Christine Clegg, a 79-year-old resident of Kesteven Grange Care Home in Hull, died following a fall in June 2025. A coroner has determined that her traumatic brain injury was underestimated by emergency services, leading to a fatal delay in medical treatment.
The 111 script error that missed Christine Clegg's brain injury
Assistant coroner Sally Robinson found that the emergency response to Christine Clegg's fall was compromised by the use of an inappropriate triage script. According to the coroner's report, the NHS 111 call handler utilized a protocol designed for minor wounds rather than the specific script required for head injuries. this technical error ensured that the severity of the situation was overlooked during the initial assessment.
The misclassification meant that Christine Clegg received only basic first aid advice despite suffering from a traumatic subdural haemorrhage. As reported in the coroner's findings, had the correct head injury protocol been followed, the system would have mandated that caregivers consult a clinician regardless of how the injury was initially described by staff.
How Kesteven Grange staff downplayed the June 2025 fall
The failure of the emergency system was compounded by the information provided by the employees at Kesteven Grange Care Home. Coroner Sally Robinson revealed that care staff described the incident to the 111 operator as Mrs. Clegg having "placed herself on the floor" with only a "bump on her head." This phrasing effectively minimized the trauma of the fall and steered the call handler toward the wrong medical pathway.
The coroner explicitly criticized the staff at Kesteven Grange Care Home for downplaying the incident. By presenting a traumatic fall as a minor occurrence, the facility contributed to a chain of errors that left a vulnerable patient without the urgent clinical intervention necessary to treat a brain bleed.
A traumatic subdural haemorrhage and the failure of triage
The death of Christine Clegg highlights a systemic vulnerability in how the NHS handles elderly patients in residential care. The reliance on rigid, script-based triage can create a "blind spot" where the nuance of geriatric fragility is lost. When a patient is described as having a "bump," the system may ignore the high risk of a subdural haemorrhage—a condition where blood collects between the skull and the brain—which is common and often fatal in the elderly.
This case echoes a broader trend of concerns regarding the dehumanization of triage through algorithmic scripts. When the human element of clinical judgment is replaced by a checklist, the risk of catastrophic misdiagnosis increases, particularly for patients who cannot advocate for themselves.
Sally Robinson's demand for NHS 111 protocol revisions
In a formal prevention of future deaths report, coroner Sally Robinson has urged the Yorkshire Ambulance Service NHS Trust and NHS Pathways to overhaul their triage systems. specifically,she recommended that head injuries be completely excluded from pathways designed for minor wounds to ensure that every head-related incident triggers a prompt clinical assessment.
Despite the gravity of these findings, several questions remain unanswered, most notably the silence of Kesteven Grange Care Home, which has not responded to requests for comment. It remains unclear whether the decision by staff to describe the fall as Mrs. Clegg "placing herself" on the floor was a genuine misunderstanding or a deliberate attempt to minimize a workplace incident. Furthermore, it is unknown if other residents at the facility have experienced similar under-reported injuries.
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