Calls for change to NHS 111 after woman dies in fatal fall

A coroner investigating the death of a woman following a “downplayed” fall has called for changes to be made to NHS 111 call scripts.

Christine Clegg, 79, died after an unwitnessed fall, which caused a traumatic brain injury, at Kesteven Grange Care Home in Hull, East Yorkshire, in June 2025.

After a carer discovered her, a call was made to 111 and a staff member said Mrs Clegg had “put herself on the floor” and had a “bump” on her head.

Assistant coroner Sally Robinson has raised concerns that the NHS 111 script followed after the fall meant Mrs Clegg did not immediately receive clinical treatment.

Call operators follow scripts based on the scenario they are given.

The script for “scratches, grazes or minor wounds” can be used for head injuries, which led to the “wrong script” being used for Mrs Clegg’s injury.

In a prevention of future deaths report following an inquest into her death earlier this year, 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.”

If the operator had used the “head, facial or neck injury” script, the outcome would have led the carers to “speak to a clinician” no matter what the answers were.

Instead, the call ended with no clinical input, just basic first aid instructions, and Mrs Clegg suffered a traumatic subdural haemorrhage, the coroner wrote.

Mrs Clegg deteriorated over the next few days, which led to her admission to hospital, where she died.

The report has been sent to Yorkshire Ambulance Service NHS Trust and NHS Pathways, advising them to exclude all head injuries from being included in 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 contacted for comment.