Statement of Principles concerning pulmonary thromboembolism (Balance of Probabilities) (No. 38 of 2021)

The SoP operationalises a medical causation test for pulmonary thromboembolism within the veterans’ entitlements framework. The principal concepts are:

• Pulmonary thromboembolism: defined substantively in s 7(2) as obstruction of the pulmonary artery or a branch by a mass of clotted blood. The instrument explicitly prefers that definition over mere reliance on the ICD‑10‑AM code I26 (ss 7(2)-(4)). That means medical diagnosis must be aligned to the textual definition, not merely the code.

• Balance of probabilities: the Repatriation Medical Authority frames the SoP on the civil standard of proof, that is, more probable than not (s 8). This is the evidentiary standard used to connect PTE to relevant service for the purposes of claims under the referenced statutory provisions.

• Factors and temporality: the SoP sets out 25 alternative factors (s 9) that, if present and related to relevant service, are sufficient to establish a connection on the balance of probabilities. Many factors include explicit temporal windows relative to the clinical onset of PTE (for example, “within the three months before the clinical onset” in s 9(1), (3), (9), (11), among others). These windows function as medical‑legal presumptions that certain antecedent conditions within the specified period materially raise the probability that PTE is related to service.

• Relationship to relevant service: s 10 requires that any factor in s 9 be related to the person’s relevant service. “Relevant service” is defined in the Schedule to include eligible war service (other than operational service), defence service (other than hazardous service and British nuclear test defence service) under the VEA, and peacetime service under the MRCA. Thus, the instrument limits its causal connection to the statutory categories of service (Schedule 1: relevant service).

• Interaction with other SoPs: s 11 creates a mechanism for overlapping medical conditions. If a s 9 factor refers to an injury or disease that already has its own SoP, the factors in that other SoP apply as prescribed, ensuring coherent application across multiple SoPs.

• Defined medical terms: the Schedule supplies operational definitions that will govern the interpretation of factors (for example, “being overweight or obese” is BMI ≥25; “one pack‑year” is smoking 20 cigarettes per day for one year or equivalent, with a Note specifying an equivalent of 7,300 grams of smoking tobacco by weight).

• Death and terminal events: s 7(5) extends the SoP to death from PTE where death arose from a terminal event or condition that was contributed to by the person’s PTE. The Schedule defines “terminal event” with an enumerated list (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function).

Together these concepts produce a structured, time‑bound list of medical conditions and exposures that the Repatriation Medical Authority considers, on available medical evidence, capable of establishing service connection for PTE when linked to relevant service. The instrument places weight on specific biomedical mechanisms (hypercoagulable states, recent surgery, recent immobilisation, infection with SARS‑CoV‑2 within three months, certain drugs, pregnancy within three months, etc.) and standardises the temporal boundaries decision‑makers must apply.

Primary affected parties

• Veterans and members who lodge claims under the VEA (s 120B) or the MRCA (s 339): The instrument applies to those claims (s 5). Claimants with an allegation that pulmonary thromboembolism or death from pulmonary thromboembolism is connected with relevant service will have their cases assessed against this SoP.

• Decision‑makers within the Department of Veterans’ Affairs and related administrative bodies: The SoP is an authoritative medical input used in assessing service connection; administrators and medical assessors will apply s 9 factors, Schedule definitions and the relationship rules in s 10 when forming decisions.

• Medical practitioners and treating clinicians: The instrument’s reliance on defined clinical measures (BMI, test results for kidney dysfunction, timing of infection, presence of implanted devices for continuous periods, anaesthetic types, timing of surgery, mechanical ventilation, etc.) means clinicians’ documentation practices materially affect claim outcomes. The SoP creates incentives for recording specific metrics and temporality (BMI, exact dates of surgery and device insertion, SARS‑CoV‑2 infection dates, smoking history quantified as pack‑years or cigarettes‑per‑day and cessation dates).

Secondary affected parties

• Legal representatives and advocates for claimants and the Department: Lawyers and advocates will be required to marshal evidence to demonstrate that one or more s 9 factors existed and were related to relevant service as required by s 10. The fixed temporal windows and specific definitions shape arguments and evidentiary strategies.

• Hospitals and record‑keepers: Because the SoP specifies thresholds and timelines (for example, central venous catheter for at least 24 continuous hours within three months of onset, s 9(16); restricted mobility for a continuous period of at least four hours within the four weeks before onset, s 9(19)), the availability and accuracy of contemporaneous records will be a significant practical determinant of entitlement decisions.

