A coroner has found no fault with New Zealand Rugby over the death of a young Northland player from a head injury he received during a tackle.
However, he has called for electronic medical histories to be available to emergency staff when patients are first admitted to hospital.
Northland rugby player Jordan Kemp, 17, was fatally injured during a July 2014 game between his Otamatea Hawks side and Old Boys Marist in Whangarei, when he made a tackle while his head was in the wrong position in front of the running player.
He emerged from the bottom of a ruck, was seen staggering, then collapsed face down and quickly became unconscious.
He died after surgery at Auckland Hospital, where doctors found he had a subdural haematoma - where blood collects between the skull and the surface of the brain.
In a report released today, coroner Brandt Shortland found Kemp had suffered a concussion during a game four months earlier, and had aggravated previous problems.
When he was eight, Kemp had suffered a head injury when he fell off his bike.
He subsequently switched from playing rugby to football, but reverted to rugby after two years.
Most importantly, four months before his death, Kemp had suffered a concussion playing rugby and became the first player to be issued a 'blue card' under a concussion system being trialled by the Northland Rugby Union.
Under the rules, he had to get medical clearance to play again, which he got after a few weeks.
Mr Shortland found no fault with the Northland Rugby Union, instead praising it and New Zealand Rugby for their concussion systems.
The 'blue card' system had "tremendous merit", he said.
"I acknowledge the foresight and courage shown by the Northland Rugby Union to address the culture around head injuries in introducing this initiative."
New Zealand Rugby had been extremely active in the last few years about addressing concussion management, he said.
It had recently come to a funding agreement with ACC to improve its concussion education programme.
When Kemp was first admitted to Whangarei Hospital, his medical history was unavailable, Mr Shortland said.
He called for electronic histories to be introduced nationally.
Kemp was a triplet who attended Auckland Grammar School before enrolling in a course for sport and fitness.
He worked at a local bottling factory in Kaiwaka.
Mr Shortland said his death had hastened progress in how rugby clubs manage concussions and head injuries.