APPENDIX 3
Supplementary Memorandum submitted by
the Ministry of Defence
MEDICAL RECORDS OF GULF VETERANS
INTRODUCTION
1. A common theme of Gulf veterans' complaints
to MoD is that they, their medical and legal advisers, the War
Pensions Agency and other who may have a legitimate reason for
access, are experiencing difficulties in obtaining their medical
records.
AIM
2. The aim of this publication is to provide
a simple explanation of the relevant parts of the Service medical
documentation system, to describe how it operated in the Gulf
conflict, to explain the generic reasons why a record may no longer
exist and to provide points of contact which veterans can use
in seeking to obtain their records. It should be clearly understood
that this paper refers to Service medical records. The medical
records of dependants belong to the National Health Service and
the MoD has no right of access to them except on the basis of
MoD employed doctors (Service or civilian) providing medical services.
WHAT ARE
MEDICAL RECORDS?
3. In civilian life there are essentially
two types of medical records. Firstly, everyone who is registered
with a General Practitioner (GP, Family Doctor) has a medical
record envelope which is held by the GP. It contains the medical
notes made by the GP as well as results of tests and summaries
of hospital attendances and the like. This record follows patients
around as they change GPs.
4. Secondly, anyone who attends a hospital
will have a hospital case file which contains hospital notes,
test results and the like. These tend not to follow patients around
but remain at the hospital. Thus a patient attending several hospitals
is likely to have a case file in each hospital and these will
not be linked. In addition employers may run an occupational health
service and keep their own sets of notes which would be unlikely
to be linked to either GP or hospital notes. Thus the notes held
by the GP are likely to be the most comprehensive but not necessarily
a complete record of a patient's medical history.
5. In the Armed Forces there are essentially
three medical record systems. There is a personal medical record
which is held in the Unit Medical Centre and follows personnel
around on posting. There is the hospital case file, which as in
civilian practice is retained by the hospital in which the patient
was seen and does not routinely follow the patient. Finally, there
is the Field Medical Record system for use on operations and exercises.
6. The Personal Medical Record. The personal
medical record is the military equivalent of what the civilian
GP holds. It consists of a buff coloured cardboard folder, the
F Med 4. On the outside is identifying information (Number, Rank,
Name, Date of Birth, Unit etc) and a record of PULHHEEMS (medical
grading) assessments, immunisations given and the like. Inside
the record are stored the notes made by Unit Medical Officers
(on the F Med 5 forms), hospital in-patients and outpatients summaries,
Medical Board proceedings and results of tests, x-rays and medical
examinations. The F Med 4 follows the patient on posting and should
provide the most complete picture of an individual's medical history
during service.
7. The F Med 4 is held on board ship for
members of a ship's company and thus is available when a ship
deploys on exercise or operational service. In the case of the
Army and the Royal Air Force, the F Med 4 is not intended to be
taken on operational or exercise deployments. The reasons are
the bulk and fragility of paper records, the nature of deployments
into the field which mean that the record is never likely to be
available when personnel are actually consulting a Medical Officer,
the ever present risk of losing the record, and the problem of
maintaining the confidentiality of the record under field conditions.
8. In addition to the F Med 4 and its contents,
Service personnel will also have a Personal Medical Summary booklet,
the B Med 27. The booklet is intended to provide basic medical
details when personnel are in transit or otherwise detached from
their Units. Such an occasion would be an operational deployment.
It used to be a small yellow booklet which fitted easily into
a pocket and contained International Certificates of Vaccination
where necessary, records of immunisations received and summaries
of important medical events and allergies. The B Med 27 has been
redesigned (in 1993) and is now a larger blue booklet with additional
space for recording more and different types of information.
9. The B Med 27 is used differently by the
three Services. For example RAF practice is for individuals to
retain their B Med 27 whereas in the Army the practice is to keep
them in the F Med 4 and to issue them as the occasion requires.
In practice the increased size and bulk of the blue B Med 27 has
made it unpopular and inconvenient to use and its use has thus
probably declined especially during operational deployments. The
whole concept of medical records is currently being examined by
MoD with a view towards producing electronic records. In the interim,
an Operational Medical Record (OMR) is being trialled to overcome
the difficulties of recording medical events during deployments.
The OMR is similar in size to the old B Med 27 and contains space
to record primary care consultations and immunisations and will
be kept by the individual during a deployment.
