Christine Joan Clegg · Prevention of Future Deaths report

On 24th June 2025 an inquest was opened and adjourned into the death of Christine Joan Clegg aged 79years. The investigation concluded at the end of the inquest on 16th March 2026, the conclusion of the inquest was accidental death.

Mrs Clegg died at Hull Royal Infirmary on 19th June 2025 following admission for an unwitnessed fall at the care home where she lived. Upon admission Mrs Clegg was diagnosed with was diagnosed with traumatic subdural haematoma and sadly succumbed to her injuries in hospital.

The cause of death was

1a. Traumatic subdural haemorrhage
1b. Unwitnessed fall

2. Dementia

Mrs Clegg died at Hull Royal Infirmary following admission for an unwitnessed fall at her care home. The circumstances of the fall were Mrs Clegg was discovered on the floor of her bedroom by a carer. The alarm was raised and a call to NHS 111 was made, During this call the staff member told the 111 operator Mrs Clegg had “put herself on the floor” and had a “bump” to her head. The situation appears to have down played 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. This resulted in a different outcome to the one the correct pathway was likely to recommend which was to seek clinician input.

Even if all answers within the Head, Facial or Neck Injury Pathway are answered negatively the outcome will be to ‘speak to a clinician for home management advise’ whereas the use of this pathway for ‘Scratches, Grazes or Minor wounds’ results in a disposition of ‘Symptom Management Advice’. In the case of Mrs Clegg the call resulted in information (basic first aid advice) that is provided by the operator to the caller and the call ends with no clinical input.

Mrs Clegg had suffered a traumatic brain injury in this fall and subsequently deteriorated over the next few days which led to her admission to Hull Royal Infirmary where she sadly died.

(1) The NHS 111 script for scratches grazes or minor wounds is available for head injuries but can lead to a non clinical outcome and basic first aid advice being given. The fact is, however, either a scratch, graze or nick above the neck indicates that either has been a head injury of some degree or other and so the script which should correctly be followed is the head injury pathway. 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 injury answered result in clinician advice being sought.
(2)