2 Treatment of casualties from operations |
Procedures for operational casualties
18. DMS personnel are deployed on operations in both
of the major theatres, on Operation HERRICK (Afghanistan) and
Operation TELIC (Iraq). Personnel are deployed on a tri-Service
basis, and there is heavy reliance on Reservists, especially in
terms of deployed hospital care and specialist roles. Around half
of the Army's deployed secondary care capability has been met
by the Territorial Army, and four TA field hospitals have provided
services for a 12-month commitment in Afghanistan (HERRICK 6 and
7), beginning in April 2007.
19. The medical personnel deployed on operations
provide assessment and immediate treatment for all casualties,
whether injured in combat or otherwise, through Incident Response
Teams (IRTs). There are also Deployed Rehabilitation Teams (DRTs)
and Deployed Mental Health Teams (DMHTs) in-theatre to provide
a first line of treatment and guidance on any further treatment
or referral necessary.
20. Seriously injured casualties are generally given
initial treatment and stabilised by medical personnel in theatre
then aeromedically evacuated to the UK when appropriate.
The deployment of a full range of clinical staff to field hospitals
has allowed much more extensive treatment of casualties in-theatre.
The decision to evacuate is a clinical one. Between January 2006
and April 2007, 367 UK personnel were evacuated from Afghanistan
and 866 from Iraq (although not all of these were battle injuries).
Birmingham as the centre for treating operational
21. Since 2001, the main receiving unit for casualties
evacuated from operational theatres has been the Royal Centre
for Defence Medicine, based at the University Hospital Birmingham
Foundation Trust (UHBFT) (though there was some use made of The
Princess Mary Hospital at RAF Akrotiri in Cyprus during the most
intense phase of Operation TELIC 1 in Iraq in 2003). The decision
to establish a partnership with UHBFT was taken because, according
to the Ministry of Defence, "the medical needs of the Armed
Forces are best served through access to facilities and training
in a busy acute care hospital that is managing severe trauma on
a daily basis".
Selly Oak Hospital, one of the five specialist hospitals within
UHBFT and the home to most of the treatment received by operational
casualties, is highly experienced in treating the most common
types of injuries sustained by Service personnel, such as polytrauma.
In addition, the main arrival point for casualties is RAF Brize
Norton, with which Selly Oak has good links.
22. Julie Moore, Chief Executive of UHBFT, explained
that Birmingham had been a particularly suitable partner for the
In terms of its central location, located near to
a big airport and its good road networks, I think that was one
of the major factors in choosing it so that patients can be easily
transported when they are aeromedically evacuated back to Birmingham.
In addition, it has got very strong partnerships with local universities,
again feeding the training environment at the Royal Centre for
Dr David Rosser, the Medical Director at UHBFT, added
The range of clinical specialties we have is very
extensive. The only major specialties we do not provide are paediatrics
and obstetrics and gynaecology. If one is injured in any form
of major trauma any part of the body can be affected and we have
surgical specialists particularly skilled in dealing with virtually
every part of the body.
23. We heard evidence from the Army Families Federation
(AFF), the Royal British Legion (RBL), SSAFA, Combat Stress and
the Royal Air Forces Association (RAFA) to support the decision
to work with UHBFT, and to attest that the clinical care offered
at the RCDM was first-class. Ms Sammie Crane, Chief Executive
of the AFF, told us that:
The feedback I have had is that the clinical care
at Selly Oak is so good it could not be replicated elsewhere and
therefore that it is the correct place to which serious casualties
should be taken.
24. UHBFT stressed that the arrangements which were
put in place were "to operate in peacetime not in times of
conflict or war".
Instead, a plan by which the NHS as a whole would become involved
in the treatment of substantial numbers of casualties was devised,
the Joint Casualty Reporting and Reception Plan (JCRRP). This
was refined in 2002 into Reception Arrangements of Military Personnel
(RAMP). That notwithstanding, RAMP has been used only once, in
2003. UBHFT has taken all other casualties sent back from Operations
TELIC and HERRICK.