10. Hospital Records. Hospital casefiles
consist of a buff cardboard cover, the F Med 9, which contains
clinical notes (F Med 10 and 11 and nursing notes), observation
records, results of tests and copies of letters between hospital
doctors and Unit Medical Officers. These are usually summaries
of in-patient admissions and outpatient appointments. As mentioned
above, it is normal practice to retain a case file at a particular
hospital. In the case of Service hospitals which have closed,
or in response for demands for space at a hospital, those records
are ultimately held at the Defence Secondary Care Agency (DSCA)
Medical Record Repository at RAF Halton. This will move to a site
in Bromley in spring 1999. To guard against total loss of records
and to enable partial reconstruction of a case-record, copies
of entry and release medical examinations, in-patient and outpatient
summaries and Medical Board proceedings are kept at the Defence
Analytical Services Agency (DASA) where they are stored on microfilm.
11. The Field Medical Record System. A separated
system of medical record keeping, the Field Medical Record, exists
when forces are deployed into the field. The system in use at
the time of Operation GRANBY was designed to meet the requirements
of a Casualty Evacuation System supporting forces deployed to
meet the Warsaw Pact threat in Northern Europe. This treat was
characterised by a likely short notice deployment, rapid transition
to high intensity conflict and the expectation that if an individual
was admitted to hospital, evacuation down the Casualty Evacuation
Chain would result. The system consists of a plastic wallet (F
Med 825) and clinical notes and continuation sheets (F Med 826
and 827) and other documents for recording observations, details
of surgical operations, test results and the like. The documentation
is initiated at the first point in the evacuation chain that the
casualty comes to (usually the Regimental Aid Post, Medical Section
or Dressing Station) and it follows the casualty through every
stage of the chain and is amalgamated into the normal hospital
case folder once a casualty is admitted to hospital in the UK.
Thereafter, the peacetime system takes over with summaries to
the Unit Medical Officer being stored in the F Med 4 and the original
notes being stored in the hospital case file. It can be seen that
this system is very much directed at hospital care and that there
is no convenient system for recording clinical information relating
to minor injuries and illnesses.
12. There are other records in the F Med
series which can be identified in the Annex but which have only
minor parts to play in the recording of clinical information.
WHAT HAPPENED
TO MEDICAL
RECORDS IN
THE GULF?
13. The Gulf experience was considerably
different. Following the Iraqi invasion of Kuwait, UK forces were
rapidly deployed to Saudi Arabia. Once in theatre there was a
long transition to war with the requirement to provide care for
the normal spectrum of routine illness and injury, in other words
the normal primary care service. With the exception of the Royal
Navy, Fs Med 4 were generally not taken out to the Gulf theatre,
in accordance with the policy not to deploy with them. Some units
took these medical documents anyway, but then made attempts to
return them once the mistake was realised and in at least one
case a unit's documents were lost in transit and still have not
been located. Thus, apart from Fs Med 5, which were in short supply,
and the field medical record system documentation, Medical Officers
had limited ability to record primary care consultations during
the conflict. Even where this information was recorded, there
was no routine for ensuring that it was sent back to peacetime
locations for incorporation into the F Med 4. Sick books were
kept on an ad hoc basis in which a minimum of clinical information
was recorded along with classification of illness and disposal.
Some of these sick books turn up as a result of searches, but
they cannot in the normal sense of the word be regarded as case
notes.
14. Similarly with hospital admissions,
a new feature of the Gulf conflict was the considerable numbers
of admissions to hospital followed by discharge back to duty in-theatre.
As mentioned above, the records system was not designed for this
eventuality. DASA have collected and microfilmed some of the records
relating to this type of admission. The completeness of these
records is not clear at present. For those cases which resulted
in evacuation, the field medical documents should have accompanied
the patient and been incorporated into the F Med 9 and admission
summaries should have been written in accordance with peacetime
documentation practice.
15. A further novel feature of the Gulf
was the requirement to conduct an immunisation programme in the
field to protect against the Iraqi biological weapon (BW) threat.
As has frequently been acknowledged by MoD, the recording of such
immunisations was poor. In retrospect, it is easy to see why this
is so. The F Med 4, which, as stated above, it the normal document
on which immunisation details are recorded, was not available
at the time as it was in peacetime locations. The alternative,
the B Med 27, was variably available but, as mentioned above,
usage differed between Services. Some units kept immunisation
registers of various sorts: again these occasionally turn up and
when they do the appropriate information is transferred to the
F Med 4. All the immunisation details for Service personnel who
served in the Gulf conflict should have been transferred to their
respective Fs Med 4 on redeployment, but in many cases they were
not.
16. There have been suggestions, by some
Gulf veterans, that medical records were routinely stored, during
the conflict, on a system called MAPPER. This is not the case.
During the conflict, MAPPER was used as a method for sending signals
and other information into and out of theatre. As such it was
used as the method for transmitting casualty notifications back
to the UK. However, the medical record system was paper based
and the field medical records should have accompanied casualties
being evacuated out of theatre, so there was no need to make an
electronic version as well. Hence the only medical information
put on MAPPER was that used to inform next of kin.
