ࡱ> 5@ }hbjbj22 bXXb`0000000$T<<<PTtثث"qssssss$fR`0hhh00ĽĽĽh00qĽhqĽĽhne00̫ @<6m E,0и@TT00000rlĽtH TTuxD-(TTx51ԹϺ Partnership NHS Trust Records Final Project Report Dr Nicole Baur Introduction The 51ԹϺ Centre for Medical History (CMR) has been collaborating with the Devon Record Office (DRO) in an interdisciplinary project on mental health treatment over a period of three months. The project was aimed to catalogue data from individual patient files stored temporarily at the DRO in order to make this data publicly accessible, gain information on potential linkages between community and institutional treatment and develop a model for sampling and preserving this kind data. Activities carried out to achieve these goals can be grouped under the following three headings Assessing Hospital Index Cards (HICs) and individual patient files for the quantity and quality of their contents and evaluating their historical importance Cataloguing data for the purpose of public accessibility, if possible with a wider impact through developing a general model for sampling this kind of data Establishing linkages between patient care in the community and in the institution in order to create a patient career Work on the project proceeded in several phases, and this is the final of three progress reports, all delivered in four-week intervals. The purpose of this report is to show the activities during the time period from 06 March 2007 to 30 March2007, to highlight the project accomplishments, and to assess its setbacks. Project phase 3 As all patient files were initially earmarked for discarding, the original workload for the third phase comprised the digitisation of a sample of the most interesting files for the time period 1870 to 1929. In the last project meeting on 08 March 2007, however, we decided against digitisation, partly because it is a very time consuming activity, partly because we were only able to retrieve 88 files belonging to 79 patients for the 595 records in our database (I searched again for the re-numbered files which I remarked in my last report that I was hoping to find, but to no avail). As their digitisation and discarding would bring only minimal spatial relief to the DRO, we decided against digitisation and in favour of including patients admitted between 1930 and 1939 into our database. Extending the database to 1939 would cover any innovations under the 1930 Mental Treatment Act. It also increased the number of records in our database by 769 to a total of 1,364, and added the legal status informal, some of the patients obtained in the late 1950s and early 1960s. Given these changes, the third phase of the project was mainly concerned with retrieving documents and filling gaps in the database, i.e. activities were very similar to the ones carried out in the second phase. Again, I started off by searching the deposit in the strongroom for the individual patient files, and again I was only marginally successful. I retrieved 78 files (belonging to 77 patients) for the time period 1930 to 1939. This is about 10% of the files that should exist, and three files were only available in fragments. With the files for the time period 1870 to 1929 they add up to a total of 166 files (for 156 patients) or approximately 12% out of 1,364 records in our database. A greater number of files is only available for patients admitted from 1949 / 1950 onwards (General Reference Numbers 25,000 and higher). Documents contained in the files are very similar to the earlier ones with the exception of a greater number of post-mortem examination results. As before, I extended my search to additional documents in order to collect as much information as possible on each individual in our database, and to date I have gone through all documents for Exminster and Wonford House patients that were available at the DRO. For 354 patients medical notes were available (casebooks or doctors and nurses notes). In twelve cases these were available in addition to the patient files, which also contained these notes. This suggests that entries in casebooks and medical notes have been copied several times. Additional documents, such as listings in civil / death or discharged registers or admission papers were available for 1,168 patients. While for many patients several of the above named documents existed, for 146 patients no documents at all could be found. During the past weeks I looked at the following documents: Exminster Patients Register of Deaths & Discharges (shelfmark 3769A H20 - H24) These are chronological registers containing the case notes and some additional documents (letters of correspondence with relatives or the county, medical documents, transfer sheets, etc.) for patients who were discharged or died between 1949 and 1955. The