A coroner has called for changes to NHS 111 call scripts following the death of a woman after a "downplayed" fall at a care home.
What happened
Christine Clegg, 79, passed away following an unwitnessed fall which resulted in a traumatic brain injury at Kesteven Grange Care Home in Hull, East Yorkshire, in June 2025. Following the conclusion of an inquest into her death earlier this year, assistant coroner Sally Robinson has raised concerns that the NHS 111 script used after the fall meant Mrs Clegg did not receive immediate clinical treatment.
When a carer discovered her on the floor, a call was placed to 111 and a staff member described Mrs Clegg as having "put herself on the floor" and having a "bump" on her head.
Wrong script used
Call handlers follow scripts determined by the information they are given. The caller script for "scratches, grazes or minor wounds" can be applied to head injuries, which resulted in the "wrong script" being used in Mrs Clegg's case.
In a prevention of future deaths report, Ms Robinson wrote: "The situation appears to have (been) downplayed 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."
Impact and recommendation
Had the operator utilised the "head, facial or neck injury" script, the outcome would have directed the carers to "speak to a clinician" regardless of the responses given. Instead, the call concluded without any clinical involvement, merely basic first aid guidance, and Mrs Clegg subsequently suffered a traumatic subdural haemorrhage, the coroner noted.
Mrs Clegg's condition worsened over the following days, ultimately resulting in her hospitalisation, where she passed away. The report has been forwarded to Yorkshire Ambulance Service NHS Trust and NHS Pathways, recommending that all head injuries be excluded from the "scratches, grazes and nicks" script.
Ms Robinson wrote: "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."
Kesteven Grange Care Home has been approached for comment.