17. In summary, UK forces deployed to the
Gulf with no established routines for recording primary care clinical
information during a long deployment in the field, nor any robust
method for recording immunisations and ensuring that the information
was subsequently captured and transferred to the F Med 4. There
were also no established routines for dealing with records relating
to short admissions to hospitals in-theatre which did not result
in casualty evacuation. A proportion of these case notes exist,
but the completeness of the data cannot easily be assessed. Hence
there are a number of reasons why Gulf veterans may now have difficulty
in obtaining details of medical consultations which they recall
taking place during the Gulf conflict.
WHERE ARE
DOCUMENTS NOW?
18. For personnel still serving in the UK
Armed Forces the F Med 4 should be in the Medical Centre which
serves their current Unit or at a hospital since the practice
is for the F Med 4 to accompany the individual attending hospital
consultations. For personnel who have left the Armed Forces, the
situation varies between Services. The Royal Navy and RAF each
store the documents of discharged Service personnel at a single,
Service specific location. For the Army, where numbers are much
larger there are two sites depending upon when an individual left
the Service.
19. Hospital records are kept at the hospital
concerned for three to five years depending upon storage space
and are then transferred to the DSCA Medical Record Repository
at RAF Halton. With the closure of military hospitals in recent
years, there has been a major transfer of medical documents into
the repository. A proportion of the field medical records from
the Gulf conflict have been microfilmed and stored at DASA, others
may be held at the DSCA Repository.
HOW CAN
GULF VETERANS
GAIN ACCESS
TO THEIR
MEDICAL RECORDS?
20. Under the Access to Medical Records
Act of 1990, anyone may seek access to their medical records compiled
after 1 November 1991. The Act provides for disclosure of earlier
records if this is essential to the understanding of the disclosed
record. It is under this provision that the Minister for the Armed
Forces has extended the period of access, for Gulf veterans, to
1 August 1990. Unless it is judged that the records contain mention
of a third person or information that would not be in the patient's
interests, disclosure of the records follows automatically from
an application. The Act provides for charging a fee, currently
£10 administrative charge and a fee to cover the cost of
photocopying.
21. Veterans wishing access to their medical
records should write to the following:
(a) Royal Navy: Head of Medical Administration,
Institute of Naval Medicine, Alverstoke, GOSPORT, Hampshire, PO12
2DL;
(b) Army: Army Personnel Centre, Relations
With The Public, Room 5109, Kentigern House, 65 Brown Street,
GLASGOW, G2 8EX;
(c) Royal Air Force: PMA Medical (RAF),
Room 040, Building 248, RAF Innsworth, GLOUCESTER, GL3 1EZ;
(d) Royal Fleet Auxiliary: Senior Medical
Officer, COM RFA, Room F 21, Lancelot Building, HM Naval Base,
PORTSMOUTH.
22. It will be apparent that with three
separate records systems in operation which might contain mention
about a particular Service person, there is scope for missing
some relevant records. Requests therefore should be specific as
to which type of record is required and as much additional information
as possible should be provided. Basic information such as personnel
number, name, unit and date of birth are self evident, but with
regard to records concerning admissions to hospital, the name
of the hospital and approximate dates of admission would be helpful
additional pieces of information. For those who have left the
Services, the date of leaving is additional useful information.
23. Gulf veterans should also be aware that
retrieval of documents can take a considerable amount of time.
Experience has shown that one of the principal causes of delay
is because, in the case of Gulf veterans, a number of agencies
representing veterans' interests request the same documents. Such
agencies include legal representative (who frequently retain documents
for long periods), the Gulf Veterans' Medical Assessment Programme,
the War Pensions Agency and other medical practitioners whom veterans
have consulted. The frequency of movement of these documents is
therefore comparatively high and with every movement the chances
of documents becoming lost increases. Not infrequently MoD receives
requests for documents from veterans who have already sought disclosure
to solicitors. It may therefore save time and money for veterans
to check if their legal representatives have already sought disclosure
and obtain copies in that way.
24. There will be cases where Gulf veterans
experience difficulty in obtaining records. In such cases veterans
are invited to write to:
Ministry of Defence, Medical Adviser, Gulf
Veterans' Illnesses Unit, Room 8276, Main Building, Whitehall,
LONDON, SW1A 2HB.
SUMMARY
25. In summary, there are three types of
medical records that were used by UK forces during the Gulf conflict.
All of these had different applications but also have a degree
of inter-relationship. The medical record system in use in the
Gulf was not specifically designed for that campaign but was the
one already in existence. A number of reasons have been offered
as to why the recording of clinical information was less than
perfect. Gulf veterans have experienced difficulties and delay
in obtaining copies of their medical records. Much of the delay
appears to be due to documents being in transit between the variety
of agencies which require to see them. Finally, details are given
above of how to make an application for medical records.
April 1999
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