Features of patients transferred to a regional neurosurgical unit in coma after recent head injury were compared with a similar audit seven years previously. There were fewer avoidable adverse factors in the recent series, but some patients received inadequate care of the airway, while in some others major extracranial injuries were overlooked or poorly managed. Only 42% of the comatose patients had had an endotracheal tube inserted; half those in whom neither a tube nor an oral airway had been inserted were transported supine. Systemic hypoxia or hypotension [corrected] were associated with a poor outcome. Even when computed tomography scanners become available in more hospitals, many patients who are unconscious after head injury will still need to be transferred to a neurosurgical unit. Detailed guidelines should be agreed locally to minimise the hazards of transfer of unconscious patients between hospitals. A rota of experienced doctors and nurses at the sending hospital should be responsible for deciding how each individual patient should be managed during transfer, according to the guidelines. Continuing audit of such cases is needed to indicate whether revision of local practice is needed.