and A&E departments. The Coroner is concerned that steps should be taken to make GP surgeries in Wales aware of the importance of these NICE guidelines, and that anyone who suffers a head injury while being treated with Warfarin should be admitted to hospital forthwith and a CT scan undertaken on them.. ”

    Source location

    Phyllis Eleanor Barlow · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a Patient Safety Notice raising awareness of NICE head-injury guidance for local health boards and general practices.

    Verbatim wording from the response

    “A lack of awareness of this important guideline is apparent from the detail of your report. In response to your concerns, Welsh Government officials are in the process of developing a Patient Safety Notice which will be issued to all local health boards and general practices in Wales.”

    Source location

    2015-0027-Response-by-NHS-Wales
    Page 1 · response
    Published 29 January 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue the Patient Safety Notice to all local health boards and general practices in Wales.

    Verbatim wording from the response

    “A lack of awareness of this important guideline is apparent from the detail of your report. In response to your concerns, Welsh Government officials are in the process of developing a Patient Safety Notice which will be issued to all local health boards and general practices in Wales.”

    Source location

    2015-0027-Response-by-NHS-Wales
    Page 1 · response
    Published 29 January 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Monitor compliance with the Patient Safety Notice after circulation.

    Verbatim wording from the response

    “The notice will be issued shortly and will raise awareness of the importance of this NICE guideline. Full compliance with this notice will be expected within a month of the notice being circulated and will be monitored.”

    Source location

    2015-0027-Response-by-NHS-Wales
    Page 2 · response
    Published 29 January 2015

    Open published response

  6. Bedfordshire and Luton

    AI-generated summary

    Gianni Khan · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Gianni Khan suffered a catastrophic head injury at a birthday party on 21 December 2013 and died at Addenbrooke’s Hospital on 28 December 2013 after his condition deteriorated and he underwent neurosurgery. The principal concern was that, after reporting a head injury at the hospital, he was streamed to an urgent GP clinic rather than being assessed by a doctor in the Emergency Department, with a failure to recognise the seriousness of the injury and lost opportunities for further medical attention.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to refer suspected head injuries to the A&E team

    Wider context from the report

    “That when Gianni was taken to the A&E Department at the Hospital and reported that he had suffered a head injury he was “streamed” to be seen in the GP Clinic rather than see a Doctor in the Emergency Department. The Consultant from the Department told me, during the course of his evidence, that it would be ‘good practice’ for all suspected head injuries to be referred to the A&E Team. I was also told that the Hospital have always requested a full triage before streaming and the Clinical Commissioning Group refused to allow for such a triage. ”

    Source location

    Gianni Khan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Exclude children with head injuries, children conveyed by ambulance, and babies aged six months or under from the streaming protocol.

    Verbatim wording from the response

    “In order to mitigate the risk, following the inquest on 28 April 2014 and our Serious Incident Overview Report, Luton Clinical Commissioning Group, the Luton and Dunstable University Hospital and the Urgent GP Clinic agreed to exclude the following patient groups from the streaming protocol with immediate effect:”

    Source location

    2014-0219-Response-by-Luton-NHS-Clinical-Commissioning-Group
    Page 2 · response
    Published 9 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the streaming process and all adult and child streaming protocols, including exclusion criteria and consideration of triage before streaming.

    Verbatim wording from the response

    “The Urgent Care Strategic Implementation Group will undertake a comprehensive review of the streaming process for both adults and children.”

    Source location

    2014-0219-Response-by-Luton-NHS-Clinical-Commissioning-Group
    Page 3 · response
    Published 9 May 2014

    Open published response

  7. London (East)

    AI-generated summary

    Roy Joseph Godfrey · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Roy Joseph Godfrey, a 71-year-old resident of a residential care home, suffered an unwitnessed fall and head injury while taking long-term warfarin. He was later found unresponsive and died from a fatal subdural haematoma. Concerns included insufficient awareness of the bleeding risk associated with head injury and warfarin, inadequate overnight neurological checks and recording, and shortcomings in the care home's investigation documentation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure awareness of bleeding risk after head injury in elderly patients taking warfarin

    Wider context from the report

    “1. Mr Godfrey was an elderly patient who was at risk of falling and who was on long term warfarin. There is an increased risk of bleeding to elderly patients on warfarin who sustain a head injury. Neither the care staff who attended to Mr Godfrey on the evening of the 23rd July 2013 or the paramedic appeared to have been aware of the increased risk of such bleeding in an elderly patient who had sustained a minor head injury. The inquest heard clear evidence from the London Ambulance Service in relation to further training that was to be provided to their staff in relation to this risk. In addition, amendments are to be considered to the LAS guidance, to highlight this risk to all staff. ”

    Source location

    Roy Joseph Godfrey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. North and West Cumbria

    AI-generated summary

    Wilhelmina Isobel Newton · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Wilhelmina Isobel Newton, a resident at Grisedale Croft Residential Home, fell from her bed and was found on the floor at about 04.30 hours. She was not attended by a nurse until 09.45 hours, was later admitted to Cumberland Infirmary, and died on 15 May 2013 from a subdural haematoma following the fall. The principal concern was the apparent absence of clear written guidance for staff responding to potential head injuries in elderly residents, particularly those receiving medication affecting blood clotting.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clear written guidance for responding to potential head injuries in elderly residents receiving medication affecting blood clotting

    Wider context from the report

    “On the evidence heard it appeared there was no clear written plan , protocol or guidance to the staff as to how they should respond to a potential head injury to an elderly resident, particularly one receiving medication which had the potential to affect the blood’s clotting ability: the absence of such guidance may apply to other residential homes operated by the Council ”

    Source location

    Wilhelmina Isobel Newton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a policy identifying procedures and checks for suspected stroke cases involving medication that affects blood clotting.

    Verbatim wording from the response

    “These specific issues have been reviewed and Cumbria Care has drawn up a new Policy that clearly identifies the procedures to be followed and the checks that need to be undertaken. This document will be cascaded throughout the organisation and to the wider adult social care workforce via Services Care Sector Alliance Cumbria. I enclose a copy of the Policy for your reference.”

    Source location

    2013-0283-Response-by-Cumbria-County-Council
    Page 1 · response
    Published 31 October 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Cascade the new policy throughout the organisation and to the wider adult social care workforce through Services Care Sector Alliance Cumbria.

    Verbatim wording from the response

    “These specific issues have been reviewed and Cumbria Care has drawn up a new Policy that clearly identifies the procedures to be followed and the checks that need to be undertaken. This document will be cascaded throughout the organisation and to the wider adult social care workforce via Services Care Sector Alliance Cumbria. I enclose a copy of the Policy for your reference.”

    Source location

    2013-0283-Response-by-Cumbria-County-Council
    Page 1 · response
    Published 31 October 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026