Posted: 21/02/2022
England got their 2022 Six Nations Championship campaign back on track with a 33-0 win over Italy in Stadio Olimpico, Rome on the 13 February. However, the game was not without controversy, with referee Damon Murphy widely condemned for his poor decision regarding a head injury assessment of England player Jack Nowell.
World rugby has had an established protocol for head injury assessments (HIA) for some years, with the rule allowing temporary substitutions for head injuries being permanently introduced in August 2015[1]. When compared with football where Circular no.21, a similar protocol which was only implemented by FIFA last January, it is clear that this is an area where rugby has made much greater advancements in a short space of time, than many other sports.
It is therefore unsurprising that referee Damon Murphy has faced criticism for not allowing sufficient time for the independent medics to review the footage before continuing play after there were concerns that Jack Nowell may have sustained a head injury. Nowell had suffered a heavy collision while attempting to make a tackle on Italian centre Marco Zanon. The tackle resulted in both players being knocked to the ground at 13:44 minutes into the game. Nowell then struggled to regain his feet, staggered slightly, before then re-joining the action. In doing so, he went completely the wrong way when seeking to make the next tackle (at 13:50 minutes). He exhibited a number of the SCAT-5 ‘observable signs’ during that period indicating he should go for a HIA, and in continuing to play put both himself and others in harms’ way.
The decision to allow Jack Nowell to continue playing before the independent doctors had finished undertaking their video review did not go unnoticed by the ITV commentators or those on social media. Progressive Rugby tweeted: “Oh my goodness. Please tell me the ref has not just rushed a team into making a decision around a HIA.” Another wrote: “As ever, there’ll be plenty of talk across the weekend of poor officiating in many different sports. Nothing will be anywhere near as bad as Damon Murphy rushing the HIA that Jack Nowell ultimately fails. Irresponsible, idiotic, wrong.”[2]
The HIA protocol applies to elite adult rugby only and is a three-stage process which assists with the identification, diagnosis and management of head impact events with the potential for a concussion. Since its introduction, fewer than 8% of players with confirmed concussion returned to play on the same day following their injury, compared to 56% before the HIA protocol[3].
Stage one covers the off-field assessments on the day. Match officials, team doctors and independent match-day doctors are responsible for identifying players who sustain head impact events that need further assessment.
The four components for the off-field HIA1 assessment are:
Despite the referee allowing Jack Nowell to continue playing initially, within minutes the medics using the pitch-side video review had identified that Nowell needed to come off. He then underwent assessment using the off-field screening tool. This is a re-formatted sports concussion assessment tool (SCAT-5) which includes a check of symptoms, memory assessment and balance evaluation. The results are then compared to the player’s baseline assessment. Jack Nowell failed the HIA and was not allowed to return to play.
Non-medical staff can alert the team’s medical staff that they have seen an incident that suggests a HIA1 assessment is required but, under the HIA protocol, the team’s on-field medical staff, referee or the independent match day doctor are the only ones allowed to request an off-field screen. The opposition’s on-field medical staff are also not allowed to request one on an opposing player.
Once the team’s on-field medical staff calls an off-field HIA1 assessment and it is acknowledged by the referee, then it must be completed and cannot be cancelled.
The laws are that the referee can decide - with or without medical advice - to order a player to leave the playing area if they consider it would be inadvisable for the player to continue[4].
Once the HIA1 assessment has been called, it is then for the team doctor to complete the HIA1 unless he assigns this to the match day doctor, which is possible in cases of emergency. In the meantime, Law 3.27 allows a temporary replacement for 12 minutes while the assessment is undertaken even if all replacements have been used. If the player cannot return to the field of play after 12 minutes (actual time), then the replacement becomes permanent.
Referee Damon Murphy’s decision to allow play to continue before the medical team had finished reviewing the footage and determining whether Jack Nowell should come off is certainly against the core principles and spirit of the World Rugby Medical Regulations and Laws. These confirm that: “Concussion and suspected concussion must be taken extremely seriously by all those involved in the Game in order to protect the safety, health and welfare of players.”
The regulations also confirm that any adult player with concussion or suspected concussion must be immediately and permanently removed from the field of play and should be assessed by a medical practitioner.[5]
Under English law, it has been held that rugby referees owe a duty of care to the players to minimise their risk of injury. However, it is acknowledged by judges that the threshold of liability must properly be a high one[6].
