A coroner has stated that a pensioner's fall in a care home, which resulted in a traumatic brain injury, was "downplayed" before her death. Christine Clegg, 79, fell alone at Kesteven Grange Care Home in Hull, East Yorkshire, in June 2025.

A 111 call was made when a carer discovered Mrs. Clegg on the floor. The staff member informed the operator that Mrs. Clegg had "put herself on the floor" and had a "bump" on her head. Mrs. Clegg later died from her injury.

Assistant coroner Sally Robinson concluded an inquest into the death, finding that the injury was "downplayed" and the information provided to the 111 operator led to the wrong script being used. This deviation meant Mrs. Clegg did not immediately receive clinical treatment.

Call operators follow scripts based on the information they receive. In this instance, the script for "scratches, grazes or minor wounds" was used, even though the injury was a head injury. If the operator had used the "head, facial or neck injury" script, the care home staff would have been instructed to "speak to a clinician" regardless of the patient's answers.

Instead, the call concluded with basic first aid instructions and no clinical input. Mrs. Clegg subsequently suffered a traumatic subdural haemorrhage and deteriorated over the following days, leading to her admission to hospital where she died.

Ms. Robinson has requested changes to the 111 script protocol. She stated in a prevention of future deaths report that the information given by care staff was "biased" and suggested Mrs. Clegg had placed herself on the floor when she had, in fact, fallen from a bed. This led to the incorrect script being followed.

The report highlighted that the head injury was actively bleeding and that the "scratches, grazes and nicks" pathway was followed instead of the appropriate head injury protocol. This resulted in an outcome that did not recommend seeking clinician input.

Ms. Robinson has recommended that all head injuries be excluded from the "scratches, grazes and nicks" script. She believes this change would eliminate the possibility of basic first aid advice being given for head injuries, as all such cases would then result in advice to seek clinician input.

The report has been sent to Yorkshire Ambulance Service NHS Trust and NHS Pathways. Kesteven Grange Care Home has been contacted for comment.