description of these documents in the DRO index book says: Volumes [are] the Medical Records of former patients bound and filed. Given that I found a considerable number of these records relating to patients in our database for whom I could not find any other patient files, I assume that at some point of time the files were bound and these are the original patient files which have been taken in by the DRO at an earlier stage. Going through these documents revealed a few records that had not been fed into the database because Hospital Index Cards (HICs) were not available for these patients. To complete the database I added the missing records. Patient Medical Records (shelfmark shelfmark: 3769A H26 H30) These provided information on some of the earliest patients and, again, might be what is left of the original individual patient file. They contain the case sheets (doctors and nurses notes up to 1959 and related medical documents such as weight charts, medicine cards, etc. very rarely evidence of correspondence) bound together. A note written on many of these notes transferred to New Type Folio seems to indicate that further particulars on patients treated longer than 1959 might still be around. However, these more recent documents are not available at the DRO. Admission Papers (shelfmark 3769A H2) These contain the Reception Order, two medical certificates and information on previous institutional treatment. Some of the more recent ones contain great number of letters exchanged between the hospital and relatives or the council respectively. Thus, contents can be very similar to the contents of the patient files with the exception that case notes are not available. As I have already hinted at in the previous report, there are a few problems related to these documents. Firstly, they are stored according to reference numbers, but their reference numbers do not follow the same system as the reference numbers on the patient files (i.e. it is impossible to search for certain patients by reference numbers). The admission date is not necessarily a key either because sometimes a considerable amount of time elapsed between the issuing of the Reception Order and the admission of the patient. Secondly, many Reception Orders have become part of the actual patient file, i.e. they are no longer stored with the other Admission Papers. Thus, if the file has gone missing, the Admission Papers have too. Thirdly, and this is also true for entries in the Civil & Patient Registers, there are many more Reception Orders than records in our database for the time period under consideration. Why these people have never been allocated a HIC or what has happened to the HIC remains unclear, but we have to be aware that we must not regard our sample as an exhaustive list of patients treated in Exminster / Wonford House Hospital between 1870 and 1939! These documents may be useful in filling gaps in the patients social scientific data (occupation, religion, next of kin, etc.), but most of the information provided by the Admission Papers could be collected from other documents. As they were difficult to find, I concentrated on patients for whom no other documents could be retrieved. This task is still in progress, and I will continue with it next week. Medical Registers (shelfmark 3769A H10) These are chronological documents containing information on the patients dates of admission and discharge, chargeability, aetiological factors assumed related to the mental disorder, and bodily state on admission. In addition, they have proven helpful in collecting information on the patients occupations civil state, age, the type of admission (direct of transfer) as well as the diagnosis. Unfortunately, they are only available for admissions up to 1916, so they are relevant for only a few of the records in our database. Register of Patients (shelfmark 3769A H3/1 H3/15) From these documents information on the patients names, occupations, religion, chargeability and dates of stay in the institution could be retrieved. Again, only a few were applicable to the time period under consideration. Civil Registers (shelfmark 3769A H4/1 H4/10 & 3769A H5/1 H5/5) The Civil Registers list all admissions to the hospital (name, date of Reception Order, date of admission, chargeability), and up to 1930 they contain information on occupation and religion. Male and female admissions are listed in separate books. From 1931 the term pauper was replaced by rate-aided and there are separate books for certified and voluntary patients: H5/1 = Male admissions, April 1925 December 1930 H5/2 = Female admissions, April 1925 December 1930 H5/3 = Male admissions (certified), Jan 1931 June 1938 H5/4 = Male admissions (voluntary), Jan 1931 Nov 1944 H5/5 = Female admissions (voluntary), Jan 1931 Sep 1942 As mentioned above, the Civil Register lists more patients than recorded in our database, as some patients do not seem to have a HIC (any more?). Wonford House Patients Admission Papers (shelfmark 3992F H8) I located several boxes of Admission Papers for this group of patients, but they are afflicted with the same problems as the Exminster Admission Papers. Casebooks (shelfmark 3992F H32/4 17) & Transfer books (shelfmark 3992 F H32 18-20) These are bound books, organized alphabetically. Prior to 1915, male and female patients are listed in separate books. They are helpful for gaining social scientific data and, in a few cases, diagnoses. I found them a little bit difficult to deal with because each patient was allocated a double page. At the top of the left page the patients name, age on admission, date of admission, civil state, religion & occupation were given. It was also stated whether the present attack was the first one and whether the patient was considered dangerous and / or suicidal. The rest of the page contained the case notes, information on treatment and, in some cases, on the personal and family history. If the space did not suffice to write down all the information about a patient, additional details might be given further down in the book or in a different book. Although references to other books were clearly indicated (e.g. continues case book 8), it might not be possible to access this information because not all of the books are still available. Thus, the problem in dealing with longstay patients is that one keeps losing track of them we might have admission information for certain patients, but whether (and when) they were discharged or died remains unclear. Another problem is that case sheets have been ripped out of these books (to go into the files?), and are no longer available. Medical Registers (shelfmark 3992F H33/4-6) These documents were helpful in obtaining social scientific data (occupation, religion, marital state). Register of Deaths (shelfmark 3992F H33/27) These are chronological register containing the deaths of voluntary, temporary and certified patients from 1931 to 1959. For a list of the contents refer to Progress Report 2, where the earlier volumes were described. Civil Register (shelfmark 3992F H33/15) Register of all patients admitted between 1931 and 1948. The book is divided into the sections voluntary, temporary and certified. Contents were helpful for completing the sections chargeability and type of admission. Project outcomes The project has accomplished its goals in cataloguing the earliest patients through the assessment of HICs, patient files and other related documents. In addition, it has shown potential for further research into the care of mental health patients. Below follows a brief description of the accomplishments of the project. 1) Achievements in cataloguing Evaluation of HICs A thorough investigation of an estimated 30,000 HICs led to a detailed report circulated to all project members on 03 February 2007. It could be shown that they were probably used as a quick reference to a patient without referring to the patient file. Although they are a valuable source into the patients social and spatial backgrounds, further investigation showed that they are not too reliable and should not be used as an only research source. Database The major output of the project is a MS ACCESS database consisting of a total of 1,361 records and including patients from three hospitals (Exminster, Wonford House and Digby). The database is based on the HICs, but additional documents held at the DRO have been used to add missing data. Nevertheless, gaps still exist, as not all variables were available for all patients. Before the end of the project on 07 April 2007, the database will be checked for spelling mistakes, missing values will be coded as NK, and CDs will be burnt and distributed to the members of the project team. Tables A and B at the end of this report give an overview of how the records relate to the time period under consideration and what kind of information has been collected from the various documents. Table A shows how many records were available for each five-year period between 1870 and 1939, and how many of these refer to patients from Exminster, Wonford House and Digby Hospital. Compared to a similar table shown in the first progress report this one shows considerable changes in numbers. The first table was based exclusively on information from the HICs, whereas this one includes additional documents. Although many patients had been in hospital for previous treatment, this was not evident from the HIC and was only revealed by consulting other documents. Therefore, several records have switched from a later to an earlier