Coronial
NSWcommunity

COOK Grant Findings

Deceased

Grant Cook

Demographics

28y, male

Date of death

2016-09-12

Finding date

2020-10-30

Cause of death

Hypoxic brain injury as a result of a respiratory arrest, after inadequate respiration and failure of airway protection associated with a grand mal seizure, following an accidental traumatic brain injury. This led to eventual cardiac arrest and brain ischaemia, causing cerebral and brainstem herniation.

AI-generated summary

Grant Cook, aged 28, collapsed during a rugby league game after a tackle caused him to fall and hit his head. He suffered a grand mal seizure with snoring/obstructed breathing, leading to respiratory arrest, cardiac arrest, and irreversible hypoxic brain injury. The coroner found that NSW Ambulance call taker Linda Griffiths failed to ask all entry and key questions about mechanism of injury and breathing effectiveness, meaning critical trauma information was not conveyed to dispatchers. No helicopter was dispatched despite cardiac arrest; the RLTC was informed too late. Attending paramedics provided appropriate care with available information. Key systemic failures involved inadequate call-taking procedures, failure to escalate appropriately to aeromedical services, and absent head injury detection policies in regional rugby league in 2016. The coroner recommended education programs for ambulance and sports organizations.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

paramedicineintensive careemergency medicine

Error types

communicationdiagnosticsystemdelay

Drugs involved

adrenaline

Clinical conditions

traumatic brain injurygrand mal seizurehypoxic ischaemic encephalopathycardiac arrestairway obstruction

Procedures

cardiopulmonary resuscitationlaryngeal mask airway insertionendotracheal intubationintravenous accesschest decompressionmouth-to-mouth resuscitation

Contributing factors

  • traumatic brain injury from head impact with ground
  • grand mal seizure
  • airway obstruction with snoring breathing
  • inadequate respiration
  • aspiration of vomitus
  • hypoxia
  • cardiac arrest
  • failure of call taker to ask entry and key questions
  • delay in escalation to aeromedical services
  • absence of head injury detection and management policies in regional rugby league

Coroner's recommendations

  1. Develop and disseminate education and training programs for NSWRL participants emphasising importance of detecting head injuries and mechanisms of injury including second impact syndrome, tailored to age and playing experience
  2. Develop and disseminate education and training programs for NSWRL coaching staff, refereeing staff, ground staff, participants and parents regarding mechanisms of head injury and how to communicate potential head injuries to sports trainers without compromising trainer responsibilities
  3. Use Grant's death as a case study in NSW Ambulance education and training to emphasise importance of call takers asking Entry and Key Questions about potential trauma, to assist dispatchers, and seeking clinical advice when questions are not asked or clinical input is indicated
  4. Investigate means of collecting data to identify whether call takers and despatchers are appropriately seeking clinical advice and input from Senior Control Centre Officers
Full text
Official source Archived copy

Related cases from NSW

NSWhome2026-04-21

Inquest into the death of Michael

28y · Male·In keeping with Hanging

A 28-year-old man with a history of depression, anxiety, and previous self-harm died by hanging during a police response to a domestic violence incident. Police attended after his sister reported he had breached an ADVO …

emergency medicineparamedicinesystemcommunicationvenlafaxine
NSWhome2026-04-01

Inquest into the death of EJJ

39y · Male·Hanging

A 39-year-old man died by hanging on 16 February 2023 at his home in St Marys, NSW. His mother requested a police welfare check at 8:40pm after he posted a suicide note on Facebook at 2:30pm. Police attended twice (11pm …

psychiatryforensic medicinecommunicationsystemdiazepam
NSWcommunity2026-03-25

Inquest into the death of Jesse Riley

31y · Male·Status epilepsy secondary to cerebral cavernoma

Jesse Riley, a 31-year-old with undiagnosed cerebral cavernoma, experienced status epilepticus triggered by an unknown cause (possibly nicotine from recent vaping). While in post-ictal delirium, he was perceived as aggre…

paramedicineemergency medicinecommunicationsystemdroperidol

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.