World Cup winner Kat Merchant was left "livid" as it emerged it took medical staff a minute to decide to pull England winger Abby Dow from the Rugby World Cup final amid confusion over whether she had been knocked unconscious.
Dow, 25, was eventually removed from the field for a head injury assessment during Saturday's agonisingly close defeat to New Zealand following a tackle from Kennedy Simon, which was deemed to warrant a yellow card. Dow duly returned to play after passing her HIA, but the delay in examining her has raised serious concerns.
Dow, who broke her leg during the Six Nations against Wales before making a miraculous recovery in time for the World Cup, appeared to stagger as she rose to her feet post-collision.
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It had echoes of the delay in removing Wales prop Tomas Francis from the field during the Six Nations despite him using post pads to try and steady himself after taking a knock.
RFU chief executive Bill Sweeney said of the incident at Eden Park: "I spoke to the pitchside doctor afterwards and he said they weren't sure whether she'd been knocked unconscious or not, and then they reviewed the footage and I think it was about a minute afterwards they said she needs to come off and have a HIA."
He told the Rugby Union Daily podcast: "You normally see a player injured like that come off straight away for a HIA, that's the normal process."
England head coach Simon Middleton was also quizzed on the incident but backed the medics, albeit being without a full debrief at that stage. "Our medical are absolutely world-class," he said. "There's no way they'd leave a player out there who wasn't fit to be out there. Abby did her HIA and comes back on, that answers the question."
Red Roses World Cup winner Kat Merchant, who retired in 2014 on medical grounds after a number of head injuries, was left fuming with the delay.
"I was livid, absolutely livid by the decision," she said. "I retired early because of concussions. We didn't know as much back then so I have no beef with anything that went on medically then.
"However now we know the dangers and if you are in doubt of whether a player has been knocked out or not, you take them off. Whether it's a World Cup final or not, it's absolutely irrelevant.
"That player, Abby Dow, would never say 'I feel a bit off', she wants to stay on that pitch, of course she does. And when you've had your head knocked you don't know if you feel alright or not. That is, for me, a player welfare issue you have to get. Even if you get dragged off that pitch, get her off immediately."
BBC rugby correspondent Chris Jones said: "If this was the men’s game we’d be criticising the decision to have Abby Dow returning. She went off for an HIA, she was showing signs, I think, of needing permanent removal. So I think that needs to be scrutinised.”
Progressive Rugby, a lobby group aimed at making rugby safer, said: "We believe Abby Dow demonstrated category one symptoms necessitating immediate and permanent removal. Despite exhibiting cat one symptoms - she passed a HIA, indicating the HIA isn’t fit for purpose as it failed its purpose of identifying a brain injury."
The consistency of cards during the tournament has been questioned, with Simon's tackle on Dow not dramatically dissimilar to Lydia Thompson's high tackle on Portia Woodman, which resulted in a red card to reduce England to 14 players for more than an hour.
The Red Roses, who at that point were on a 30-match winning run, managed to lead for most of the final but the Black Ferns managed to successfully defend their world champions status on home soil with a late try and a 34-31 victory.
While Red Roses boss Middleton agrees player welfare should be top of the agenda in rugby, he backed a 20-minute red card in the aftermath of the defeat and wants intent taken into account by referees.
"Player welfare should be rightly top of the agenda," he said. "Absolutely, it should be.
"Lydia Thompson is one of the best beautiful and caring people you will ever meet in your life. If they don't take intent into account of situations, then you'll never reflect accurately, I don't think, what's going on.
"100% there has to be a penalty for a high tackle, or a head clash, or things that endanger players, but I just think you have to take intent into consideration. Maybe that's the little bit that's missing from our protocols, and consistency."
Asked specifically about whether he backed a 20-minute red card, whereby a player who was sent off could not return to the field but could be replaced after 20 minutes, Middleton said: "I think that's a great solution, or a potential solution.
"If it hadn't been for the character of the side and the grit and determination, it might not have been the spectacle it was because of the red card because we've seen what that does to games.
"I'm not saying it shouldn't, 100% we should look after player welfare and I think all of the things that have been brought in have clearly had a huge positive impact on the game in terms of concussion and head injuries and we should keep going and going as hard as we can to make the game as safe as we can.
"But there were some far more intentful incidents across this competition that didn't get what Lydia got, and she is one person who does not deserve that."
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