Statement of Principles concerning aplastic anaemia (Reasonable Hypothesis) (No. 58 of 2020)

The central concept is the "reasonable hypothesis" standard. Under the VEA, for claims involving operational service, the decision-maker must accept the claim unless satisfied beyond reasonable doubt that there is no sufficient ground for determining that the injury or disease is war-caused. This standard is lower than the civil balance of probabilities. However, the VEA requires that to raise a reasonable hypothesis, the hypothesis must be "pointed to by" a Statement of Principles (see 120A(3)). This instrument defines which hypotheses are legally permissible. A hypothesis that a veteran's aplastic anaemia was caused by, say, ionising radiation exposure is not raised unless the factors in this instrument include radiation exposure (they do not). The RMA's determination binds decision-makers; no individual medical expert opinion can create a factor outside the list.

"Aplastic anaemia" is defined clinically in section 7(2): bone marrow failure with destruction of haematopoietic stem cells, peripheral blood cytopaenia, and hypocellular marrow replaced by fatty marrow. This definition is independent of ICD-10-AM codes, though the ICD codes D61.1, D61.2, D61.3, D61.8 are referenced as typical but not definitive. The exclusion list is critical: inherited syndromes, isolated leukopaenia or thrombocytopaenia, myelodysplastic syndrome, paroxysmal nocturnal haemoglobinuria, and marrow replacement by fibrosis or infiltrative neoplastic process. This means a diagnosis of aplastic anaemia must rule out those conditions. If a veteran has, for example, myelodysplastic syndrome misdiagnosed as aplastic anaemia, the SOP does not apply, and the claim must be determined without it.

The "factors" are the causal or contributory events, exposures, or conditions listed in section 9. They are not exhaustive of all possible causes; they are the ones the RMA considers have sufficient medical-scientific evidence to support a link to service. The instrument explicitly states the RMA's view that "sound medical-scientific evidence" supports these factors. This is a claim by the Authority, not a conclusion the reader must accept uncritically. In practice, the RMA's process relies on systematic reviews and expert panels, but the instrument does not disclose the evidence base. Users must take this on faith or investigate the underlying reviews themselves.

"Clinical onset" and "clinical worsening" are key temporal concepts. Most factors require the exposure or event to occur within a specified time window before clinical onset (e.g., one year for drugs, six months for infection, two years for autoimmune disease). This creates evidentiary hurdles: the exact date of clinical onset must be determined from medical records, and the exposure or event must be shown to have occurred within the window. For worsening factors (pregnancy and inability to get appropriate management), the condition must have existed before the relevant service and the worsening must be materially contributed to by service circumstances.

"Relevant service" is defined in the dictionary to mean only operational, peacekeeping, hazardous, or British nuclear test defence service under the VEA, and warlike or non-warlike service under the MRCA. This excludes peacetime service for the reasonable hypothesis standard. However, the same SOP may be used for claims under the MRCA which has its own standard of proof (reasonable satisfaction). Practitioners must check which section applies to each claim.

The instrument also defines "terminal event" for death claims: pneumonia, respiratory failure, cardiac arrest, circulatory failure, or cessation of brain function. Death must be contributed to by aplastic anaemia; it does not require aplastic anaemia to be the sole cause. This is consistent with typical VEA causation principles, but the terminal event list is exhaustive, so deaths from other mechanisms (e.g., suicide precipitated by the condition) might not be covered unless the death is contributed to by a listed terminal event.

"Being exposed to benzene as specified" is defined with a specific TWA of five parts per million over eight hours, or cutaneous/ingestion contact with liquids containing more than 1% benzene. This is a high threshold compared to general occupational exposure limits in Australia (which are lower). It means typical low-level exposure (e.g., from fuel handling) may not meet the factor unless the concentration or duration was extreme. The instrument does not specify how to prove the exposure level; it presumably requires records or reliable reconstruction.

"Specified list of herbicides and insecticides" includes carbamate, organochlorine, organophosphate insecticides, and paraquat. This is a finite list; other pesticides (e.g., glyphosate, neonicotinoids) are not included. Claimants alleging exposure to non-listed pesticides must show they meet another factor or fail.

"Specified list of autoimmune diseases" includes ABO mismatched haematopoietic stem cell transplant, coeliac disease, eosinophilic fasciitis, graft versus host disease, hyper/hypoimmunoglobulinaemia, and systemic lupus erythematosus. This is a narrow list. Common autoimmune conditions like rheumatoid arthritis, type 1 diabetes, or multiple sclerosis are not included, so they cannot serve as the autoimmune disease factor.

