The grandfather of a young Northland rugby player who died after receiving a head knock in a game - suffering a "re-bleed" of a large brain clot no one knew he had - wants more CT scans carried out on people who receive head injuries.
Jordan Kemp, 17, died in Auckland Hospital on July 6, 2014, as a result of a significant head injury suffered while playing rugby the previous day, Coroner Brandt Shortland has ruled.
Mr Shortland found Jordan 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 Jordan was knocked out playing rugby.
Forensic pathologist Dr Fintan Garavan noted the clot was "clinically silent" unless a CT scan was carried out.
Over time, they developed a tendency to re-bleed even with "minor trauma". Jordan had not had a CT scan after the March injury.
Jordan had been staying with his grandfather Russell Kemp in Kaiwaka at the time of his death and Mr Kemp said the death had devastated Jordan's family, his friends and rugby colleagues.
Mr Kemp said the medical people who dealt with Jordan did the best they could under the circumstances of the time, but with the advancement of technology he hoped CT scans would be carried out far more often on people with head injuries.
"I'm not saying they should be compulsory and the medical people are in the best position to make decisions, but for the sake of a CT scan a life could be saved," he said.
"It's about whether they make the right call at the right time, but I'd like to see more CT scans done."
Mr Kemp said it was a concern that when Jordan was being treated in hospital the medical staff were not aware that he had suffered an even earlier head injury, when he fell off his bike in Maungaturoto when he was aged about 8.
That injury was not recorded on Jordan's electronic medical file as it was put down on an early paper system that had not been transferred.
He said it was pleasing that everybody involved in the game was taking steps to ensure a situation like Jordan's did not happen again.
Mr 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."