An elderly patient suffered a head injury in an accidental fall and was transported to hospital by ambulance, where she subsequently died. The Coroner commented that the case highlighted the need to make enquiries beyond the patient where circumstances indicated the patient may be confused, and also noted that while ambulance staff gave a comprehensive patient report it was hoped that the providers might review the handover procedures to determine whether they are sufficient to prevent any gaps in the patient history for ED doctors. The Coroner made a recommendation directed to all DHBs, and the Medical Council, for dissemination to all hospitals and doctors in private practice: "that all clinicians should adopt a very low threshold in deciding whether to request a CT scan for elderly patients presenting with a head injury". Rippey [2011] NZCorC 10