"Specified list of haematological malignancies" includes chronic lymphocytic leukaemia/small lymphocytic lymphoma, Hodgkin's lymphoma, non-Hodgkin lymphoma, and T-cell large granular lymphocytic leukaemia. Other haematological cancers (e.g., acute myeloid leukaemia, multiple myeloma) are not listed, so they do not count.

The drug schedule (Schedule 2) lists 91 entries, many of which are specific drugs or drug classes including chemotherapy agents, antibiotics, anticonvulsants, immunomodulators, and others. The factor requires treatment with the drug within one year before onset, or a more specific alternative: drug associated with development within six months of therapy and improvement within six months of discontinuation or tapering (factor 9(3)). This alternative is useful when the drug is not on the list but the individual's response suggests a causal link. It allows for case-by-case evidence, but the improvement requirement may be hard to satisfy if treatment continues or if other treatments are given simultaneously.

This instrument directly affects three groups: veterans and members claiming compensation for aplastic anaemia under the VEA or MRCA; the Repatriation Commission and the Military Rehabilitation and Compensation Commission as decision-makers; and legal and medical professionals advising claimants.

For claimants, the instrument determines whether they can raise a reasonable hypothesis that their aplastic anaemia is service-related. If they cannot satisfy at least one factor from section 9, their claim must be refused regardless of other medical evidence. This is a significant barrier. Many veterans may have aplastic anaemia from causes not on the list (e.g., radiation exposure, viral infections not specified, idiopathic cases). The instrument's closed list means these claimants have no path to acceptance unless they can identify another factor. This creates a disparity: a veteran who took a listed drug for an unrelated condition gets a possible claim; one who developed aplastic anaemia spontaneously does not.

The instrument also affects dependants of veterans who died from aplastic anaemia or where aplastic anaemia contributed to death. They must show a factor existed for the veteran before clinical onset (or worsening) and that the death was a terminal event contributed to by the condition. The same factor requirements apply.

For decision-makers, the instrument is binding. They cannot accept a claim based on a factor not listed. They must assess the evidence against each factor's definition, including temporal windows, dose thresholds (for benzene), and latency periods. This reduces their discretion but also reduces the risk of inconsistent outcomes across claims. Compliance with the instrument is mandatory under s 120A(3) VEA and s 338 MRCA. Failure to apply it correctly is a reviewable error.

For medical practitioners, the instrument influences diagnosis and reporting. A diagnosis of aplastic anaemia must be precise and exclude the listed exclusions. If a doctor writes a diagnosis code D61.9 (aplastic anaemia unspecified) without further specification, the claim may be delayed while a specialist clarifies whether it meets the definition. Similarly, doctors treating veterans should document all potential exposures, drug histories, and relation of onset to exposures to assist claimants.

For the Department of Veterans' Affairs (DVA) and Comcare (under MRCA), the instrument affects liability and funding. Accepting aplastic anaemia as service-related triggers pension payments, medical treatment costs, and possibly permanent impairment compensation. The instrument's narrow factors tend to limit the number of accepted claims, which reduces government expenditure. However, it also means some borderline cases will be rejected and later overturned on review if new evidence emerges, leading to back-payments and administrative costs.

Legal practitioners and advocates must be intimately familiar with the instrument to advise on claim viability. Pre-claim investigation should focus on documenting any factor, especially drug history (many veterans have taken NSAIDs like ibuprofen, which could satisfy factor 9(4) if taken at sufficient frequency), or occupational benzene exposure (e.g., mechanics, painters, fuel handlers). The instrument gives a lower threshold for non-aspirin NSAIDs: at least four days per week for a continuous period of at least four weeks, within one year before onset. This is a relatively low bar and may cover many veterans who self-medicate for joint pain.

The instrument also affects researchers and the RMA itself. The RMA must review the evidence periodically and update SOPs. This 2020 version repealed the 2012 version, signalling that medical evidence has evolved. Future versions may add or remove factors, which creates dependence on the state of medical science at the time of claim. A claim determined under this instrument cannot be reopened solely because a later SOP adds a new factor unless the new SOP expressly allows it.

The instrument does not impose duties or confer rights directly; it is a legislative instrument that defines the legal framework for determining claims. However, several duties and rights can be inferred from its application.