• Defence organisations and employers: Records of service periods, whether particular service constitutes “relevant service” under the Schedule’s definition, and circumstances of service (travel, restraint, medical evacuation and treatment) can affect the application of the SoP.

Who pays and who benefits

• The SoP itself does not authorise payment. However, it materially determines eligibility for entitlements under the VEA and MRCA by providing the medical basis for causation determinations. If a decision‑maker accepts a s 9 factor as present and related to relevant service, the claimant may obtain benefits under the relevant statutes. The financial consequences therefore flow through the statutory benefit framework rather than through the SoP directly.

Special populations and scenarios highlighted by the SoP

• Persons with recent SARS‑CoV‑2 infection: s 9(11) includes infection with SARS‑CoV‑2 within the three months before clinical onset as one of the enumerated factors. This ties recent COVID‑19 infection to the causal matrix for PTE in the veterans’ entitlements context.

• Pregnant persons: s 9(9) includes pregnancy within the three months before clinical onset.

• Those who have undergone surgery requiring general, spinal or epidural anaesthesia within six months (s 9(17)), or who have had implantation of an intravenous device for at least 24 continuous hours within three months (s 9(16)), will have specific pathways to link PTE to service, provided the factor relates to relevant service under s 10.

• Smokers: s 9(23) sets out two alternative smoking‑related criteria , one pack‑year or 10 cigarettes per day for at least three months , and contains rules about cessation (onset must be within six months of cessation). The Schedule clarifies pack‑year calculations and provides a gram‑equivalent.

In short, the SoP affects claimants, medical professionals, record‑keepers, and administrators by specifying medical factors, definitions, and temporal boundaries that determine whether PTE may be accepted as connected with relevant service for the purposes of statutory entitlements.

This instrument is not a statute conferring rights or imposing enforceable duties in the manner of criminal or regulatory legislation; instead, it creates binding criteria for administrative decision‑making within the veterans’ entitlements framework. The key operational duties and rights can be mapped as follows:

Duties of decision‑makers and authorities

• Apply the SoP to relevant claims: If a claim falls under s 120B VEA or s 339 MRCA (s 5), decision‑makers must consider the SoP. The Repatriation Medical Authority’s view, as recorded in s 8, is that PTE can, on the available medical‑scientific evidence, be related to relevant service on the balance of probabilities. Administrators must apply the SoP’s factors and definitions when assessing causation issues in those claims.

• Establish whether at least one s 9 factor exists and is related to relevant service: Section 9 lists 25 alternative factors. Section 10 mandates that the existence of any s 9 factor must be related to the person’s relevant service. Thus decision‑makers must undertake a fact‑sensitive link analysis , presence of a factor plus service relatedness.

• Give effect to cross‑SoP references: Section 11 requires that where a s 9 factor refers to an injury or disease for which there is another SoP, the factors in that other SoP apply as in force from time to time. Decision‑makers must therefore consult other SoPs and apply them in accordance with their terms when relevant.

Rights/benefits of claimants

• Right to an entitlement decision informed by the SoP: For claimants whose claims fall under s 120B VEA or s 339 MRCA, the SoP forms part of the medical criteria the decision‑maker uses. When a s 9 factor exists and is related to relevant service, this can ground acceptance of service connection on the balance of probabilities and, through the statutory apparatus, lead to entitlement outcomes.

• Evidentiary expectations shaped by the SoP: Claimants have the practical right to present medical evidence tailored to the SoP’s factors and Schedule definitions (BMI records, surgery and anaesthesia records, device insertion timing, evidence of infection including SARS‑CoV‑2, smoking history quantified according to the pack‑year/grams rules, etc.). The SoP does not preclude other evidence, but it sets out the conditions that, if met, will support a finding of service connection.

Operational implications and duties on other actors

• Clinical documentation duty: Treating clinicians have a de facto duty to document the clinical facts and timing that the SoP requires for adjudication (dates of events, BMI, relevant lab values, documentation of immobilisation, details of anaesthesia, device implantation duration). While the SoP does not place statutory obligations on clinicians, their record‑keeping materially affects claim outcomes.

• Administrative record‑keeping duty: The Department and decision‑makers must maintain processes to evaluate the specified temporal relationships and definitions in s 9 and the Schedule when adjudicating claims.

