Epidemiology of trauma deaths across a mature regional trauma system: patterns of pre-hospital and in-hospital fatalities.
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Authors
Nijhawan A.
Ter Avest E.
Twohig C.J.
Webster S.J.
Morris J.
Lendrum R.
FitzpatrickSwallow V.
Lockey D.J.
Perkins, Z. B.
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2026
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INTRODUCTION: In mature trauma systems, most trauma deaths occur soon after injury yet studies often only include patients who survive to hospital admission. These studies exclude pre-hospital deaths and introduce substantial survival bias. Understanding trauma fatalities across all phases of care is essential to identify opportunities to further improve trauma outcomes. METHOD(S): This retrospective cohort study analysed adult trauma fatalities attended by London's Air Ambulance from 1 January 2019 to 31 December 2020. Deaths were classified as pre-hospital if traumatic cardiac arrest occurred before hospital arrival. Timing of death was recorded as minutes from injury to arrest for pre-hospital cases and days from admission to death for in-hospital cases. A multidisciplinary panel determined the likely cause of death using clinical, radiological, and post-mortem findings. RESULT(S): Among 3,089 adult trauma patients attended, 497 (16.1%) died. Most deaths (77.1%) occurred pre-hospital, with a median time from injury to traumatic cardiac arrest of 12 minutes (IQR 6-24). Haemorrhage and traumatic brain injury accounted for 81.9% of deaths overall, but their distribution differed markedly by phase of care: 96.2% of haemorrhage deaths occurred pre-hospital, whereas 84.2% of in-hospital deaths were due to traumatic brain injury. In addition, deaths from all other potentially reversible causes, and 95.1% of penetrating trauma deaths, occurred pre-hospital. CONCLUSION(S): In mature trauma systems, most trauma deaths now occur before arrival in hospital, with many due to potentially reversible causes. The greatest opportunities to improve trauma outcomes now lie in the pre-hospital phase of care. Copyright © The Author(s) 2026. Published by Oxford University Press on behalf of BJS Foundation Ltd.
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The British journal of surgery