The primary duty of the decision-maker (the Repatriation Commission or the Military Rehabilitation and Compensation Commission) is to apply the instrument correctly when assessing claims for aplastic anaemia. This duty arises under sections 120A(3) and 120B of the VEA and section 338 of the MRCA. The decision-maker must determine whether at least one factor in section 9 exists, and if so, whether that factor is related to the person's relevant service. The decision-maker also has a duty to consider the definitions in Schedule 1, especially for benzene exposure, autoimmune disease list, and drug list, and to assess temporal requirements correctly.

A claimant has the right to have their claim assessed under this instrument. That right is procedural rather than substantive: it means the decision-maker cannot use an earlier repealed SOP (e.g., No. 50 of 2012) for claims made after 28 September 2020, and cannot ignore the factors listed here. Conversely, the claimant does not have a right to have their claim assessed under a more favourable SOP that does not exist. The right is to have the instrument applied, not to have it applied favourably.

Claimants also have the right to seek review of a decision that fails to apply the instrument correctly. Under the VEA, an initial adverse decision can be reviewed by the Veterans' Review Board (VRB) and then the Administrative Appeals Tribunal (AAT). The VRB and AAT must apply the same SOP. If the decision-maker misapplied the factor definitions (e.g., wrongly concluded that the NSAID frequency was not met, or that benzene exposure did not meet the TWA), the review body can overturn. However, the review body cannot accept a factor that is not in the instrument.

Claimants have a right to provide evidence to satisfy a factor. The burden of proof is initially on the claimant to point to material pointing to the factor. Under the reasonable hypothesis standard, the claimant does not need to prove the factor on balance; they need to raise a hypothesis that is consistent with the factor. The decision-maker then must be satisfied beyond reasonable doubt that the factor does not exist or is not related to service. In practice, this means the claimant must produce some credible evidence (medical records, service documents, witness statements) that suggests the factor may exist.

The instrument also creates a duty on the RMA to base its determinations on sound medical-scientific evidence (as stated in section 8). This is a self-imposed duty under the Act; the RMA must periodically review and revoke or amend SOPs as evidence changes. Stakeholders have the right to apply to the RMA for amendment of an SOP, though the RMA is not obligated to accept such applications.

There is also a duty on the Commissioner for the Safety, Rehabilitation and Compensation (for MRCA claims) to ensure that the SOP is applied consistently. The instrument cross-references other SOPs via section 11, creating a duty to consult those SOPs if a factor involves a condition like autoimmune disease or haematological malignancy. For example, if a veteran claims aplastic anaemia due to systemic lupus erythematosus (an autoimmune disease in the list), the decision-maker must also apply the SOP for systemic lupus erythematosus to determine whether that condition itself is related to service. This duty to chain SOPs can complicate claims significantly.

For practitioners, the instrument imposes a de facto duty to conduct thorough histories of drug use, occupational exposures, and medical events. Missing a factor that could have been raised due to inadequate history-taking may constitute negligence.

This instrument does not itself create any penalties. It is a rule for determining entitlement, not a regulatory offence. However, enforcement occurs through the claims and review process. The relevant sanctions are adverse decisions: if a claimant fails to establish a factor, their claim is rejected, and they receive no compensation. This is a financial penalty on the claimant, albeit an indirect one.

There are no criminal penalties for misapplying the instrument, but decision-makers who knowingly or negligently misapply it may be subject to internal discipline or civil liability for misfeasance in public office. Such cases are extremely rare.

The instrument does have a built-in enforcement mechanism for temporal and evidentiary thresholds. For example, factor 9(3) requires that the drug be associated in the individual with development of aplastic anaemia within six months of therapy and improvement within six months of discontinuation or tapering. This is a high standard that implicitly enforces a strict causal relationship. If a claimant's aplastic anaemia improved after drug discontinuation, that suggests the drug caused or contributed, but if other treatments were given simultaneously, the decision-maker may conclude the improvement was due to those other treatments, not the drug taper. This allows enforcement of causation even without mandatory reporting.

The instrument's definition of "being exposed to benzene as specified" includes an 8-hour TWA exceeding five parts per million. This is a threshold that must be proved; if the claimant only has evidence of exposure at lower levels, the factor is not met, and the claim cannot succeed on that basis. This enforces a minimum dose-response relationship, consistent with occupational health standards, but it also excludes any risk from lower-level chronic exposure that medical literature might support.