Limitations and legal effect

• The SoP does not itself grant monetary benefits, impose penalties, or create direct private rights enforceable in court. Its legal effect is to provide the medical causation template that decision‑makers use to determine whether an acknowledged injury/disease is connected to relevant service for the statutory purposes set out in s 5.

• The SoP binds the medical assessment component of the entitlement process, but final entitlement determinations remain governed by the VEA and MRCA and their decision‑making processes. The SoP therefore supplies the medical criteria that feed into statutory decision‑makers’ duties under those Acts.

In short, the principal duties produced by this instrument fall on decision‑makers to apply the listed factors and Schedule definitions when deciding claims under the specified statutory provisions. The practical rights conferred to claimants are evidentiary and procedural: a claimant whose clinical history satisfies a listed factor, and where that factor is related to relevant service, can expect that the SoP will favour a finding of service connection on the balance of probabilities.

The SoP itself contains no provisions that impose criminal penalties, administrative fines, or direct enforcement mechanisms. It is an expert medical instrument made under subsection 196B(3) of the VEA (s 3) to be applied within the statutory claims processes for veterans’ entitlements. The enforcement and penalty landscape therefore has to be described in the context of how the SoP is used rather than in the instrument itself.

Key points on enforcement and practical effect

• No standalone sanctions: The instrument does not prescribe penalties for non‑compliance, nor does it create offences. There is no enforcement machinery within the SoP text that penalises parties for failing to conform to its definitions or procedures.

• Role in administrative decision‑making: The SoP operates as the authorised medical framework that decision‑makers adopt when assessing causation for claims under s 120B VEA and s 339 MRCA (s 5). Administrative remedies and review mechanisms available under the VEA and MRCA continue to apply to decisions where the SoP has been applied. The SoP’s determinations affect entitlement outcomes; any enforcement of those outcomes (such as payment of benefits, continuation, or cessation of entitlements) will be through the statutory processes in the VEA and MRCA, not by the SoP itself.

• Evidentiary and procedural enforcement: While there are no penalties within the SoP, the practical operation of the factors and definitions imposes enforcement‑like pressures: claimants must marshal medical evidence aligning with the SoP’s time windows and thresholds (e.g., s 9 temporal windows; Schedule definitions such as BMI ≥25; pack‑year calculations). Failure to provide adequate evidence in these terms may lead to denial of service connection by decision‑makers. The “penalty” in practice is an adverse entitlement decision rather than a statutory sanction.

Decision‑maker obligations and possible appellate pathways

• Obligations to apply the SoP: Decision‑makers tasked with evaluating claims under the VEA and MRCA are obliged to consider the SoP when the statutory provisions require. The SoP will be an authoritative medical input. Administrative law remedies (internal review, tribunal review, judicial review) available under the relevant Acts and common law may be engaged if a claimant argues the SoP was misapplied, not applied, or applied capriciously. The SoP itself does not set out the review process.

• Potential for dispute: The specific definitions, temporal cut‑offs and cross‑SoP references were designed to reduce medical uncertainty, but they may be contested in particular cases (for example, interpretation of “continuous period” for immobilisation at s 9(19); interpretation of “related to the relevant service” at s 10). Such disputes will be resolved within the statutory review and appeal mechanisms of the VEA and MRCA process; again, the SoP does not create its own enforcement channel.

In summary, the instrument does not create penalties or an enforcement apparatus. Its practical enforcement effect is indirect: it shapes the medical findings that determine entitlement decisions under the VEA and MRCA. Administrative and judicial remedies available under those Acts and general administrative law govern any challenge to the way the SoP is applied in a particular claim.

Statutory embedding: VEA and MRCA

• Source of power and scope: The instrument is made under subsection 196B(3) of the Veterans’ Entitlements Act 1986 (s 3). Its explicit application is limited to claims under s 120B of the VEA and s 339 of the MRCA (s 5). That embedding means the SoP is an operational medical determination that feeds into the statutory frameworks and decision processes established by the VEA and MRCA. The SoP does not alter those Acts; it provides medical criteria decision‑makers must apply when the Acts require a causation assessment.

Cross‑SoP relationships

• Section 11 provides an internal statutory interaction mechanism: if a factor in s 9 refers to an injury/disease covered by another SoP determined under subsection 196B(3) of the VEA, then the factors in that other SoP apply in accordance with its terms. This creates a web of SoPs where one instrument can invoke another. Practically, adjudicators must consult the other SoP(s) and apply their terms where a s 9 factor references a disease/injury that has its own SoP (s 11). This interaction ensures consistency across SoPs but requires administrative cross‑reference and harmonisation.

