Grievous Wounds System

A consistent theme throughout dark fantasy and related stories is the consequences of actions. While the roleplay ramifications of a party's decision can be highlighted through story outcomes, combat ramifications can be a little harder to implement. Grievous Wounds are an effective method of adding grit and realism to combat encounters, bringing consequences of a difficult fight to the forefront of storytelling.
Whenever a player character is reduced to 0 hit points they must make a Constitution saving throw of a DC equal to half the damage taken, or 10; whichever is higher. If they fail they must then roll 2d6 and subtract the amount of Grievous Wounds they already have from the total, then check the Grievous Wounds Table and apply the result.

2D6	Grievous Wound
2 or less	Permanent Wound. You have sustained a serious wound that is most likely Permanent. Roll on the Permanent Wound Table and apply the result.
3	Major Internal Damage. You have suffered major damage to your internal organs. On your turns if you take a bonus action, you cannot take an action until the start of your next turn, and if you take an action, you cannot take a bonus action until the end of your next turn. This wound heals with a week's worth of DC 15 Wisdom (Medicine) checks and rest.
4	Broken Arm or Hand. You can no longer hold anything with two hands, and you can only hold a single object at a time. This injury heals after someone sets the bone with a DC 15 Wisdom (Medicine) check and you spend two weeks resting the arm.
5	Broken Leg or Foot. Your walking speed is halved and you must use a crutch or cane to move. You fall prone after using the Dash action and you have disadvantage on Dexterity checks to remain balanced. This injury heals after someone sets the bone with a DC 15 Wisdom (Medicine) check and you spend two weeks resting the leg.
6	Broken Finger. You have disadvantage on Dexterity (Sleight of Hand) checks and Dexterity checks to use fine tools (such as Thieves tools) with the hand with the broken finger. This injury heals after someone sets the bone with a DC 15 Wisdom (Medicine) check and you spend a week resting the hand with the broken finger.
7	Deep Wound. You have taken a blow that under different circumstances would kill most humanoids. When you are reduced to 0 hit points, you start with an additional failed death saving throw.
8	Battered. Your muscles ache and you have had the wind knocked out of you. You gain a level of exhaustion.
9	Damaged Eardrum. You have suffered a blow to het head and your hearing has been impaired. You gain the deafened condition.
10	Sprained Ankle. You have badly sprained your ankle, unable to use it effectively. Your speed on foot is halved and if you take the Dash action, you must succeed on a DC10 Dexterity saving throw or fall prone.
11	Damaged Item. A randomly determined nonmagical item you hold, wear, or carry on your person is broken or ruined. Roll a d10, on a roll of 1 the item is a weapon, on a roll of 2 the item is a shield or armour, on a roll of 3-10 the item is an item that is none of these things.
12	Close Call. You narrowly miss an otherwise dangerous blow. Instead of being reduced to 0 hit points, you fall to 1 hit point instead, and become prone.

Unless otherwise stated, Grievous Wounds are healed after completing a long rest, and the character or someone helping them, succeeds on a DC10 Wisdom (Medicine) check, a player can remove all effects from Grievous Wounds, but not Permanent Wounds.

Permanent Wounds

Permanent Wounds are injuries that were not lethal, but left the recipient maimed. They represent a serious impediment that requires creativity to overcome, especially at lower levels. The effects of a permanent wound are irreversible unless the recipient is targeted with the regenerate spell.

D6	Permanent Wound
1	Lose an Eye. You have disadvantage on Wisdom (Perception) checks that rely on sight and on ranged attack rolls. If you have no eyes left after sustaining this injury, you are blinded.
2	Lose an Arm. You can no longer hold anything with two hands, and can only hold a single object at a time.
3	Lose a Leg. Your walking speed is halved and you must use a cane or crutch to move unless you have a peg leg or other prosthesis. You fall prone after using the Dash action. You have disadvantage on Dexterity checks made to balance.
4	Scarred Voicebox. You have disadvantage on Charisma (Persuasion) checks. When you cast a spell with a verbal component there is a 50% chance the spell will not wok. If the spell fails, you still use your action to cast it, but the spell will not use any slots or material components.
5	Lose an Ear. You have disadvantage on Wisdom (Perception) checks that rely on hearing. You have advantage on Charisma (Intimidation) checks and disadvantage on Charisma (Persuasion) checks.
6	Hideous Scar. You have been horribly and visibly scarred. You have disadvantage on Charisma (Performance) and Charisma (Persuasion) checks. Additionally, indifferent NPC's may prefer not to converse with you.