Enforcement of the instrument also occurs through the requirement in section 5 that it applies to claims under section 120A of the VEA or section 338 of the MRCA. If a decision-maker purports to assess a claim under the wrong standard (e.g., using the reasonable satisfaction standard for operational service without this SOP), that decision is legally flawed and may be set aside on review.

The instrument does not provide for any administrative penalties for claimants who provide false information. However, the general law on fraud and false statements applies. Claimants who fabricate drug use or exposure to meet a factor face potential criminal prosecution under the Criminal Code (Cth) for obtaining a financial advantage by deception, though such prosecutions are rare in veterans' cases.

For the RMA, failure to base a SOP on sound medical-scientific evidence could theoretically be challenged by judicial review, though the High Court has been reluctant to interfere with the RMA's discretion as long as the Authority has complied with its statutory obligations.

This instrument operates within the framework of the Veterans' Entitlements Act 1986 and the Military Rehabilitation and Compensation Act 2004. It is a subordinate legislative instrument made under section 196B(2) of the VEA. Its primary interaction is with sections 120A and 120B of the VEA, which govern the standard of proof for claims involving operational service. Section 120A(3) provides that a reasonable hypothesis must be pointed to by a SOP determined by the RMA. This instrument therefore defines the content of the hypothesis for aplastic anaemia.

The instrument also interacts with section 120B, which requires the RMA to determine SOPs for certain kinds of injury, disease, or death. The RMA may determine SOPs under the reasonable hypothesis standard (subsection 196B(2)) or the balance of probabilities standard (subsection 196B(8)). This instrument is under subsection (2) only; there is no companion SOP for aplastic anaemia under the balance of probabilities standard. This matters because for claims involving peacetime service (under section 120(4) VEA), the decision-maker must be reasonably satisfied that the condition is war-caused, and an SOP can be applied, but this instrument does not cover that standard. In practice, the RMA often determines both standards for major conditions, but not for aplastic anaemia. This means a claim for aplastic anaemia from peacetime service must be assessed without this SOP, using general medical evidence. This creates an asymmetry: veterans with operational service get a structured pathway; those with peacetime service do not.

Under the MRCA, section 338 requires that the Commission must, in determining a claim, take into account any relevant SOP. The Commission must apply the SOP as a factor in its decision, but the MRCA uses a "reasonable satisfaction" standard generally. The SOP provides guidance but is not determinative in the same way as under the VEA's reasonable hypothesis standard. The interaction here is that the SOP factors are still relevant but may be weighed against other evidence.

The instrument cross-references other SOPs via section 11. If a factor refers to an injury or disease covered by another SOP (e.g., autoimmune disease or haematological malignancy), the factors of that SOP apply. This creates a chain: the claimant may need to satisfy the SOP for systemic lupus erythematosus to use factor 9(10). That other SOP itself may list factors that require further proof. This can increase the evidentiary burden substantially. For instance, the SOP for lupus may require evidence of exposure to ultraviolet radiation or certain drugs. The decision-maker must apply all relevant SOPs progressively.

The instrument also interacts with the Safety, Rehabilitation and Compensation Act 1988 (SRCA) for Commonwealth employees who are not veterans. However, the instrument is not made under the SRCA, and the SRCA does not formally adopt RMA SOPs (though they may be used as guidance). This means a civilian Commonwealth employee who develops aplastic anaemia from work exposure would not have the benefit or burden of this instrument; their claim would be assessed under general law of causation.

The instrument's definitions import external standards: ICD-10-AM Tenth Edition, copyrighted by the Independent Hospital Pricing Authority. If the ICD codes change in future editions, the instrument still refers to the Tenth Edition, effective 1 July 2017. This means later diagnostic coding changes do not automatically update the instrument. Practitioners must use the 2017 codes. This can cause confusion if a veteran's current diagnosis uses a newer code (e.g., D61.9) that is not listed; the decision-maker must still apply the definition in section 7(2) rather than the code.

The instrument also implicitly interacts with state workers' compensation laws, but it is not binding on those schemes. Veterans who have dual claims (e.g., under state workers' comp for a civilian job and under VEA for service) may face inconsistent outcomes.

The Repeal provision (section 4) terminates the 2012 SOP. Claims lodged before 28 September 2020 but not yet determined may fall under the repealed SOP or this one depending on the lodgement date and the transition provisions in the VEA. Practitioners must check section 120A(3) to see which version applies.