ICD coding and clinical classifications

• Interaction with ICD‑10‑AM: The instrument notes that PTE attracts ICD‑10‑AM code I26 but indicates that the statutory meaning for the SoP is the textual definition in s 7(2). Subsections 7(3)-(4) therefore clarify that while the ICD code is identified, adjudicators must treat the statutory definition as determinative. The instrument references the ICD edition and its copyright holder (Independent Hospital Pricing Authority) for specificity (s 7(4)).

Overlap with other medical or compensation regimes

• MRCA and VEA exclusivity: The SoP explicitly applies to claims under s 120B VEA and s 339 MRCA. It does not purport to bind decision‑makers under other statutes outside the veterans’ framework. Where conditions or factors referenced in s 9 cross over into other statutory systems, that interaction is not governed by the SoP; it governs only the VEA/MRCA claim context.

Administrative law and review

• Application within review regimes: Because the SoP is an expert medical instrument used in administrative decisions under the VEA/MRCA, it will interact with administrative law doctrines (procedural fairness, reasonableness, evidence). The SoP’s definitions and time limits will shape what evidence is material; how tribunals or courts view the reasonableness of medical assessments that rely upon or depart from the SoP will determine the practical legal interactions. The SoP itself does not set out the review process.

Interactions with clinical and public health practice

• Clinical record obligations: The SoP’s reliance on documented clinical thresholds (e.g., BMI, lab values for kidney function, dates of device implantation, timing of SARS‑CoV‑2 infection) creates de facto interactions with record‑keeping practices under health data and privacy laws. The instrument does not amend privacy or health records legislation, but it makes such records functionally salient in entitlement determinations.

Amendments and legislative history

• The instrument has been amended (see Endnotes 3 and 4). The compilation includes the Veterans’ Entitlements (Statements of Principles,definition of "one pack-year") Amendment Determination 2022 (No. 94 of 2022), which amended the notes to subsection 9(23) and the Schedule definition of one pack‑year (Endnote 3). This demonstrates the SoP’s capacity to be updated and interact temporally with amending instruments; decision‑makers must apply the current SoP as in force (s 11’s cross‑SoP reference requires application of other SoPs as in force from time to time).

In sum, the SoP operates within the VEA/MRCA architecture and interfaces with other SoPs, clinical classification systems, clinical record frameworks, and administrative law. It does not displace other statutes; rather, it supplies a medical standard that decision‑makers must apply under the specified statutory claims processes.

The compilation provided shows the original Statement of Principles concerning pulmonary thromboembolism (Balance of Probabilities) (No. 38 of 2021) registered on 9 March 2021 and commencing 5 April 2021 (Endnote 3). The compilation includes amendments up to the Veterans' Entitlements (Statements of Principles,definition of "one pack‑year") Amendment Determination 2022 (No. 94 of 2022), registered 26 August 2022 and commencing 19 September 2022 (Endnote 3).

Specific amendment annotations recorded in the compilation (Endnote 4) indicate:

• Section 2 was affected (not shown in the compiled text) and annotated as “rep LA s 48D”. The compiled text, however, does not contain a Section 2, suggesting amendments in the template or removal of provisions under the Legislative Acts (LA) provisions; the compilation notes the replacement or repeal under the Legislation Act s 48D.

• Section 4 was affected and annotated as “rep LA s 48C”. Again, those changes relate to legislative housekeeping or the Legislation Act’s provisions and the compilation notes those replacement/repeals.

• The Note to subsection 9(23) was replaced or otherwise amended by No. 94 of 2022 (Endnote 4: “rs No. 94 of 2022” , “rs” meaning repealed and substituted). That indicates the note accompanying subsection 9(23) on smoking measures (pack‑year and cigarettes per day equivalences) was revised by the 2022 amendment.

• The Schedule 1 - Dictionary definition of “one pack‑year” was likewise repealed and substituted by No. 94 of 2022 (Endnote 4). The compiled Schedule shows the current definition and two notes explaining gram equivalents and calculation examples; these are the form produced by the 2022 amendment.

