Finding into death of George Diamond

Contributing factors

• failure to obtain CT or MRI imaging on 31 October 2018 despite persistent symptoms following head injury
• failure to obtain CT or MRI imaging on 5 November 2018 at ED presentation
• failure to review prior medical records before signing boxing clearance certificate on 25 January 2019
• failure to access ED discharge summary before clearing George to return to boxing
• inadequate clinical documentation and note-keeping by GP
• premature return to sparring with underlying chronic subdural haemorrhage
• rebleeding phenomenon in context of chronic subdural membrane from earlier undiagnosed injury

Coroner's recommendations

1. As part of DJSIR's regulatory review, consideration should be given to requirements for medical clearance before commencing or returning to amateur boxing/combat sports following injury, including whether clearance must be obtained from certified medical practitioners, and whether the VABL Certificate of Fitness form should be enhanced with more information for practitioners
2. The Neurosurgical Society of Australasia, RACGP and ACSEP should develop appropriate mandatory training for medical practitioners in relation to providing medical clearance for individuals to commence and return to boxing and combat sports
3. The Neurosurgical Society of Australasia, RACGP and ACEM should develop guidelines for patients presenting with mild head injuries from potentially dangerous mechanisms falling outside the Canadian CT Head Rule, including specific thresholds for CT or MRI in boxing and mixed martial arts contexts