No. 58 of 2020 is the first and only amendment to the SOP for aplastic anaemia since the 2012 version. It repeals and replaces the Statement of Principles concerning aplastic anaemia No. 50 of 2012 (registered as F2012L01791). The 2012 version was originally made under both subsections 196B(2) and (8) of the VEA, meaning it covered both the reasonable hypothesis and balance of probabilities standards. The 2020 version is made solely under subsection 196B(2), covering only the reasonable hypothesis standard. This is a notable narrowing: the RMA decided not to issue a separate SOP for the balance of probabilities standard for aplastic anaemia. The reason is not stated in the instrument, but it may reflect a view that the medical evidence does not support a higher degree of certainty for causal factors. This means for peacetime service claims (balance of probabilities under VEA s120(4)), there is no applicable SOP, so the decision-maker must rely on general medical evidence. This could be either a benefit or a burden: it allows more flexible evidence but also less structure.

The instrument does not provide a transitional provision. Claims made after 28 September 2020 are assessed under this instrument. Claims made before that date but not yet determined may be assessed under the old 2012 SOP if the claim was lodged before commencement, depending on the claim lodgement date and the provisions of the VEA. The instrument does not address this; practitioners must refer to the VEA's transitional regulation.

The 2012 SOP's factor list may have been different. Without the text of No. 50 of 2012, we cannot compare the factors directly. However, the 2020 version adds specificity: the definition of benzene exposure now includes a TWA of 5 ppm, whereas the 2012 version may have had a different threshold. The specified drug list in Schedule 2 is likely expanded; it now includes immune checkpoint inhibitors, osimertinib, and others reflecting modern therapies. The list of autoimmune diseases and haematological malignancies may also have changed.

The instrument also adds a new factor: "using 3,4-methylenedioxymethamphetamine (ecstasy) within the three months before the clinical onset" (factor 9(5)). This was not in the 2012 version, reflecting emerging evidence linking the drug to aplastic anaemia. This is a significant addition because ecstasy use may be relevant to younger veterans or members with peacekeeping service.

No other amendments have been made to this instrument since its commencement. The RMA may amend it in future if new evidence warrants changes, but as of the date of this instrument, no subsequent instruments have been published.

The instrument is a standalone legislative instrument; it is not part of a regulation or principal Act. It is registered on the Federal Register of Legislation. Its legislative status means it can be amended by the RMA without parliamentary approval, subject to disallowance by the Senate. This is typical for RMA SOPs.

The instrument itself has not been litigated; it is too recent. However, the general framework of RMA SOPs has been the subject of significant litigation in the Federal Court and High Court. The leading case is Repatriation Commission v Vietnam Veterans' Association of Australia (2000) 98 FCR 503, which established the "raised hypothesis" test and the role of SOPs. The High Court in Repatriation Commission v Deledio (1998) 83 FCR 82 set out the four-step process for assessing reasonable hypothesis claims, which includes checking if the hypothesis is consistent with the relevant SOP. This is known as the "Deledio steps". Under that framework, if the SOP points to a factor, the hypothesis is upheld unless the decision-maker is satisfied beyond reasonable doubt that the factor does not exist.

No specific cases concerning aplastic anaemia under the 2012 or 2020 SOP have been identified in public repositories, though there may be Tribunal decisions. The AAT often deals with aplastic anaemia claims. Typical issues at the AAT may include: whether the diagnosis meets the SOP's definition (especially excluding myelodysplastic syndrome); whether the temporal connection for drug use is established; and whether benzene exposure meets the 5 ppm TWA threshold given that veterans rarely have air monitoring records from service.

Because the 2020 SOP is new, no litigation under it has occurred. However, practitioners should anticipate potential challenges: the definition of "being exposed to benzene as specified" may be contested if a claimant can show exposure below 5 ppm TWA but contends that cumulative exposure or peak exposures should count. The SOP's strict arithmetic (8-hour TWA) ignores short-term high exposures that some studies associate with aplastic anaemia. Claimants may argue that the factor should be read more broadly, but the SOP's language is clear, so such arguments are likely to fail.

Another potential challenge is the exclusion of paroxysmal nocturnal haemoglobinuria (PNH). PNH can evolve from aplastic anaemia, and some patients have overlapping features. The SOP explicitly excludes PNH from the definition. If a veteran has both aplastic anaemia and PNH, the decision-maker must separate the conditions. This could lead to disputes about primary diagnosis.