What the amendments changed, practically

• From the compilation, the most concrete amendment visible is the 2022 change to how “one pack‑year” is defined and how cigarette equivalences are described. The Schedule now includes Note 1 explaining that an equivalent amount of tobacco products is 7,300 grams of smoking tobacco by weight, and Note 2 explaining pack‑year calculation with worked examples. The SoP’s smoking criterion in s 9(23) therefore relies on that revised Schedule language.

• The 2022 amendment also altered the note to subsection 9(23). The content of that note in the compiled text clarifies how cigarettes per day or equivalents are calculated and references the Schedule definition, reflecting the amendment’s purpose to standardise smoking exposure quantification.

Amendments and commencement

• The compilation states the day of commencement of the 2022 Amendment Determination is 19 September 2022. Users must apply the SoP as amended from that date forward. The compilation emphasises that uncommenced amendments are not shown and that details of amending laws and application details are set out in the endnotes. Practitioners must check whether later amendments exist beyond the compilation date.

Implications for practitioners

• Because the SoP has been amended at least once, decision‑makers and litigators should verify they are applying the current version. The Schedule’s precise definitions (for example, one pack‑year and the 7,300 gram equivalence) have specific operational consequences for proving a smoking history that meets s 9(23).

• The Endnotes show subject matter changes and legal housekeeping changes (repeal/replace under the Legislation Act). While the compilation contains the current text up to 19 September 2022, parties should consult the Legislation Register or series page for any later amendments or uncommenced changes.

In sum, the instrument was first made in 2021 and formally amended in 2022 to refine definitions, especially for smoking exposure. The compilation explicitly logs those changes and notes where provisions were repealed or substituted. Practitioners must apply the current text and be attentive to further amendments.

The compiled Statement of Principles concerning pulmonary thromboembolism (Balance of Probabilities) (No. 38 of 2021) contains no internal references to judicial or tribunal determinations, and the endnotes list amendment and legislative history only. The instrument itself does not record any litigation that has interpreted its provisions.

Practical consequences for litigation

• No reported cases in the compilation: Because the compilation provides only the instrument text and amendment history, and does not include court or tribunal citations, one cannot identify any instances where courts or tribunals have construed the SoP from this document alone. The SoP’s legal force derives from the VEA/MRCA processes; disputes about how the SoP is applied will arise in administrative review, tribunal appeals, or judicial review proceedings under those Acts, but the compilation does not record them.

• Likely areas of legal dispute: Although no cases are recorded in the instrument, parts of the SoP are susceptible to contestation in claims or review proceedings. The issues likely to generate litigation are identifiable from the text:

  • Interpretation of “related to the relevant service” (s 10): Determining whether a listed factor was related to the person’s relevant service is necessarily fact‑driven and may be contested in individual claims.

  • Temporal window disputes: Sections 9 contain numerous temporal thresholds (three months, six months, continuous periods of specified lengths). Parties may dispute whether the timing evidence meets the specified window.

  • Definitions: The Schedule contains technical thresholds (e.g., BMI ≥25 for “being overweight or obese”; one pack‑year equivalence and grams of tobacco). Disputes may arise over how these metrics are calculated or recorded.

  • Cross‑SoP application: Section 11 instructs that other SoPs apply where factors refer to other injuries/diseases. Litigation may involve whether the cross‑SoP application was properly performed.

  • “Inability to obtain appropriate clinical management” (s 9(25) and s 10(2)): This factor includes a narrow relationship clause (applies only to material contribution or aggravation where the PTE was suffered or contracted before or during but did not arise out of the person’s service). Determining when inability to obtain management is causally sufficient and related to service involves factual and legal analysis that could be litigated.

• Evidence and standard of proof: The SoP adopts the balance of probabilities standard (s 8). In review proceedings, disputes will centre on whether the medical and factual evidence, applied against the SoP’s criteria, is sufficient to meet that civil standard.

What the compilation cannot supply

• The compilation contains no case law, tribunal decisions, or appellate interpretations of this SoP. Practitioners seeking precedents on how courts or tribunals have interpreted the instrument must search case law databases and tribunal decisions beyond the compilation.

• Any litigation history that post‑dates the compilation date (19 September 2022) will not appear in the compiled text. Verification against up‑to‑date sources is required.

In sum, the instrument itself does not supply litigation history. It sets out criteria likely to be litigated in the context of administrative appeal or judicial review, but the compilation does not record any such decisions.

