Unexpected item in J's notes!

As of this morning I now have a copy of all the notes in J's file from the Birmingham Royal Orthopaedic Hospital, plus the x-rays on a disc. They wouldn't let me have a copy of the MRI scan, only the report, as it was taken elsewhere.

I am surprised/shocked by two things:

1. The incompleteness of the file. 
Although the initial referral from Mr M's private practice to the NHS hospital says that there will be a full, detailed letter, there is none in the file. The notes from the consultant we saw in July are only a couple of lines long and then it says "tape goes blank here!!".

There's no summary of the issues or findings at all. Just the referral letters and reports about the x-rays and MRI scan! Oh and lots of the "soft cast been changed today" entries.

Is this normal? I know they're very busy, but it doesn't seem right.

2. The line in one of the consultant radiologist's reports on the July x-ray mentioning suspected spina bifida.
"Appearances do suggest the presence of an underlying lumbo sacral spina bifida defect"
What the heck??? Why hasn't this been mentioned before???

Using my calm, rational side, I can only assume that the spinal deformity consultants looked at the x-rays and came to a different conclusion, so decided it would be best not to say anything.

Of course, my not-so-calm side had a field day on Dr Google... but I have to say I can't see any of the symptoms they mention on the web in my son so I don't think it's affecting him if he does have spina bifida. It's true that his "toddler gait" and stumbling/falling over may not be related to his age and could actually be evidence of an underlying problem but he looks like any of the other kids in the nursery to me.

I have composed a letter to Mr M and asked for clarification.

I've read that it's good to have a full copy of all notes and all scans/x-rays and now have most of them. I don't want to be awkward or overly pushy. My aim is to be the best possible advocate for my precious little boy. One big thing I've learnt is that you really do have to be on the ball and pro-active - and I guess being polite and well prepared are key elements too.

Fingers crossed that all is fine...