My Latent Self Anne Ricketts

My Latent Self

Recovering My Soul After Brain Injury
Recovering My Soul After Brain Injury

Glasgow Coma Scale

Should the Glasgow Coma Scale (GCS) be Abandoned?

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In brief, the GCS provides point values to different levels of observed physical and cognitive functions.  A score of 3 is the worst score that can be obtained, and a score of 15 is the best. Based upon this criterion, and the results of the observations made, the patient is then placed in one of three categories, mild brain injury, moderate brain injury or severe brain injury.

The scale is used to predict long term prognosis.  In the area of mild traumatic brain injury in particular, to conclude that a score of “15” translates into ‘no brain injury or no cognitive damage,’ is both an unfair and ignorant use of the grading system.  It seems that any nurse, with no specific training in the care or assessment of brain injury, can be trusted to assess the condition of a brain injury patient. If this is not tantamount to neglect through ignorance, then I don’t know what is.

NO diagnosis of any brain injury should be made without the patient undergoing some kind of proper cognitive assessment. EVERY incident should be followed up. Even cases of mild concussion should be followed up by a general practitioner.

Everyone I know who has a brain injury, or has a loved one with brain injury, agrees that yes, the GCS should be abandoned. This may amount to less than 30 people, but no one I have ever discussed this issue with has thought that the scale is useful in any way. In fact, everyone I have spoken to feels that the scale is misused and that it has perhaps been responsible for the inadequate care they received. One thing is for absolute sure – YOU CANNOT CATEGORISE BRAIN INJURY. Every person is unique, every injury is unique and every patient should be both assessed and followed-up as this unique individual.

This doesn’t sound too good, does it? Let me share my example. My own experience was that instead of been scored as ‘confused and disorientated,’ which I definitely was, the nurse gave the opinion that I was slightly deaf because I was slow and inaccurate in my responses to her questions! I scored a ‘healthy’ 15/15 despite my cognitive problems, as mentioned, and despite the fact that I was lapsing in and out of consciousness and having double vision.

It is the opinion of a medical expert that my hospital records are rather scant, but I have an unanswered question. Is it possible that this nurse was responsible for the fact that I ‘fell through the net’ and didn’t receive any follow-up or care? Were my notes later reviewed, and because they recorded a score of 15/15 on the GCS, was my case was dismissed as unimportant? I saw a doctor prior to being discharged from the hospital. He diagnosed me as having a serious traumatic brain injury with some kind of syndrome. I was never able to recall what the ‘syndrome’ was. I wasn’t given any information and I didn’t even recognise the serious implications of this diagnosis. No one was with me. I was sent home to my fifteen-year-old daughter who was only around for a few days before leaving to start her summer job.

A letter was sent from the hospital to my GP a number of weeks later. At the bottom it clearly says that I should be reviewed in out-patients,’ – but this never happened either. The hospital are now of the opinion that this was a mistake.

Back in July there was an editorial published in the Annals of Emergency Medicine. It said that the Glasgow Coma Scale (GCS), used to assess the extent of brain injury in hospital emergency departments and at the scene of an accident, is unreliable, hard to remember and too non-specific to be useful for emergency patients.

“The Glasgow Coma Scale (GCS) is obsolete within acute care medicine,” said the editorial’s author, Steven M. Green, MD, FACEP of Loma Linda University in Loma Linda, Calif. “The GCS should be abandoned in the emergency department and pre hospital settings altogether. There are other, better ways to assess trauma patients, such as SMS or TROLL, which stands for Test responsiveness: obeys, localizes or less.”

‘Annals of Emergency Medicine’ is the peer-reviewed scientific journal for the American College of Emergency Physicians, a national medical society.

It really must be obvious to everyone who has ever been affected in any way to brain injury that the current methodologies and procedures absolutely HAVE to be tightened-up. Misdiagnosis does not only screw up the lives of those directly affected, it also adds a huge and unnecessary burden onto our social systems.

The following is an excerpt from My Latent Self: –

Dr Martyn Rose FRCS, Consultant in Neuropsychiatric Rehabilitation, wrote an independent report for my solicitors, in December 2006. He has kindly given his permission for his comments to be used here. The solicitor posed the following question: “Whether there was negligence in allowing [me] to return home on 23 July 2000, the date of accident?”  The answer to this was:

“I cannot comment as an expert on what appear to be the very clear failings of the A & E Department on 23 July 2000.

One of the problems with the extremely sketchy triage notes is that we do not know about [her] state. It is worth remembering that in order to score 15/15 on the Glasgow Coma Scale one needs only to open ones eyes spontaneously, be oriented (usually to ‘what is your name, what is the date, where are you?’) and to move one limb appropriately to command. The often stated comment that “the GCS was 15/15 – normal” can be very misleading. It does not require a very high level of brain function to score 15 – whilst one could indeed be “normal.”

It further says: –

“I have consulted a draft document commissioned by the National Institute for Clinical Excellence but this is dated November 2002. Clearly, even the draft recommendations would not have been in place at the time of [her] attendance at A & E. Nevertheless this document includes the statement:

Head injured patients who are discovered to be low risk on initial triage for clinically important brain injury and/or C-Spine injury should be assessed within a further hour by an A & E Clinician…” (page 37)

My colleague agrees that this management is probably totally inadequate and assuming that there are no other records to indicate no other management could be regarded as negligent. We cannot be sure of the meaning of the triage category 3 but suspect it is low priority, particularly as [she] was not seen despite waiting for more than two and a half hours even though the triage nurse has recorded a period of unconsciousness.”




The undisputed universal measurement tool for mental status assessment, the Glasgow Coma Scale, is unreliable, hard to remember and too non-specific to be useful for emergency patients, according to an editorial in Annals of Emergency Medicine. Please click here for more details:

Glasgo Coma Scale Must Go






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(c) 2011 - Anne Ricketts - Sandown, Isle of Wight, PO36 9EL - Tel: 01983 407557 - Traumatic Brain Injury, Loss of Self, Loss of Soul, Misdiagnosis, Survivors Guide

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