Annex E
MEDICAL RECORDS IN THE GULF
INTRODUCTION
1. A common theme of Gulf veterans' complaints to MoD is that they, their medical and legal advisers, the War Pensions Agency and others 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 was used during Gulf deployment of 1990-91, 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 medical 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 casefile 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 casefile in each hospital and these may 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 casefile, 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 folder are stored the notes made by Unit Medical Officers (on the F Med 5 forms), hospital in-patient and outpatient 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 may 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 was used differently by the three Services. For example RAF practice was for individuals to retain their B Med 27 whereas in the Army the practice was to keep them in the F Med 4 and to issue them as the occasion required. 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 used 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. In addition electronic capture of medical events is now occurring in some operational situations
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 casefile 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) Central Health Record Library in Bromley.
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 DSCA Central Health Record Library where they are stored electronically. This function was previously carried out by the Defence Analytical Services Agency (DASA).
11. The Field Medical Record System. A separate 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 threat 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 casefile. It can be seen that this system is very much directed at hospital care and that there was no convenient system for recording clinical information relating to minor injuries and illnesses.
12. There are other records in the F Med series which are listed the Annex to this publication 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 casenotes.
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, is 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 exists, 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, when the primary care record is requested. 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 Central Health Record Library. 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 Central Health Record Library.
HOW CAN GULF VETERANS GAIN ACCESS TO THEIR MEDICAL RECORDS?
20. Under the provisions of the Data Protection Act of 1998, anyone may seek access to their medical records. 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 should follow automatically from an application. Applicants seeking copies of their records should state exactly what they want and should provide evidence of identity which links the applicant to the address from which he/she is writing. A copy of a utility bill or current driving licence would be appropriate. The Act provides for a fee to be charged to cover administrative costs but at present MoD does not intend to charge applicants.
21. Veterans wishing access to their medical records should write to the following:
Royal Navy
Head of Medical Administration, Alverstoke, GOSPORT, PO12 2DL
Army
Army Personnel Centre, Disclosures 3 Mailpoint 525 Kentigern House, 65 Brown St GLASGOW G2 8EX
Royal Air Force
Royal Air Force PMA Medical Room 040, Building 248, RAF Innsworth, GLOUCESTER GL3 1EZ
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 personal 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 representatives (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 6/04,St Christopher House, Southwark Street, LONDON SE1 0TD
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.
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