If in Doubt, Sit Them Out: What UK Concussion Guidelines Mean for Coaches

Key takeaways

• "If in doubt, sit them out" is a formal principle embedded in the November 2024 UK Concussion Guidelines for Grassroots Sport, not an informal motto.
• Any sign or symptom of concussion - even a single one - is enough to remove a player immediately, regardless of the sport or the stakes of the match.
• A player who insists they are fine must still be removed; a coach cannot override removal on the basis of the player's own assessment.
• The decision to remove is not a diagnosis; it is a precautionary step within every non-clinical adult's competence.
• Documentation of removal, observation, and follow-up is part of the same duty of care as the removal itself.

---

A player takes a knock to the head. They get up, say they are fine, and want to carry on. You are not a doctor. You are not sure. What do you do?

The answer is straightforward. If there is any doubt, they come off. This is not just a sensible instinct; it is what the UK Concussion Guidelines for Grassroots Sport require of every coach, teacher, and official working with community sport.

This article explains where the principle comes from, what "doubt" actually means in practice, and how to handle the difficult conversations that follow.

---

The principle in one sentence

The November 2024 update to the UK Concussion Guidelines for Grassroots Sport (Sport and Recreation Alliance) states that any player suspected of having a concussion must be immediately and permanently removed from play for that day. "Immediately" means now, not at the next break in play. "Permanently" means they do not return that same day under any circumstances.

---

Where it comes from: UK guidelines and World Rugby

The "if in doubt, sit them out" principle is not unique to the UK. World Rugby's concussion guidance uses the same language and has done so for over a decade. What the November 2024 UK Grassroots update did was consolidate the principle across all sports - not just rugby - and clarify the standard that applies to every coach, PE teacher, and match official in community sport, regardless of whether a medic is present.

The guidelines were produced in collaboration between the Sport and Recreation Alliance and the major national governing bodies. They apply to football, rugby union and league, hockey, netball, basketball, and every other sport played in UK schools and clubs.

The important distinction is that these are the grassroots guidelines, not the elite Head Injury Assessment (HIA) protocol used in professional rugby. The HIA involves qualified doctors and a structured return-to-play window within a match. That pathway does not exist at community level. The grassroots principle is simpler and more conservative: remove immediately, do not return that day, and begin the graduated return-to-play process the following day at the earliest.

---

What "doubt" means in practice - the signs to remove

Doubt does not mean certainty of concussion. It means the presence of any feature that could indicate a concussion. The Concussion Recognition Tool 6 (CRT6), produced by the Concussion in Sport Group, gives coaches a structured checklist of signs and symptoms.

Remove a player immediately if you observe any of the following:

• Loss of consciousness, even briefly
• Confusion, disorientation, or blank staring
• Unsteady on their feet or slow to get up after a head knock
• Clumsy movements or stumbling
• Facial expression that looks dazed or vacant
• Visible seizure or convulsive activity

Or if the player reports any of the following:

• Headache or pressure in the head
• Blurred or double vision
• Nausea or vomiting
• Dizziness
• Feeling slowed down, foggy, or not themselves
• Sensitivity to light or noise
• Memory problems, including not recalling the incident

You do not need to see all of these. One is enough. You do not need to diagnose concussion. You need to act on suspicion.

A useful practical test is the Maddocks Questions, which are included in the CRT6. Asking a player where they are, what the score is, or who they played last week is a quick check for disorientation - though a correct answer does not rule out concussion, and a wrong answer is a clear trigger for removal.

---

The conversation with the player who wants to keep playing

Young athletes in particular have strong motivation to stay on the pitch. Culture, team pressure, fear of letting people down, and a genuine belief that they are fine all work against removal. Research cited in the CISG 6th Consensus Statement notes that under-reporting of symptoms by athletes is one of the most significant barriers to safe concussion management.

Some practical language that works in the moment:

• "I'm not saying you have a concussion. I'm saying I'm not sure, and that's enough. You're off for today."
• "The rules say I remove you when there's any doubt. That is what I am doing."
• "The decision is mine to make, not yours. That is how it works."