The SoP’s specificity reduces ambiguity in some respects but creates multiple technical traps for claimants, clinicians and decision‑makers. The following “gotchas” are drawn from precise textual features and procedural interactions in the instrument; practitioners should treat them as practical pitfalls to watch for rather than normative criticisms.

Temporal windows are strict and discrete (s 9)

• Many factors require occurrence within narrow time frames relative to the clinical onset of pulmonary thromboembolism: three months (deep vein thrombosis s 9(1); acute myocardial infarction s 9(3); pregnancy s 9(9); SARS‑CoV‑2 infection s 9(11); specified drugs s 9(21) is within three months; etc.), six months (superficial vein thrombosis s 9(2); surgery requiring specified anaesthetic s 9(17); note also six months intervention for smoking cessation), four weeks for a continuous period of restricted mobility assessed over a continuous period of at least four hours occurring within the four weeks before clinical onset (s 9(19)), and other time frames. Small errors in date records (e.g., clinical onset date) can determine acceptance or rejection.

• Clinical onset determination risk: The instrument repeatedly anchors factors to “the clinical onset of pulmonary thromboembolism.” Determining that onset date with precision can be difficult in practice, particularly where diagnosis is delayed. Adjudicators will focus on the onset finding because the temporal tests hinge on it. Clinicians and advocates need to document onset carefully.

Definitions carry measurement and conversion hurdles (Schedule 1)

• BMI and “being overweight or obese”: The Schedule defines BMI as W/H2 and “being overweight or obese” as BMI of 25 or greater. BMI calculations require accurate contemporaneous weight and height. If weight records are missing or not contemporaneous with clinical onset, a claimant may struggle to meet s 9(7).

• Smoking evidence and the unusual 7,300 grams equivalence: The Schedule’s Note 1 equates one pack‑year to 7,300 grams of smoking tobacco by weight. That figure may be counter‑intuitive to clinicians or records custodians. Practitioners should ensure smoking histories are converted using the Schedule’s formulae and that pack‑year calculations are clearly explained in evidence.

• Pack‑year vs cigarettes per day dual test: Subsection 9(23) offers two alternative smoking thresholds , “at least one pack‑year” or “at least 10 cigarettes per day … for a period of at least three months before clinical onset.” If a claimant has varied consumption over time, careful calculation and explanation are required. If smoking ceased before onset, the so‑called cessation rule (onset must occur within six months of cessation) must be demonstrated.

“Related to relevant service” is a separate legal requirement (s 10)

• A listed factor is necessary but not sufficient; it must also be related to relevant service. This two‑part test means that even where a factor appears on s 9, claimants must show a service connection. Section 10 does not define “related” further in this instrument, so adjudicators must interpret the connection in the context of statutory definitions of relevant service and available evidence. This creates an evidentiary gap that needs to be bridged.

Narrow application of s 9(25) (inability to obtain appropriate clinical management)

• Section 9(25) is included but s 10(2) limits its application to material contribution to or aggravation of PTE where the PTE was “suffered or contracted before or during (but did not arise out of) the person’s relevant service.” This is a narrow pathway and requires both a temporal framing (before/during service) and a causal framing (did not arise out of service) plus evidence of inability to access appropriate care. Practitioners must be attentive to this nuanced limitation.

Cross‑SoP referencing can complicate causation chains (s 11)

• Section 11 requires application of other SoPs when a s 9 factor refers to a disease/injury covered by those SoPs. This can produce multi‑instrument analyses where proofs of factors require meeting independent SoP thresholds. Evidence must be marshalled across instruments; failing to consult linked SoPs can lead to misapplication.

Specificity of medical lists means narrow inclusion/exclusion (Schedule 1 lists)

• The Schedule lists specific hypercoagulable states, specified drugs, specified kidney diseases, and specified injuries/illnesses. Conditions outside these enumerated lists may not be captured, even if clinically relevant in particular circumstances. Parties must map clinical diagnoses to the exact enumerated items rather than relying on broader clinical impressions.

ICD code note is not the operative definition (s 7(3)-(4))

• The instrument notes that PTE attracts ICD‑10‑AM code I26 but then states that “in applying this Statement of Principles the meaning of pulmonary thromboembolism is that given in subsection (2)” (s 7(3)). Practitioners should not rely on an ICD code alone; the textual definition in s 7(2) governs.

Documentation burdens and record availability

• Many factors require documentary proof (e.g., imaging, biopsy, lab values, device insertion duration of “at least 24 hours,” anaesthetic type and date, surgery date). Where records are missing (for example, if care occurred overseas or in a mobile operational context), claimants face evidentiary friction. The SoP’s reliance on these records creates a practical burden that must be anticipated.

