A young Northland rugby player who died after hitting his head in a tackle had suffered a "re-bleed" of a large brain clot that no one knew he had.
Jordan Kemp, 17, died in Auckland Hospital on July 6, 2014, as a result of a significant head injury while playing rugby the previous day, Coroner Brandt Shortland has ruled.
Shortland found Kemp suffered a blunt-force head trauma, which caused a re-bleed of an existing acute chronic subdural haematoma - a large brain clot - on the left side of his head.
This clot had formed four months before in March after Kemp was knocked out playing rugby.
Forensic pathologist Dr Fintan Garavan noted that such a clot was "clinically silent" unless a CT scan was carried out. Over time, they developed a tendency to re-bleed even with "minor trauma".
Kempo had not had a CT scan.
Shortland noted that there had been a suggestion that every player returning to rugby from a head knock should have a CT scan.
It was a "sensible" notion in principle, but would be an enormous logistical challenge and could not be properly funded and resourced.
"The decision to treat remains with the medical profession alone."
Shortland also noted that Kemp had received another head injury to the left side of his head in 2006 after a bicycle accident.
Emergency medicine staff treating Kemp in March were not aware of this, as the record of the injury was noted on paper records.
Shortland said quick access to previous records electronically would "invariably shape the type of treatment".
Shortland said the March 2014 concussion led to Kemp being stood down under the Northland Rugby Union's 'blue card' system. Kemp was the first person issued with a blue card, which is a stand-down for any player who received a head knock and a suspected concussion.
A player issued with a blue card must leave the field of play immediately and is prevented from playing rugby or resuming contact training until they have a concussion clearance notice, which requires clearance from a doctor. Kemp was cleared to play about a month later.
Shortland said New Zealand Rugby, with the assistance of ACC, was leading the way with its RugbySmart v2.0 community concussion education programme, which seeks to educate players directly and general practitioners. He said the programme was making everybody involved in the game proactive in keeping players safe as much as possible.
"It is now mandatory to pull players off the field when it is suspected they may have suffered a head injury," Shortland said.
"It is the referees, coaches, administrators and players themselves that are being directly educated to watch out for such signs and to be proactive in protecting individuals as much as possible form head injuries."
He also acknowledged the efforts of the Northland Rugby Union in initiating the blue card system.
"It should be acknowledged that Jordan's death has had an impact on the rugby community both in Northland and wider, which has been a catalyst for change and further education and processes around identifying the risks and potential injuries that come from playing rugby," Shortland said.
"Jordan's death is one of two rugby deaths within 12 months of each other that has strengthened the resolution to keep honing the processes to help restrict injury and death."
The report also noted that both of Kemp's concussions had occurred after his head was positioned incorrectly during a tackle.
Kemp's former coach Michael Peeni was so moved by Kemp's death that he had re-dedicated his coaching efforts to teaching younger players correct tackling techniques.