Keep it short. This is not the moment for a detailed medical explanation. The player can be frustrated. That is manageable. A second impact during the same event is not.

If the player is an adult, they have more autonomy in theory - but the guidelines are clear that the coach's duty of care does not dissolve because the player consents to return. The liability and the professional responsibility remain with the person running the session.

---

The conversation with the parent

Parents at youth sport fixtures can be a different challenge. Some will push back, especially if they have driven a long distance or if it is a cup final. The same principle applies.

Explain what you observed, not what you diagnosed. "I saw your child look disoriented after that challenge. The guidelines require me to take them off." Most parents, once the word "guidelines" or "duty of care" appears in the conversation, will accept the decision even if they are unhappy about it.

If a parent insists on removing their child from your care to return them to play, document that you advised against it and that the parent took responsibility. This does not release the club or school from liability if a coach then facilitates the return, so the position must be firm.

---

What happens after immediate removal

Once a player is removed:

1. Move them to a quiet area away from the pitch. Loud environments make symptoms worse.
2. Do not leave them alone. A responsible adult should stay with them until they are with a parent or carer.
3. Use the CRT6 to make a structured observation record. Note what you saw, what time it happened, and what symptoms the player reported.
4. Contact the parent or carer if they are not present, and communicate what occurred clearly.
5. If you observe any red flags - repeated vomiting, worsening headache, one pupil larger than the other, seizure, or deteriorating consciousness - call 999 or direct to A&E immediately. For less urgent situations, NHS 111 can advise.
6. Do not allow the player to drive home.

The graduated return-to-play process, which takes a minimum of 21 days for under-18s under the November 2024 UK Grassroots Guidelines, begins after a period of symptom-free rest. It does not begin on the day of the incident.

Luca's clinician-led platform supports coaches and schools from the moment of sideline removal through each stage of the graduated return, with structured documentation at every step.

---

Why erring on the side of caution is the right call every time

Two concerns come up regularly among coaches about over-removing players.

The first is: what if I remove someone who doesn't actually have a concussion? The answer is that a brief, precautionary stand-down for a player who turns out not to be concussed costs almost nothing. A missed concussion followed by return to play during the same session carries risks that are serious and in some cases irreversible.

The second is: what about the team, the match, the result? The guidelines are not balanced against match results. They exist because the risk of harm is real, the consequences can be severe, and the person making the decision in the moment has a legal and ethical duty of care to the player - not to the scoreline.

The standard the guidelines set is not "remove if you are certain." It is "remove if you are not certain." That is a deliberately low bar, because uncertainty on a noisy sideline without medical equipment is the normal condition every grassroots coach operates in.

---

What to do next

If you have not already, download the CRT6 from the Concussion in Sport Group and keep it accessible on your phone or in your kit bag. Read the UK Grassroots Concussion Guidelines. Make sure every member of your coaching staff has done the same.

If you are responsible for sport in a school or club, make sure your concussion policy names these guidelines, assigns responsibilities clearly, and covers documentation. The Luca Safe Concussion Framework includes structured protocols for sideline identification, graduated return to play, and record-keeping. See how it works at /how-it-works/.

---

Sources

1. Sport and Recreation Alliance. UK Concussion Guidelines for Grassroots Sport (November 2024 update). https://sportandrecreation.org.uk/files/uk-concussion-guidelines-for-grassroots-non-elite-sport---november-2024-update-061124084139.pdf
2. Concussion in Sport Group. Concussion Recognition Tool 6 (CRT6). https://bjsm.bmj.com/content/57/11/692
3. World Rugby. Concussion guidance and the "if in doubt, sit them out" principle. https://www.world.rugby/the-game/player-welfare/health/concussion
4. Concussion in Sport Group. 6th International Conference on Concussion in Sport: Consensus Statement 2023. https://bjsm.bmj.com/content/57/11/695

---

Luca's clinician-led platform supports coaches and staff from the moment of sideline removal through to safe return. See how the full pathway works at /how-it-works/.