Potential for interpretative disputes over adjectives like “continuous” and “significantly reduced mobility”

• Terms such as “continuous period” (s 9(16) and s 9(19)) and “significantly reduced mobility” (Schedule: injury or illness as specified, para (h)) require construing what constitutes “continuous” or “significant.” These are fact‑sensitive and potentially litigable.

In sum, the SoP’s technical detail and interlocking conditions create multiple points where claims can fail on evidentiary or interpretive grounds. Practitioners should prepare evidence to meet the specific tests set out in s 9 and the Schedule, be precise about dates and measurements, and be ready to justify how a factor was related to the person’s relevant service per s 10.

Compliance here means preparing, presenting and adjudicating claims in a way that aligns with the SoP’s criteria so that the relevant decision‑maker can lawfully and properly apply it. The SoP’s precise factors and Schedule definitions dictate the evidence and processes necessary for claimants, clinicians and decision‑makers.

Evidence,what to collect and how to present it

• Establish the clinical onset of pulmonary thromboembolism: Because many factors are keyed to timing relative to clinical onset (for example, three months, six months, four weeks), determine and document the clinical onset date. Collect emergency department notes, hospital admission records, imaging reports (CT pulmonary angiography or ventilation‑perfusion scans), clinician letters specifying onset, and diagnostic test results that confirm obstruction of pulmonary arterial branches as defined in s 7(2).

• Demonstrate one or more s 9 factors with dates and supporting tests:

  • Deep vein thrombosis (DVT) within three months before onset (s 9(1)): document duplex ultrasonography, venography, clinical notes.

  • Superficial vein thrombosis within six months before onset (s 9(2)): clinical notes, ultrasound.

  • Acute myocardial infarction within three months before onset (s 9(3)): ECGs, troponin levels, cardiology reports.

  • Heart failure or right‑sided intracardiac thrombus at time of onset (s 9(4)): echocardiography, cardiology notes.

  • Malignant neoplasm at time of onset (s 9(5)): pathology reports, oncology records.

  • Venous aneurysm in deep system (s 9(6)): imaging records.

  • BMI and overweight/obesity (s 9(7) and Schedule): contemporaneous weight and height, calculate BMI (W/H2), include nursing and admission records.

  • Sleep apnoea (s 9(8)): sleep study reports, CPAP treatment records.

  • Pregnancy within three months before onset (s 9(9)): antenatal records, obstetric notes.

  • HIV or hepatitis C infection (s 9(10)): serology results, specialist letters.

  • SARS‑CoV‑2 infection within three months before onset (s 9(11)): positive PCR/antigen test results with dates, clinical notes.

  • Autoimmune disease (s 9(12)) and diabetes mellitus (s 9(13)): specialist letters, diagnostic criteria, laboratory evidence.

  • Hypercoagulable states as specified (s 9(14) and Schedule): relevant laboratory tests, specialist haematology reports, documentation of inability to access anticoagulant treatment if applicable.

  • Kidney disease from specified list (s 9(15) and Schedule): GFR results (<60 mL/min/1.73 m2), renal biopsy reports, transplant records, albuminuria or urinary sediment evidence.

  • Implanted intravenous device for at least 24 continuous hours within three months (s 9(16)): operative notes, device insertion records, nursing records showing continuous duration.

  • Surgery requiring general/spinal/epidural anaesthetic within six months (s 9(17)): theatre records, anaesthesia records specifying anaesthetic type and date.

  • Injury or illness as specified within three months (s 9(18) and Schedule): radiology, ICU admission notes, mechanical ventilation documentation.

  • Restricted mobility for a continuous period of at least four hours within the four weeks before onset (s 9(19)): transport records (flight manifests), detention/restraint documentation, clinician notes specifying immobilisation.

  • Neurological disease causing limb motor loss within three months (s 9(20)): neurology notes, imaging, functional assessments.

  • Specified drugs within three months (s 9(21) and Schedule): pharmacy records, prescription records, oncology regimens, hospital drug charts.

  • Combined estrogen‑progestogen contraception or menopausal hormone therapy as specified for a continuous period of at least four weeks within three months (s 9(22)): prescription records, pharmacy dispensing, contraception notes.