25. UHBFT suggested that it has become the dominant
reception centre for casualties because there was a strong preference
for using it among military personnel. Aeromedical staff preferred
to transfer to UHBFT because it was a regular occurrence, and
the clinical staff were familiar with the procedure. Military
doctors in Afghanistan and Iraq preferred to return casualties
to an atmosphere which they knew and trusted.
Clinical care and welfare services
26. In order to achieve the level of specialised
treatment which was required for injured Service personnel, it
was deemed necessary to place casualties in the appropriate clinical
environmentburns patients were treated in the burns unit,
neurosurgical injuries in the neurosurgical unit and so on. UHBFT
told us that its initial contract with the MoD specifically asked
for military casualties to be treated in the appropriate area,
rather than in a specific ward. Similarly, military clinical staff
were deployed in different areas within the hospital rather than
on a specific ward, in order to give them the most appropriate
experience and opportunity for training and skills development.
27. Initially, there was also a military-managed
ward to allow DMS staff to gain experience of clinical management.
It was not a trauma unit but a mixed-sex general surgical ward.
However, this arrangement was brought to an end when the majority
of the ward staff were deployed to Afghanistan at 24 hours' notice.
28. Prior to our inquiry, there had been considerable,
often adverse, press coverage of the standards of care at Selly
Oak Hospital in particular. This included allegations that patients
had been asked to remove their uniforms for fear of causing offence
and had been verbally abused by visitors who opposed the war in
Iraq. We asked Ms Moore, the Chief Executive of UHBFT, if there
had been any complaints related to the stories highlighted from
a number of newspapers. These included a report in the Daily
Telegraph that an injured paratrooper had been verbally abused
by a Muslim visitor, a story in the Daily Star that an
injured Servicemen had been told to remove his uniform for fear
of causing offence and an article in the Mail on Sunday
that a soldier at Selly Oak had been accosted by a group of Muslim
women. She confirmed
that the trust had received no complaints. She went on to tell
us that scrutiny by the press had placed considerable demands
on the Trust:
The time taken to deal with this has been quite considerable.
The senior nurse in charge of the ward at one time said she felt
she was doing organised visits round the ward instead of looking
after patients, and that cannot be right.
Her written memorandum on behalf of the Trust highlighted
the same concern.
My concern is that these debates [over the standard
of care] were played out in the press rather than by considered
discussion between those concerned and senior hospital staff.
This sustained negative press campaign has had a significant demoralising
effect on clinical staff, NHS and military, I am sure it has affected
the morale of deployed troops and their families and it has certainly
affected our reputation with our own population and patients.
29. The evidence from UHBFT, that the negative press
coverage had not been based on accurate representations of factual
cases, echoed what we had been told by the MoD. It
seems clear that there has been much inaccurate and irresponsible
reporting surrounding care for injured Service personnel at Birmingham,
and that some stories were printed without being verified or,
in some cases, after the Trust had said that they were untrue.
We condemn this completely. Editors have a responsibility to ensure
that their newspapers report on the basis of verified fact, not
assumption or hearsay. The effect of such misrepresentation on
the morale of clinical staff and Service personnel and families
was considerable. We consider the publication of such misleading
stories as reprehensible.
30. Another criticism in some sections of the media
was the loss of the military-managed ward, with some people emphasising
the importance of Service personnel being treated in a military
atmosphere in which they would be comfortable. In response to
this, in late 2006 UHBFT was asked to provide a new Military Managed
Ward (MMW), in which the senior nurse in charge would be a military
nurse. The preference of the DMS was that this should be the trauma
ward where most injured Service personnel are treated. However,
there was not a military nurse with the required skills and experience
to manage a ward, so it was necessary to train someone to fulfil
that role. Furthermore, there were insufficient military nurses
to staff the ward, and it was claimed at the time that it would
not be possible to reach the required numbers to have a 70% military
staffing level until July 2007.
