Safety in the football codes: a historical review of fatalities in Australian print media

The dangers of modern football are often scrutinised, but has safety actually evolved over time?

In Australia, four major football codes (focusing on soccer, rugby union, rugby league and Australian football) are generally considered to be high risk sports. On rare occasions, serious injury and death can occur.1,2 The popularity of these sports for spectators and participants tends to result in a bias on the reporting and awareness of any serious events that happen. This has been further heightened by the emphasis on head trauma and concussion in recent years. At the same time, the peak bodies of the football codes in Australia, including the Football Federation Australia, Rugby Australia, the National Rugby League and the Australian Football League, have been proactive in addressing safety concerns. This includes rule changes,3 return to play protocols,4 and direct funding of research.5 Perhaps counterintuitively, positive safety management can result in the public image being presented with an unfair focus on the risks of participation.

In the United States, media reports have been successfully used since 1905 as a tool for identifying, and subsequently preventing, fatalities associated with sport, particularly for American football.6 In Australia, following a fatal injury, a compilation of historical media reports from cricket injury fatalities helped to contextualise safety changes in the modern game, including, for example, the reductions in head injury deaths likely attributable to the introduction of helmets.7 The current study is designed with a similar intention in seeking to identify historical football fatalities from injury in print and online media and map these against the introduction of key safety strategies.

Both presently and historically, footballers are considered the epitome of fitness and youth and fatalities are thus out of place in this context. Fatalities in sport have always been tragic, evidenced by the headlines and language used in reporting them. In the first case of this series, the author described: “It is about time something was done to stop this murderous game, as now played”.8 The transition of football from “murderous game” in 1873 to calls for banning parts of all of the modern sport appear unjust, considering the trends in our series, with peak number of cases having occurred through the early and mid‐1900s and since sharply declining.

We undertook an extensive search for football injury‐related deaths and performed multiple searches of digitised newspapers (Trove [https://trove.nla.gov.au/newspaper] and Australian Newspapers [www.newspapers.com.au]) and biomedical journal databases (PubMed, SPORTDiscus) during April–July 2018. These searches used combinations of various terms derived from an earlier study.2

Trove covers all the major national, metropolitan, suburban and country newspapers in Australia from about 1800, but coverage ended in 1954 due to copyright reasons. A small number of newspapers allowed their archives to continue to be included. For the football fatalities occurring after the 1950s, the search focused on Australian Newspapers and Google.

All cases were initially included if a fatality or serious injury occurred in a football participant (player, official or spectator) during a match or training. Several newspaper accounts of each case were analysed, including publicly available coronial inquests to verify the cause of death where available. All cases were reviewed.9 Cases were removed from analysis when the death was attributed to travelling to or from a football match or training, or to an atraumatic medical cause (eg, cardiac death).

We tabulated cases and presented descriptive data to identify the number and proportion of fatalities by sex, age, football code, location, time period, cause, and activity at the time.

For rugby, the precise code was often not able to be differentiated as league or union. Even the term “football”, usually associated with rugby league, was used to describe both rugby codes in the first half of the 20th century. For all rugby‐related deaths before 1907, rugby union was deemed the code, as rugby league was first played in Australia in 1907.10 The task was easier for differentiating soccer and Australian football in the southern states, given the term “soccer” is more commonly used as an identifier. The description of positions or the play of the game also assisted in differentiating the football codes.

There were 424 football‐related deaths identified from the initial search, of which 295 deaths were confirmed as resulting from injury (Box 1). Ages ranged from 8 to 43 years. All except one death were in males. Almost all deaths were in players, with one soccer referee. There were 48 deaths in rugby union, 58 deaths in rugby league and a further 42 deaths for which the rugby code could not be discerned. Given the large number of cases where the exact code could not be identified, the cases from each rugby code have been combined.

The most common cause of death was traumatic brain injury (n = 128), followed by traumatic intra‐abdominal injuries (n = 74) and spinal cord injuries (n = 28; 25 of these were cervical spine injuries) (Box 2).

Most deaths (n = 256) occurred in organised sport, with the majority occurring at community‐level football (Box 3).

Injury prevention principles stipulate the importance of safety laws in sport and their enforcement. The reduction seen in traumatic brain injury‐related deaths compared with the 1930s is in part attributable to rule changes and stronger penalties over the decades for head‐high and unnecessarily rough contact.11 In the most recent decade, deaths related to traumatic brain injury in football appear to have increased. This could reflect the unpredictable nature of severe head injuries, the difficulty in treating them, and protective equipment having little effect on severe impacts.12

The absence of deaths from abdominal injuries recently may be due to rule changes.11 However, improved access to emergency care through the introduction of mobile ambulances13 and blood banks14 in the late 1930s is probably most important, as rapid access to blood products can prevent death due to blood loss from a large intra‐abdominal haemorrhage.

Deaths from spinal cord injury have also diminished since the 1930s, likely due to improved surgical decompression techniques and rule changes specific to rugby union. In 1954, rules were first introduced to prevent the deliberate collapse of the scrum, a technique often used to slow gameplay but with potentially dramatic consequences.15

When comparing codes, deaths related to traumatic brain injury and spinal cord injury were more likely to occur in rugby, while deaths from abdominal injuries were more prevalent in Australian football. This is attributed to how these games are played. The rugby codes are head‐on sports involving high impact forces, with the head and neck in more vulnerable positions. Australian football on the other hand is a “360‐degree sport”, where unexpected contact can come from any direction, with a player more likely to be impacted in the unprotected abdomen.

Most deaths occurred in organised community‐level competitions, in contrast to the previous study on traumatic cricket deaths,7 where deaths during informal play outweighed those in organised matches. This is likely due to informal play involving less physical impact in football codes, while informal cricket involves less protective equipment and a higher chance of accidents. Nevertheless, these findings highlight the importance of appropriate regulation of rules, equipment and emergency care by an organised competition.

Despite the high profile nature of the tragic death of a young footballer warranting significant attention, this study is limited by the reliance on media articles, which may result in missed or inaccurately reported deaths. Additionally, while Trove is a comprehensive database, newspapers published after 1954 are still protected by copyright and most have not released this material to be digitised and uploaded, except for the Canberra Times and several local and country newspapers. While the Australian Newspapers database covers The Sydney Morning Herald (1831–2002) and The Age (1854–2000), and Google searches attempt to fill the void, it is more likely that deaths after 1954 have been missed in our searches.

Furthermore, while rates of deaths per exposure have likely fallen due to population growth and increased participation, this cannot be calculated as it is not possible to know historical participant numbers. These limitations highlight the fact that Australia would benefit from its own national database of sporting deaths, much like the US has had since the 1970s.16 This would help to better inform public health initiatives in the sporting context to ensure the risk of catastrophic events are reduced, and more accurately quantify the likely low risk of death from sporting activity compared with the consequences of inactivity.

Overall, 295 deaths due to football‐related injuries were identified in the past 146 years. The majority of deaths resulted from head, neck or abdominal injuries at the community level of the collision codes. While most of these deaths have substantially decreased, traumatic brain injury‐related deaths have made a resurgence in the most recent decade. This highlights the need to accurately report catastrophic events, protect players from head‐high contact, and improve emergency responses at the community level.

Box 2 – Number of cases of traumatic brain injury, spinal cord injury and abdominal injuries by decade

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