Background In 2014, the South Australian coroner recommended that residents of residential aged care facilities (RACF) who had sustained a head injury should be transported to emergency departments (ED) for assessment and a head CT scan, with the view to preventing mortality. The evidence base for the recommendation is unclear. Aims To determine the rate of emergent intervention (neurosurgery, transfusion of blood products or reversal of anti‐coagulation) in residents transferred to ED with minor head trauma who had their usual cognitive function on ED assessment. Methods This was a retrospective cohort study by medical records review at two university‐affiliated community ED. Participants were patients from RACF attending ED who had suffered minor head trauma and had their usual cognitive function. Exclusions were altered conscious state, new neurological findings or associated orthopaedic injury requiring hospital admission. The primary outcome was rate of emergent intervention in residents transferred to ED with minor head trauma who had their usual cognitive function on ED assessment. Results A total of 366 patients was studied; median age 86 years, 45% taking anti‐coagulant/anti‐platelet medication. Eighty per cent underwent head CT. Six per cent had intracranial haemorrhage (ICH; 95% CI 4–8.9%). No patient underwent neurosurgery. One had emergent intervention, reversal of anti‐coagulation (0.3%, 95% CI 0.05–1.5%). Conclusion The rate of emergent intervention for ICH in patients from RACF who sustained a minor head trauma but had their normal cognitive function was <1%. None underwent neurosurgical intervention. The low rate of intervention seriously challenges the appropriateness of routine transfer and CT for this patient group.

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Standards and regulations have no intrinsic practical effect without taking into account those who are the object of them; standards and regulations do not become operationally effective until they are implemented by the entities which are subject to them. Accordingly, there is a necessary synergy between the regulator and the regulated — the regulators whose task it is to make and enforce the rules for safe, efficient and reliable transport, and those whose job it is to transport within the rules. The bottom line of transport safety regulation is safety, but safety is not a factor exclusively of the working of regulatory provisions. Stability, clarity and consistency in the international regulatory regime also are important to safety. The experience of the nuclear transport industry operating within the regulations has been positive. The issues which have arisen have related principally to differences in interpretation of the regulations by modal organisations and competent authorities coupled with different time schedules for implementation. Such differences take on added importance in the context of an accelerated two-year review cycle. It is the operators who have the experience of dealing with the international regulatory regime across jurisdictions. The periodic review of the international transport safety regime is important, but it may be that such review could be more fully informed by a sharing of experiences. Does a periodic review have of necessity to require proposals for change, or rather, shouldn’t such proposals flow from a review first, and then be advanced if deemed appropriate on the basis of the review? It is important to show confidence in a regulatory regime that has proven its effectiveness over several decades. All stakeholders to the regime benefit from stability. This paper will examine industry’s experience of operating within the two-year regulatory review process and present some suggestions for consideration. If industry is to be persuasive in urging greater regulatory harmonisation worldwide, it must work to develop consolidated industry positions on practical issues which it then can carry to the other stakeholders for consideration. This paper will cite specific examples of industry, within WNTI, working to develop such consolidated views.

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