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n inquest into the death of a grassroots rugby league player, Grant Cook, in 2016 due to a traumatic head injury has led to recommendations for NSW Rugby League (NSWRL) to develop training programs for all participants to better detect head injuries.

The deputy state coroner, Derek Lee, handed his findings today following the inquest, revealing the operator who took the initial 000 call failed to ask critical questions about the incident.

Lee found the trainers only gave a ‘cursory assessment’ following the accidental head injury, but a more thorough check likely would not have saved Cook’s life due to the lack of medical equipment, expertise and policies in place at Murwillumbah’s rugby league field.

“The more pertinent issue is the questions [the control centre communications assistant (CCCA)] did not ask, but ought to have,” Lee said, when delivering the findings.

“If [the CCCA] has asked entry question 3 (“OK, tell me exactly what happened”), or further interrogated the description of Grant’s breathing as ‘more of a snort or a snore’, or asked all of the key questions, it is likely that relevant information would have been elicited that might have either altered the response priority and/or the correct protocol to be applied.

“The most critical information… was whether there was a possible traumatic cause for Grant’s convulsions and subsequent collapse.

“However, this information was not readily available,” he said.

As part of the inquest, Lee ruled Cook’s cause of death as a hypoxic brain injury as a result of respiratory arrest following an accidental brain injury he suffered due to heavy contact.

Evidence from the club’s head trainer, Kevin Spencer, who conducted the ‘cursory assessment’ showed the assessment was limited to telling Cook to “stay down” in the hope of a penalty.

Spencer revealed he had no concerns about a potential head injury as he didn’t know exactly where Cook was hit.

In the inquest, Lee said evidence from Country Rugby League operations manager, Bert Lowrie, showed the association did not have its own policy for the detection and management of head injuries.

There was no available life support equipment at the rugby league venue, and no one trained in how to use such equipment regardless.

NSWRL told the ABC improvements in detecting head injuries have been made since the 2016 incident.

“The Deputy State Coroner… acknowledged ‘significant improvements have been made since 2016 in relation to the detection and management of head injuries in rugby league players, particularly those playing in regional competitions’,” the NSWRL said in a statement.

“The report also made no adverse comment regarding the conduct of the Murwillumbah trainers in response to Cook’s distress before and after leaving the field.

“Participant safety at every level of the game is of the utmost importance to the NSW Rugby League.

“We have an existing extensive and robust education system that is reviewed every year,” the statement said.