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This article looks at the expansion of the Glasgow Coma Scale to assist in classifying severity and prognosis in brain injury.

What is the Glasgow Coma Scale?

The Glasgow Coma Scale (GCS) is a term which will be familiar to anyone who has attended hospital with a head injury and to fans of Holby City, Casualty and other TV hospital dramas who frequently reference the GCS.

Developed at the University of Glasgow in 1974, it is used to assess the level of consciousness after an injury and measures response to stimuli in three main areas – eye, motor (movement) and verbal. The quality of each response is assessed by paramedics who attend the scene of an accident, as well as triage, A&E staff and the attending clinicians once a person is admitted to hospital, and the quality of each response is ‘scored’, giving a final 3 to 15 point score across all three main areas. So, for example, someone who scores 15/15 would be a patient who is fully alert and responsive, whereas a score of 3/15 would indicate that the patient is totally unresponsive.

If pursing a brain injury claim, one of the first things your solicitor will look at is the scores within hospital records.

The Glasgow Coma Scale

Table showing The Glasgow Coma Scale

LevelEye responseVerbal responseMotor response
1No eye openingNo verbal responseNo motor response
2Eye opening in response to painIncomprehensible soundsExtensions to pain (eg extension of wrist)
3Eye opening to speechInappropriate wordsAbnormal flexion to pain (eg flexion of wrist)
4Eyes opening spontaneouslyConfusedFlexion/withdrawal to pain (eg pulls away when pinched)
5Oriented to time, place and personLocalises to pain (eg purposeful movements towards painful stimuli)
6Obeys commands

Glasgow Coma Scale – Pupils System (GCS-P)

An updated system, known as the GCS-Pupils system (GCS-P) has recently been published, which produces a score system aimed to assist with assessing the severity of and prognosis for, a brain injury. The new system combines the reactivity of a patients pupils which is a key prognostic indicator, with the severity of injury as determined by the GCS.

So in practice, the GCS assessment will be carried out followed by an assessment of the patients pupil reactivity which is scored 0, 1 or 2 (poor pupil responsiveness being scored 2), and this score is then subtracted from the GCS score, resulting in the GCS-P score (1-15). Other factors such as age and CT findings also impact on the long term prognosis and these must also be considered when predicting prognosis.

Combining all these factors, the team behind GCS-P have developed prediction charts based on the GCS-P, patient age and simplified CT findings to show (1) probabilities as to the risk of death and (2) probabilities of favourable outcomes in patients 6 months after TBI which can be used by clinicians in decision making as well as to manage expectations of patients and families.

About the authors of GCS-P

GCS-P was developed by a team from University of Glasgow and University of Edinburgh which included one of the original creators of the GCS. When asked about the study, the authors commented:

‘Decisions about patient care in the immediate aftermath of a head injury are influenced by physician perceptions of the patient’s likely outcome, so its important that assumptions that underlie these decisions are correct. Working together between Glasgow and Edinburgh, we have developed the GCS-P and associated prognostic charts. These simple and easy to use tools provide reliable estimates of outcomes at 6 months and will support clinician decision making in neurotrauma.’

The Glasgow Coma Scale is a simple to use scoring system, used throughout the World which can be performed, interpreted and communicated by people with even a basic level of training. It is hoped the GCS-P, which is equally easy to perform, interpret and communicate, will also be adopted Worldwide for the benefit of those who have sustained a brain injury.

View from specialist solicitor

We spoke to Philippa Luscombe, Partner in the personal injury team at Brain Injury Group member firm, Penningtons Manches to ask her views on the benefits of the new GCS-P system. Philippa specialises in claims involving brain injury and commented:

‘The early management of a patient with a head injury can have a significant impact on the outcome, therefore anything that helps to evaluate a patient with a head injury and identify if quick and active management is likely to make a difference can only be a good thing. This assessment may assist in justifying ongoing rehabilitation for patients with serious injuries after acute care (which is an issue often encountered when acting for clients with head injuries), whose GCS-P was a good prognostic indicator. It should also support the communication and management of expectations of families.’

What is the Brain Injury Group?

The Brain Injury Group exists to support individuals and families affected by brain injury and the health and social care professionals working in this specialist field. Our mission is to provide anyone affected by brain injury with access to advice on legal, financial and welfare benefit issues delivered by proven experts in the field who have been chosen not only for their skills and knowledge, but also for their passion and dedication to helping people.

How can Brain Injury Group help you?

If you would like advice about bringing a personal injury claim, capacity, deputyships or managing the award of compensation or any other aspect of brain injury welfare, legal or financial advice, we have specialist brain injury solicitors and Court of Protection solicitors who can assist.

You can find full details of Brain Injury Group members on our website or there are several ways to get in touch:

  1. Call us on 0800 612 9660 or 03303 112541
  2. Email us at
  3. Complete this short enquiry form and we’ll get back to you
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