The factor for autoimmune disease (9(10)) requires the disease to be from the specified list. "Graft versus host disease" is included, which could benefit veterans who received a stem cell transplant. However, the list does not include "autoimmune hepatitis" or "autoimmune thyroiditis", so those conditions cannot be used. Claimants with such conditions may challenge the exclusion as arbitrary, but courts generally respect the RMA's expertise.

There is also potential for litigation under the Administrative Decisions (Judicial Review) Act 1977 if the RMA failed to consider relevant evidence or acted unreasonably in making the SOP. Such challenges are difficult, but not impossible, if new medical evidence contradicts the RMA's findings.

Several traps in this instrument can catch unwary claimants and practitioners.

First, the definition of aplastic anaemia in section 7(2) excludes myelodysplastic syndrome (MDS). MDS can present similarly to aplastic anaemia (hypocellular bone marrow, cytopaenia). If a veteran is diagnosed with aplastic anaemia but later investigations show MDS, the claim fails under this SOP. The veteran may need a separate SOP for MDS (if one exists). A misdiagnosis or change in diagnosis mid-claim can lead to wasted effort.

Second, the temporal windows are strict. Factor 9(2) requires treatment with a specified drug within one year before clinical onset. If the veteran took a drug four years ago and then developed aplastic anaemia, the factor is not met. However, factor 9(3) might be used if the drug is not in the list but the reaction pattern fits. For drugs in the list, factor 9(2) is the primary pathway; but note that many listed drugs are chemotherapy agents that might have been given years earlier for cancer. The one-year window may exclude those.

Third, factor 9(4) for non-aspirin NSAIDs requires use "on at least four days per week for a continuous period of at least four weeks". This is easily satisfied by a veteran who took ibuprofen regularly for back pain. But "continuous period" is ambiguous: does it mean the four weeks must be consecutive, or can they be cumulative? The plain language suggests consecutive. If a veteran took NSAIDs every day for three weeks, missed a week, then took for another week, that may not meet the "continuous period of at least four weeks". The decision-maker may strictly require four consecutive weeks.

Fourth, the benzene exposure threshold is an 8-hour TWA of 5 ppm. Typical occupational exposure in the past was often higher, but in peacetime or modern service, levels may be lower. The veteran must prove the TWA, not just that they were around benzene. Without air monitoring records, this is nearly impossible. The alternative cutaneous or ingestion exposure is also hard to prove. This factor will be difficult for most veterans.

Fifth, factor 9(7) for herbicides and insecticides is limited to the specified list (carbamate, organochlorine, organophosphate, paraquat). Organochlorines include DDT, but many veterans were exposed to other chemicals like 2,4-D or glyphosate, which are not listed. Even if the veteran has heavy pesticide exposure, if the chemical is not on the list, the factor fails.

Sixth, factor 9(15) for inability to obtain appropriate clinical management applies only to clinical worsening (not onset) and only where the aplastic anaemia existed before service. This is narrow. "Inability" must be due to service circumstances (e.g., being deployed in a remote area without access to treatment). If the veteran had access but chose not to seek treatment, that is not inability.

Seventh, the definition of "terminal event" includes only five specified causes. Death from aplastic anaemia itself (e.g., from haemorrhage or infection) would be covered if infection leads to pneumonia or sepsis leading to cardiac arrest. But if death is from pulmonary embolism or suicide, it may not be covered unless it falls within the list. Practitioners should check if the terminal event is included.

Eighth, the cross-reference in section 11 means that if the factor is, for example, "having an autoimmune disease from the specified list", the veteran must also satisfy the SOP for that autoimmune disease. That SOP may have its own strict factors. A veteran with lupus may need to show it is service-related under the lupus SOP. This can create a chain of causation that is hard to prove.

Ninth, the instrument applies to claims under section 120A and 338 only. If a claim is for a veteran who served only in peacetime (non-operational, non-hazardous), this SOP does not apply. The decision-maker cannot use this SOP's factors to reject the claim, but also cannot use them to accept it. This can lead to confusion if the decision-maker wrongly references this instrument.