period of time (e.g. from the 1942 [admission date on HIC] to 1935 [admission for first treatment]). Table B lists the variables used in the database and gives the number of records available. Although a step into the right direction, the database in its current form cannot fulfil the request of being a model for sampling and archiving this kind of data. It would need further improvements and linkages to visual materials, an aspect we ruled out for the reasons mentioned above. Although utmost care towards accuracy was applied in building up the database, it may contain a few potential flaws. In several cases the same information was provided by more than one document (i.e. date of birth, religion), but the details given were contradictory. In these cases I relied on the information given in the actual patient file or register, rather than the HIC. An issue that came up with longstay patients was that potential changes (place of residence, next of kin, chargeability) have not been recorded in the database otherwise it would have become too difficult to analyse. The information recorded always refers to the time the patient was admitted. A problem for analyses might be that a few patients have been allocated the same General Reference Numbers, which might require the creation of a new ID when analysing the database. 2) Establishing links between patient care in the community and institution The second major objective of the project was to establish potential linkages between community and institutional care through the documents available. Unfortunately, this goal could not be achieved due to a lack of information. The only clue provided was the National Insurance number, which was available for only 55 patients. John Draisey tried to pursue this issue by contacting people dealing with community records, but thinks it might be very difficult to get access to this kind of data. He has scheduled a meeting with Nick Hopkinson from the Devon Partnership NHS Trust for 03 April 2007, which hopefully shed some light on this issue as well as the whereabouts of the earliest files. Proceedings of the meeting will be presented to the other project team members in our last meeting the same afternoon. Conclusion The project revealed several issues we did not expect (e.g. a considerable number of patients admitted before the 1930s, opportunity to link our patients with documents already available at the DRO). However, they way we started it misled us a little, as we believed that we would be able to match all the HICs with patient files, but had to realise that the majority of patient files refers to patients admitted from the 1950s onwards. While for the Exminster patients at least a few patient files existed, none could be retrieved for the Wonford House patients information about them is exclusively based on documents stored at the DRO. Also, a detailed investigation into other deposits at the DRO revealed that for a considerable number of patients admitted to the hospitals no HIC existed, and they therefore never entered our database, which questions the completeness of our data. In retrospect it would have been better to use the civil / patient register as a basis for our database. This said, the project has led to a database where information on very early patients as well as longstay patients in mental health treatment is stored. In addition, it covers the regulations under two mental treatment legislations. Thus, apart from its archival value, the project could also be exploited to further advance research into mental health treatment and will hopefully lead to an application to the Wellcome Trust for a larger research project. Table A: Records relating to the time period 1870 to 1939 Five-year intervals Total number of records Exminster Hospital Wonford House Digby Hospitalup to 1874111875 1879111880 1884331885 18892111890 18944131895 18999451900 1904261881905 19092317511910 19146747201915 19198465191920 19241261022311925 19292511451061930 193434521313111935 19394242561653unknown11Total13648674916 Table B: Structure of the MS ACCESS Database InformationACCESS ColumnDescription of columnPossible entriesTotal number* Administration & Linkage InformationGenRefGeneral Reference Numbernumber VB = voluntary boardern = 1364NRefNew Reference Numbern = 614HospHospitalD = Digby E = Exminster W = Wonford House n = 1364NINational Insurance Numbern = 55FilePatient file availabley = file available y(2) = 2 files available (y) = only fragments of the file available n = 166AdDocAdditional documents availableAP = admission paper R = registers n = 1025MedRecsMedical Documents availableCB = case book CN = case notes (doctor / nurse) MR = medical records n = 354 Contact DetailsLNamePatients last namen = 1364FNamePatients first