A Head Injury Assessment investigation has found Wales prop Tomas Francis should have been “immediately and permanently removed from play” during last months' Six Nations clash with England.
However, no disciplinary action will be taken against the Welsh Rugby Union. Instead, a number of recommendations have been put forward by the review panel for consideration.
Francis left the field temporarily during the first-half of Wales' defeat to England at Twickenham, only to return after being assessed by the Independent Match Day Doctor. However, following the circulation of footage of Francis stumbling around, the decision to bring him back on came under intense scrutiny.
Lobby group Progressive Rugby labelled it "a clear and flagrant breach of protocol".
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Following the match, Six Nations Rugby referred the incident to a HIA Review Panel for further consideration. And their findings have now been revealed, with the panel finding that more than one of the criteria required for an instant and permanent removal were met.
There are, as listed in World Rugby's guidelines, 12 different criteria that would warrant a player to be removed permanently from a match, including things such as suspected loss of consciousness. convulsion, tonic posturing, balance disturbance or ataxia and being clearly dazed.
The panel's findings read: "The HIA Review Panel concluded that in this instance one or more "Criteria 1" indications had been present that should have resulted in Francis being immediately and permanently removed from play.
"As part of the review process, the panel found that a number of factors appeared to have contributed to the failure to identify these indications, that ultimately led to Francis not being removed from the field of play. As such, a set of recommendations has been put forward by the Panel, that warrants consideration.
"The panel highlighted that it had the benefit of time for review of the video footage and the other materials at length, without any match-day pressure, and also had access to more camera angles and clips than the match-day medical team."
As a result, it has laid out nine recommendations, but eight of them already exist within World Rugby HIA process and supporting education modules. They include things like footage being reviewed throughout the period the player is undergoing a HIA, half-time being used to re-review any first half incidents and extensive video footage being made swiftly available.
No specific details are given on the events that transpired at Twickenham.
The only entirely new recommendation concerned setting appropriate minimum standards for the size of screen(s) and number of screen(s) available pitch-side for video footage review.
A statement from the Welsh Rugby Union said: "The head injury assessment (HIA) is an extremely important protocol. We do not – and will not – compromise on player welfare.
"We note the Six Nations HIA review process findings and cooperated fully with the review undertaken by Six Nations.
"Our medical personnel are very experienced and we completely support all of their actions during the England v Wales Guinness Six Nations match, which were entirely appropriate and in accordance with all the relevant protocols. They were unsighted to the incident involving Tomas Francis in real time and, as had been agreed prior to the match, Francis was removed from the field of play to undertake his HIA with the independent match day doctor.
"We are committed to continuing to work with Six Nations, World Rugby and other unions in respect of these matters."
Coach Wayne Pivac also came out in defence of their handling of the situation prior to the match with France.