  • Smoking criteria (s 9(23) and Schedule): detailed smoking history, pack‑year calculation (use Schedule Note 2 or the 7,300 gram conversion in Note 1), dates of cessation if applicable.

  • High altitude exposure (at least 3,000 metres for five days within three months, s 9(24)): travel itineraries, military movement documents, expedition logs.

  • Inability to obtain appropriate clinical management (s 9(25)): contemporaneous records showing denial or inability to access care; documentation linking the lack of care to material contribution or aggravation where the PTE was suffered or contracted before/during service (see s 10(2)).

• Where s 9 factors refer to other SoPs (s 11), gather evidence that meets the other SoP’s requirements as well. Cross‑reference other SoPs and provide parallel evidence to satisfy those instruments.

Medical and expert evidence

• Obtain specialist reports that map clinical findings to the SoP’s language: cardiology, haematology, nephrology, infectious disease, obstetrics, neurology and oncology opinions should explicitly state whether the condition met the SoP criterion and the timing relation to clinical onset. Experts should address whether the factor is related to the person’s relevant service as required by s 10.

• For BMI and pack‑year calculations, include explicit calculations and document the data sources used for weight/height and smoking history. Use the Schedule’s formulae and the 7,300 gram equivalence where applicable.

Administrative procedures and submissions

• Link factors to relevant service per s 10: Prepare a clear factual narrative tying the identified s 9 factor to the defined category of relevant service in Schedule 1 (eligible war service other than operational, defence service other than hazardous and British nuclear test defence service, or peacetime service under the MRCA). Provide contemporaneous service records, personnel files, movement documents, and any orders or logs that place the factor in the context of relevant service.

• Where relying on s 9(25) (inability to obtain appropriate clinical management), build evidence showing (1) the PTE was suffered/contracted before or during service but did not arise out of the person’s service; (2) inability to obtain appropriate care materially contributed to or aggravated the PTE; (3) evidence of attempts to obtain care and the denial or unavailability of appropriate management.

• Anticipate cross‑SoP application (s 11): If a s 9 factor relates to another SoP, consult that SoP and satisfy its factors. Include citations to the relevant SoP in submissions and provide the supporting medical evidence required by that instrument.

Record‑keeping and documentation best practice

• Time‑stamp events: Where possible, secure date‑stamped test results, theatre and anaesthesia records, admission and discharge summaries, lab reports, and medication administration records.

• Preserve chain of evidence for device duration requirements: For s 9(16), be precise about the continuous 24‑hour period for implanted intravenous devices. Nursing charts and device logs are essential.

• Document mobility limitations: For s 9(19), obtain and preserve transport manifests, police reports, restraint orders, and clinician notes that specify the start and end times of immobilisation.

• Provide contemporaneous evidence for medical management access issues: For s 9(25), keep records of referral attempts, handwriting logs showing attempts to obtain care, emails, and formal decision notices denying access.

Decision‑maker processes

• Apply the SoP systematically: Decision‑makers should first determine the clinical onset of PTE, then test each s 9 factor against the evidence and schedule definitions, then assess whether any established factor is related to relevant service as required by s 10. If a s 9 factor invokes another SoP, follow s 11 and apply the other SoP’s factors.

• Record reasons: Administrative decisions should explicitly state which s 9 factor(s) were found present (if any), how evidence met the Schedule definitions, why such factor(s) were or were not related to relevant service under s 10, and whether cross‑SoP application under s 11 was necessary. This will aid internal and external review processes.

Practical compliance checklist for clinicians and advisers

• Confirm the date of clinical onset of PTE.

• Calculate BMI contemporaneous to onset and document weight/height.

• Obtain diagnostic imaging and lab reports specific to listed factors.

• Record exact dates and durations for surgeries, device implantations and immobilisations.

• Secure SARS‑CoV‑2 test results with dates and clinical context.

• Compile smoking history in pack‑years using the Schedule method and document cessation dates.

• Provide written specialist opinions that address s 9 factors and s 10 service relatedness.

• If relying on inability to obtain clinical management (s 9(25)), gather evidence of attempts to access care and reasons for inability.

• Cross‑check whether any s 9 factor points to another SoP and collect the evidence required under that other instrument.

In short, compliance requires precise, time‑stamped clinical documentation mapped directly to the instrument’s factors and Schedule definitions, together with clear service records demonstrating the required relation to “relevant service.” The SoP’s technicality makes meticulous evidence gathering the primary compliance pathway.