Given that the RFU has introduced mandatory concussion education for all professional players, coaches and referees and, as Damon Murphy had the resources of the medics to rely on, his decision to continue play without waiting for the consensus of the off-field doctor who was reviewing the position, is arguably in breach of his duty of care.
He should have waited for the match-day doctor to conclude his review, or at the least, asked the match-day doctor how much more time they thought they would need to conclude the review. As it happened, the amount of time taken for the review, including stoppage time, was only about two minutes. It is therefore not a surprise to discover that the Six Nations officials are reviewing the circumstances that led to Nowell being allowed to continue play[7].
Under the World Rugby regulations, a person (including a referee) who contravenes the regulations or “engages in conduct, behaviour or practices which may be prejudicial to the interests of World Rugby or the game” shall be subject to sanctions[8]. At the lowest level, such sanctions can include a caution, reprimand or fine[9].
Subject to the information he had at the time of continuing play and given that Damon Murphy did remove Jack Nowell as soon as the medics confirmed a HIA1 was required, it is perhaps arguable this is an incident warranting a less serious sanction such as a caution. It remains to be seen whether a sanction will be forthcoming.
Some people may defend Damon Murphy by arguing that tools like VAR and HIA slow the game play but, while VAR aims to increase fairness in the game, the HIA protocol is at the core of protecting a player’s safety and should not be compromised.
Many other aspects of the game (such as scrums, lineouts and TMO decisions) cause delays to rugby matches, frequently taking a minute or longer. Here the match day doctor was given about a minute only, to make a decision that pertains to player welfare. When compared to these other aspects of the game and the current knowledge around head injuries, opting to maintain game flow over this is hard to justify.
On a more positive note, there are exciting technological developments for taking HIA even further. For example, OPRO+ has developed a smart mouthguard which utilises the connection between a player’s jawbone and their skull to transmit data on impact using high precision sensor technology. In order to be accurate, smart mouthguards need to be tight fitting around the player’s teeth but this development could be the future for enhancing player safety and welfare. There are also saliva tests which have the potential to give very accurate pitch-side tests within the HIA period[10].
In the future, these types of products may assist in minimising disruption to the game while providing adequate protection to the player. These advancements are not 100% accurate tools and should not act as a replacement for the SCAT-5 test, but in conjunction with it. However, they have great potential for improving the safety of the grassroots game where they do not have the luxury of independent medical staff etc. Nonetheless, given the potential ramifications of concussion it is vital that those responsible for implementing the HIA protocol are allowed sufficient time to make decisions and players are not put at risk by playing on.
As personal injury solicitors we have extensive experience in handling claims involving traumatic brain injuries. If appropriately treated, with rest and medical assessment, then in the majority of cases there will be no long-term damage caused by concussion. However, if a player sustains a second blow to the head before they have recovered from the initial concussion, then the damage to the brain can be significant and permanent, at worst leading to Second Impact Syndrome (which is fatal). While this is rare, long-term effects of brain injury can include impact on balance, mood, ability to concentrate and much more. There is also increasing research into the links between traumatic brain injury increasing the risks of dementia.
As former Ireland rugby player, Barry O'Driscoll said "The bottom line in sport is: Recognise & Remove. Even with the suspicion of a possible concussion, it is essential that the player leaves the field immediately, with NO return to play until considerable rest and medical advice has been effected."
[1] https://www.world.rugby/news/612891
[2] https://twitter.com/JayCeeRadio/status/1492885070457319425?ref_src=twsrc%5Etfw%7Ctwcamp%5Etweetembed%7Ctwterm%5E1492885070457319425%7Ctwgr%5E%7Ctwcon%5Es1_&ref_url=https%3A%2F%2Fwww.rugbypass.com%2Fnews%2Freferee-criticised-for-allegedly-rushing-jack-nowell-hia-decision%2F
[3] https://www.world.rugby/the-game/player-welfare/medical/concussion/hia-protocol (Q34)
[4] World Rugby Medical Regulations and Laws, Law 3.22(c)
[5] World Rugby Medical Regulations and Laws, Regulation 10.1.1
[6] Vowles v Evans [2003]
[7] https://www.thetimes.co.uk/article/italy-v-england-six-nations-to-review-handling-of-jack-nowell-hia-decision-wwcn3lj7m
[8] World Rugby Medical Regulations and Laws, Regulation 19.1.2
[9] World Rugby Medical Regulations and Laws, Regulation 19.4.1
[10] https://www.birmingham.ac.uk/news/latest/2021/03/rugby-concussion-saliva-test-research.aspx
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