If in doubt, sit them out.

Quick reference from England Rugby's HEADCASE guidance. You don't diagnose concussion; you recognise it and remove the player.

Summary as of the 2023 HEADCASE update. Not an official England Rugby resource. For guidance only: follow your HEADCASE training and the latest England Rugby advice.

The 4 Rs

1. Recognise the signs and symptoms.
2. Remove the player from play straight away. No return that day.
3. Recover fully: rest, then back to normal daily life and school.
4. Return only via the Graduated Return to Activity & Sport (GRAS).

Red flags: call 999 or go to A&E

• Any loss of consciousness
• Getting drowsier, or less responsive
• Can't remember events before or after the hit
• Increasing confusion, irritability or odd behaviour
• Trouble speaking, understanding, reading or writing
• Numbness, weakness, loss of balance or double vision
• Fit or seizure, twitching limbs, or lying rigid
• Severe or worsening headache
• Repeated vomiting, or severe neck pain
• Possible skull fracture

Neck pain: don't move them. Keep them still and call 999.

Signs: what you might see

• Lying still, or slow to get up
• Unsteady on their feet, balance problems, falling over
• Dazed, blank or vacant look
• Slow to answer, or confused about play or events
• Holding or clutching their head
• Fit, or lying rigid
• More emotional or irritable than usual
• Being sick

Symptoms: what they might tell you

• Headache or "pressure in the head"
• Dizzy, or feeling off balance
• Confused, foggy, or "slowed down"
• Can't concentrate, or drowsy
• Blurred or double vision
• Feeling sick, or very tired
• Bothered by light or noise
• More emotional, or "I just don't feel right"

A concern from a parent, referee, team-mate or spectator counts too.

Memory check (over-12s)

Adapt to the session. Any wrong answer suggests concussion.

• Where are we today?
• Which half is it?
• Who scored last?
• Who did you play last week?
• Did your team win last time?

Younger children often can't answer reliably. Never use a correct answer to keep a child on: signs and symptoms come first.

Ask yourself

• Did I see any sign from the list?
• Has the player said they feel any symptom?
• Has anyone else raised a concern?
• Did they get any memory question wrong?
• Am I unsure?

Yes to any: remove them for the rest of the day. Then check the red flags.

Straight away

• Don't leave them alone. Hand over to a parent or carer in person.
• No return to play, even if they feel better.
• Get them assessed: on site, or NHS 111 within 24 hours.
• Tell the parent what happened, and pass on the advice below.
• Report it to your club (safeguarding or injury lead).

For the parent

• Someone stays with them for the first 24 hours.
• Rest and sleep as needed for 24 to 48 hours. Gentle walking and easy daily activity are fine.
• Limit screens (phone, TV, computer) for at least 48 hours.
• NHS 111 within 24 hours if not already seen.
• Any red flag at any time: A&E or 999.
• Getting worse, or not improving by 14 days: NHS 111.
• Symptoms lasting over 28 days: see the GP.
• Tell school. Back to normal life and school comes before rugby.

Return to rugby (GRAS)

1. Relative rest first 24 to 48 hours
2. Daily life & light activity after at least 24 hours
3. Aerobic exercise, light bodyweight work as symptoms allow
4. Non-contact rugby drills no earlier than day 8
5. Full contact training no earlier than day 15
6. Return to play no earlier than day 21

Move on only if activity makes symptoms no more than mildly and briefly worse. They must be symptom-free for 14 days before contact training. Minimum 21 days out for all community rugby players.

Summary as of the 2023 England Rugby HEADCASE update (in line with the UK Concussion Guidelines for Grassroots Sport). Always check the latest at englandrugby.com/headcase.