Tenth, the instrument does not consider radiation exposure, which is a known cause of aplastic anaemia. If a veteran was exposed to radiation during service (e.g., nuclear test participant, radiographer), they may have a strong case but cannot rely on this SOP. They would need to rely on general medical evidence, which is harder to prove under the reasonable hypothesis standard.

Compliance with this instrument is primarily a matter for decision-makers, but claimants and their advisors must also take steps to ensure the claim is presented in a way that fits within the factors.

For the decision-maker (the Repatriation Commission or MRCA Commission), compliance requires:

• Confirm that the claim involves relevant service (operational, peacekeeping, hazardous, British nuclear test defence, warlike, or non-warlike). If not, this SOP does not apply.
• Obtain a confirmed diagnosis that meets the definition in section 7(2). This usually requires a specialist haematologist's report stating the criteria (destruction of haematopoietic stem cells, peripheral cytopaenia, hypocellular marrow). Exclude inherited syndromes, MDS, PNH, and infiltrative processes.
• Determine the date of clinical onset. This is critical for the temporal windows.
• Review the medical and service records for any of the factors in section 9. For each potential factor, assess whether the evidence raises a reasonable hypothesis that the factor exists and is related to service.
• For drug factors, check the drug against Schedule 2. If the drug is listed, verify that it was taken within one year before onset (for factor 9(2)). If not listed, check if the reaction pattern meets factor 9(3): development within six months of therapy and improvement within six months of discontinuing or tapering. This requires objective medical evidence of both timing and improvement.
• For NSAIDs, ensure the veteran used a non-aspirin NSAID on at least four days per week for a continuous period of at least four weeks, within one year before onset. Common drugs include ibuprofen, naproxen, diclofenac.
• For benzene exposure, require evidence of exposure as defined: cutaneous/ingestion contact with liquids >1% benzene, or inhalation at ambient 8-hour TWA >5 ppm. Exposure must occur on at least 30 days within one year before onset. This may need occupational records, unit histories, or expert reconstruction.
• For herbicide/insecticide exposure, confirm the chemical is from the specified list (carbamate, organochlorine, organophosphate, paraquat), exposure on at least 30 days within six months before onset.
• For autoimmune disease or haematological malignancy, check the specified lists. Confirm the disease exists and that the veteran also meets the SOP for that condition if it has one (via section 11).
• For pregnancy, obtain evidence of pregnancy at the time of clinical onset or worsening.
• For inability to obtain clinical management, confirm that the veteran's aplastic anaemia existed before service and that service circumstances prevented appropriate management (e.g., remote deployment, lack of specialist care).
• For death claims, confirm that death was from a terminal event contributed to by aplastic anaemia.
• Document all findings and reasons.

For claimants and advisors, compliance means:

• Obtain a clear, specialist diagnosis of aplastic anaemia that addresses the exclusions. A bone marrow biopsy report is essential.
• Construct a detailed chronological history of all medications ever taken, with dates and dosages. Include over-the-counter NSAIDs, herbal remedies, and illicit drugs. Many veterans do not remember NSAID use; look for prescriptions or pharmacy records.
• Identify any service-related exposures: fuel handling, painting, degreasing, pesticide application, combat zone dust (though dust is not a factor). For benzene, focus on activities involving solvents, fuels, or chemical work. For pesticides, identify the specific chemicals used.
• Gather evidence of any autoimmune diseases or haematological malignancies, with diagnoses and dates. Note that the lupus or lymphoma must itself be service-related under its own SOP.
• Ensure that the timing of exposures aligns with the windows. If the exposure was many years before onset, the claim will not meet the factor unless the disease has a long latency (not recognised here).
• If the only potential factor is inability to obtain clinical management, the veteran must have had aplastic anaemia before service and the worsening must be directly due to lack of treatment. This is rare.
• Consider alternative arguments: if the veteran does not meet any factor, consider whether the claim can be made under a different standard (e.g., peacetime service) where no SOP applies. This may allow a reasonable hypothesis based on general medical evidence, but the standard of proof is different.
• Prepare a thorough written submission linking the evidence to each relevant factor, citing the SOP sections. This helps the decision-maker comply and reduces the chance of rejection on technical grounds.

For all parties, the key to compliance is meticulous documentation. The instrument is rigid; minor gaps in timing or definition can defeat a claim. Practitioners should not assume that a plausible causal link outside the factors will succeed. The instrument is designed to limit acceptance to specific pathways, and the RMA's view of sound medical-scientific evidence prevails over individual expert opinion.