31. We asked the Minister about progress on the Military
Managed Ward when he appeared before us in November 2007. He explained
that there were around 39 military nurses at Selly Oak, a Regimental
Sergeant-Major ward manager to deal with discipline and matters
relating to Service life, and two liaison facilities who maintained
links with patients' parent units. He concluded:
You walk around Selly Oak now, and it is like new.
There are a lot more military people and uniforms [
hope going to the new ward is that we can put in an actual ward
manager who would have responsibility on that ward for all the
things that happen in that ward.
32. There were also criticisms of the welfare and
support services provided at Selly Oak. When we spoke to representatives
of welfare organisations in June 2007, they assured us that the
clinical care at Selly Oak was of a very high standard, but that,
in the words of one witness, "support for people who visit
and for the individuals whilst there in terms of providing basic
essentials is currently provided by charities which some [
suggest is perhaps not appropriate".
Among the issues identified were travel assistance for families
of injured Service personnel, provision of toiletries and basic
clothing for Service personnel who had been separated from their
possessions, and accommodation for relatives of patients. Improvements
were taking place, but some of the slack had been taken up by
welfare organisations. For example, the Army Families Federation
had paid for the temporary refurbishment of flats originally built
for doctors and nurses so that they could be used by patients'
33. One significant development which bridged the
gap between clinical care and welfare was the appointment of a
Standing Joint Commander (Medical), who was an experienced infantry
officer. His role has been to take responsibility of command and
control issues and to coordinate the care pathways for casualties
brought into Birmingham. Lieutenant-General Baxter stressed the
importance of this appointment: "an experienced soldier is
going in there, he knows the issue in the operational theatres,
he knows what it is like looking after soldiers".
34. We acknowledge
the progress which has been made at Selly Oak in terms of creating
a military environment, to take advantage of the healing process
of being surrounded by those who have been through similar experiences,
to make patients feel comfortable and give them familiar surroundings.
The MoD has made substantial efforts in this regard, and we look
forward to hearing of further progress in the response to this
report. The MoD must make sure that the issues of welfare for
patients and families are central to its planning in developing
its medical facilities in and around Birmingham.
35. We also
welcome the improvements in welfare provision and pay tribute
to the work of welfare and charitable organisations. We consider
that there is nothing intrinsically wrong in welfare and charitable
organisations contributing to the support of our injured Service
personnel. Indeed, quite the reverse is the case, since it builds
on a proud tradition in the United Kingdom of linking the community
with the Service personnel who have been injured fighting on their
behalf. The MoD and the voluntary sector should engage openly
with the debate about which services are more appropriately provided
by the Government and which by charities and voluntary groups.
we also underline the fact that many of the improvements set out
above are relatively recent, and there has been a great deal of
change over the past 18 months. The MoD should not be complacent:
they have had to learn important lessons and it is clear that
the picture at Selly Oak was not always so positive. Nor should
progress now stop, but the MoD should continue to learn lessons
from its experiences in treating injured Service personnel at
The concentration of services: criticisms and
37. While there was almost unanimous praise for the
clinical standards at Selly Oak, the decision to site a single
trauma unit in Birmingham was questioned by Mr Terence Lewis,
Medical Director of Plymouth Hospitals NHS Trust. Mr Lewis pointed
out that his trust had one of the biggest hospitals in Europe
under one roof, was a major tertiary care provider and was home
to one of only a handful of level-one trauma units in the UK.
He therefore regarded it as "a great pity" that his
trust did not provide any trauma infrastructure to military personnel.