namen = 1364MName1Patients middle namen = 878MName2Patients middle namen = 109AdmC/OPatient in care of s.o. before admissionn = 12AdmHNoHouse numbern = 510AdmHNameName of Housen = 601AdmPhPhone numbern = 4AdmStStreetn = 676AdmAdAdditional element of addressn = 249AdmCityCity / Townn = 1146AdmCountyCountyn = 1150NoKTitleTitle of Next of kinn = 719NoKFNameFirst name of Next of kinn = 755NoKNameLast name of Next of kinn = 851NoKRelRelation Next of kinn = 632NoKHNoHouse number of Next of kinn = 327NoKHNameHouse name of Next of Kinn = 307NoKStStreet of Next of Kinn = 532NokCityCity of Next of Kinn = 749NoKCountyCounty of Next of Kinn = 750 Personal DetailsSexPatients sexF = female M = malen = 1364MStatePatients marital stateDivorced Married Judicially separated Separated Single Widowed n = 1347 NePatients maiden namen = 1ReligionPatients religionAnglican Anglo-Catholic Baptist Bible Christian Brethren Church of England (C of E) Church of Scotland Catholic Apostolic Christian Christian Scientist Congregationalist Dissenter Episcopalian Jewish Methodist No religion Non-Conformist (Non-Con.) Plymouth Brethren Presbyterian Protestant Roman Catholic (RC) Salvation Army Society of Friends Unitarian Wesleyan Wesleyan Methodist unknownn = 1187DoBPatients Date of Birthn = 465DoBY++Patients Year of Birthn = 417Professional InformationOccupationPatients occupationExcluding not stated (29 patients)n = 1128IndustryIndustryn = 400 Admission InformationAdmDateDate of admissionn = 1363AdmAgeAge on admissionn = 1358AdmTypeType of admission Direct Indirectn = 1281AdmIndIndirect AdmissionReadmission due to elapsed order Statutory readmission Statutory transfer Transfer from hospitaln = 179CriminalConvicted patientCriminal None n = 1285ChargeChargeabilityHealth System (HS) Pauper Private Rate-aided (RA) Servicen = 1284 Removal InformationLeavDatDate of discharge, transfer or deathn = 1235LeavAgeAge on discharge1 transfer or deathn = 849OutcomeOutcomen = 1012DisposalDisposaltransferred discharged died departedn = 1188LeavC/OPatient in care of s.o. on leavingn = 60LeavHNoHouse number on leavingn = 106LeavHNameName of Housen = 300LeavPhPhone numbern = 1LeavStStreetn = 144LeavAdAdditional element of addressn = 51LeavCityCity / Townn = 407LeavCountyCountyn = 406 Death InformationCoD (Ia)Principal cause of death**n = 640CoD (Ib)Principal cause of deathn = 235CoD (Ic)Principal cause of deathn = 39CoD (II)Secondary cause of deathn = 108LeavAgeAge on Deathn = 641 Legal InformationAdmStatStatus on admissionCertified Temporary Voluntary Voluntary Boardern = 1362RegrStat1Status to which regradedCertified Informal Sec. 5 Temporary Voluntaryn = 505RegrDat1Date on which regradedn = 498RegrStat2Status to which regarded, if second regradingCertified Informal Sec. 5 Temporary Voluntaryn = 171RegrDat2Date on which regradedn = 170LeavStatStatus on dischargen = 1176 Medical ConditionPDiaPrincipal Diagnosisn = 1309SecConSecondary Conditionn = 44NoteDiaAny notes concerning the diagnosisn = 293Medical HistoryPADateDate of previous admissionn = 93PLDateDate of previous discharge or transfern = 57PHospName of hospital of previous treatmentn = 253RA1Date of readmissionn = 194Leav1Date of leaving after readmissionn = 179RARef1Reference number of readmissionn = 180RA2Date of readmissionn = 73Leav2Date of leaving after readmissionn = 72RARef2Reference number of readmissionn = 71RA3Date of readmissionn = 42Leav3Date of leaving after readmissionn = 41RARef3Reference number of readmissionn = 42RA4Date of readmissionn = 22Leav4Date of leaving after readmissionn = 22RARef4Reference number of readmissionn = 22RA5Date of readmissionn = 17Leav5Date of leaving after readmissionn = 17RARef5Reference number of readmissionn = 17RA6Date of readmissionn = 11Leav6Date of leaving after readmissionn = 10RARef6Reference number of readmissionn = 11RA7Date of readmissionn = 9Leav7Date of leaving after readmissionn = 8RARef7Reference number of readmissionn = 9RA8Date of readmissionn = 8Leav8Date of leaving after readmissionn = 8RARef8Reference number of readmissionn = 8RA9Date of readmissionn = 6Leav9Date of leaving after readmissionn = 6RARef9Reference number of readmissionn = 6RA10Date of readmissionn = 4Leav10Date of leaving after readmissionn = 4RARef1Reference number of readmissionn = 4MRAMore readmissionsn = 3Hereditary InformationHereditaryInsanity of family membersn = 189General remarksNotesn = 114* Numbers are provisional, as the database is not completed yet. A number lower than 1,364 does not necessarily equal missing values, as some fields are not applicable to all patients (e.g. not everyone was readmitted) ++ only for patients whose DoB is not available ** A total of 650 patients died in hospital PAGE  PAGE 10 I  ! 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