High-quality resuscitation and care during transfer of head-injured patients is essential to prevent secondary brain injury. We have prospectively assessed the standard of resuscitation in 50 consecutive head-injured patients transferred to our unit, and compared our findings with previous studies performed before the advanced trauma life support course (ATLS) had become widespread and national guidelines on the transfer of head injuries had been produced by the Association of Anaesthetists of Great Britain and Ireland (AAGBI). Delays in transfer, management of the airway, adequate cervical spine assessment, hypoxia (P(a)O(2) <13 kPa), hypotension (systolic BP <90 mmHg), missed injuries and the experience of the medical escort were compared against the standards laid out in ATLS and AAGBI Guidelines. The mean, unavoidable delay from arrival at the local accident and emergency unit to arrival was 7.4+/-1.9h (mean+/-95%CI) with most of the delay being prior to initial referral. Two patients arrived with an unsecured airway with a GCS=8/15; 26 had inadequate cervical spine imaging; 7 patients arrived hypoxic and 2 patients arrived hypotensive; most of these insults occurred during the transfer. Forty-six percent of medical escorts did not fulfil the minimum standard of experience. ATLS and AAGBI guidelines have provided only modest improvements in patient care at the expense of long delays in transfer. The incidence of hypoxia and hypotension remains unacceptably high.