38. We put this criticism to the Parliamentary Under-Secretary
of State for Defence, Derek Twigg MP, in November 2007. He told
us that the advice he had received was that the use of Birmingham
as a single site for the treatment of operational casualties was
right "because of the concentration of our medical expertise
and the range of cases that our people are seeing and, of course,
the NHS people are seeing as well". He added that "there
is an argument as welland this has come over quite strongly
from the individual Service personnelthat they like to
be grouped together, which of course we can do." He concluded
that the numbers of operational casualties, while higher than
they had been before 2001, were relatively small compared to other
conflicts, and were not high enough to require or allow the treatment
in several different locations.
39. The Surgeon-General added two points in support
of the Minister's answer. The first was that a criterion in choosing
Birmingham had been the presence of a university, which there
had not been at that time in Plymouth. The second was that Birmingham
was a large conurbation, which would allow the MoD to "spread
out in a local way should the number of casualties exceed the
capability of whatever it was that we chose". He noted that
the three short-listed facilities had been in large conurbations:
Birmingham, Newcastle-upon-Tyne and Guy's and St Thomas' in London.
40. Another criticism of the Birmingham site which
we heard from Service personnel when we visited in June 2007 was
that it was not close to any major Service population (unlike,
say, Plymouth or Portsmouth), which meant that the families of
the injured being treated there often had to travel considerable
distances, and that personnel serving in Birmingham did not feel
that there was a sense of community, sometimes making it an unpopular
41. The MoD has plans to develop the facilities in
and around Birmingham. When we visited the RCDM, we were told
that it had been involved from a very early stage in the Birmingham
New Hospitals Project, which would provide brand new facilities,
including dedicated military areas. We were also told that there
were plans to develop facilities for training and messing at Whittington
Barracks in Lichfield. This was part of the Midland Medical Accommodation
(MMA) project, which would bring together on one site the headquarters
of the DMS, DMETA, the Defence Medical Services Training Centre
and 33 Field Hospital (currently based at Gosport).
42. Lieutenant-General Baxter explained to us in
oral evidence that the MoD intended Birmingham and Lichfield to
form a "dumb-bell" in terms of shape:
We are looking [
] to continue to build on that,
if you like, fissionable mass, bringing the various components
together, making sure the thinking piece goes into the training
and the education and to look at concentrating other bits of training.
Our eyes are on taking Whittington Barracks and converting that
into a satellite to the main Birmingham piece. We are looking
at plans now, we are looking at budgets and we are looking to
what we call a Main Gate submission, the investment decision,
early in the New Year .
acknowledge the case for concentrating the main clinical and training
assets of the DMS and DMETA on one cluster of sites. While Birmingham
may not be close to a major Service community, we accept that
it is suitable in terms of transport links and proximity to a
university, both of which are important factors. However, the
MoD needs to make its case for the Birmingham-Lichfield 'dumb-bell'
more explicitly, and we expect the Government response to our
report to set out in detail the plans and progress on this. The
MoD and, where appropriate, the voluntary sector should also make
sure that there are adequate travel and accommodation arrangements
for families visiting patients in Birmingham, and, as important,
that these are easily understood and accessible.
44. The UHBFT/RCDM
services are delivered at Selly Oak in buildings which are in
many cases ageing. Delivery of the PFI development is scheduled
to bring new, state-of-the-art buildings and facilities by 2012.
We expect the MoD, as part of its annual reporting process, to
state whether delivery on the Birmingham New Hospitals project
is on target.
6 That is, transported by air, accompanied by medical
Ev 91 Back
Q 108 Back
Q 109 Back
Q 2 (Ms Crane) Back
Ev 107 Back
Ev 106 Back
Q 161 Back
Q 159 Back
Ev 107 Back
Ev 107 Back
Q 409 (Mr Twigg) Back
Q 3 (Ms Freeth) Back
Q 23 Back
Q 409 (Lieutenant-General Baxter) Back
Q 168 (Mr Lewis) Back
Q 407 (Mr Twigg) Back
Q 407 (Lieutenant-General Lillywhite) Back
Ev 97 Back
Q 406 (Lieutenant-General Baxter) Back