Certificate issued under s 7.23 (1) of the Motor Accident Injuries Act 2017

1. The Panel revokes the certificate of Medical Assessment of David Grange dated

31 October 2024. 2. The Panel considers that the following treatment and care: * CT SPECT scan,

does not relate to the injury caused by the motor accident.

1. The Panel considers that the following treatment and care:
   • CT SPECT scan,

is not reasonable and necessary in the circumstances.

1. The claimant is a 41-year-old woman who was injured in the motor vehicle accident which occurred on 20 May 2022. Following the accident, she lodged an Application for personal injury benefits. Thereafter it was determined that the claimant had sustained non-threshold injuries. The claimant sought a concession from the insurer that her injuries caused by the motor accident gave rise to a permanent impairment of greater than 10% following a review. The insurer declined to make this concession and thereafter the matter was referred for an assessment of degree of permanent impairment. A certificate dated 26 September 2023 of Medical Assessor Adam Rapaport determined that the claimant has a permanent impairment of 0%.
2. In 2024 the claimant sought a concession from the insurer that the CT SPECT scans requested by Dr David Freeberg relate to the injury caused by the accident and are reasonable and necessary in the circumstances. The insurer declined to make this concession and thereafter the matter was referred for an assessment of treatment and

care - causation. 3. The claimant was examined by Medical Assessor Christopher Grainge who, in a certificate dated 31 October 2024, determined that the CT SPECT scan relates to the injury caused by the motor accident and is reasonable and necessary in the circumstances. 4. The insurer sought a review of this determination and, in a certificate dated

31 October 2024, President's delegate Melinda Drew determined that there is a reasonable cause to suspect that the medical assessment was incorrect in a material respect. Accordingly, the matter was referred to this Medical Panel. 5. Clause 14F of schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A "new decision maker" is defined in cl 14 A(1) of the schedule 1 of the PIC Act. As the medical assessment, the subject of the review, was made on or after 1 March 2021, the new review provisions apply. 6. The new review provisions provide that a review Panel consists of two Medical Assessors and a Member assigned by the Motor Accidents Division of the Personal Injury Commission (Commission). 7. Part 5 of the PIC Act enables the Commission to make rules with respect to its practice and procedure including proceedings before a Panel reviewing a decision of a Medical Assessor. 8. Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A Review Panel determines how it conducts and determines the proceedings and may determine the matter solely based on the written application. 9. The review of the medical assessment is by way of a new assessment of all the matters with which the medical assessment is concerned. 10. Ms Rexhepi attended as arranged and was unaccompanied for the assessment.

1. Ms Rexhepi had graduated from the University of Technology in 2006. She said she had worked with Sigma-Aldrich in Castle Hill company for about 10 years, with the first year being part time as she was still completing her final year of studies. The job was about 40 minutes' drive from home.
2. She said she left the job after her first child was born in 2010. She subsequently had two other children, in 2012 and 2016. She said that all the pregnancies were without incident.
3. She had commenced work as a hospital scientist with Liverpool Hospital and worked there for about three years prior to the COVID-19 period. She left work when her husband's job was relocated to Western Australia. They had lived there between 2018 and 2020. Over this period, she had worked at the Red Cross blood testing centre and then moved to the scientific team in a laboratory position.
4. After they returned to Sydney, she resumed full-time work at Liverpool Hospital as a haematology technician/hospital scientist. She had worked there for the next four years.
5. Following the subject accident, she had continued to work on a full-time basis, although she had some days off work on sick leave. When asked, she said these absences had related to insomnia, anxiety and also shortness of breath. However, she said she had been highly anxious over this period, as she was feeling quite pressured at work as they were encouraging her to take on a master's degree. She had reduced to part time hours around mid-2023 and was then working three days per week.
6. Ms Rexhepi said the family had decided to move back to Western Australia in early 2025. She said her husband was offered a transfer and they both decided they were better off getting out of Sydney and away from all the memories relating to her illness and the compensation case. She hasn't worked since they arrived in Western Australia as she is planning to take a year off work.

1. Ms Rexhepi said that over the years she had always been a healthy active woman.
2. The Panel noted that on 1 July 2022 the general practitioner (GP) had recorded a diagnosis of iron deficiency in the absence of any issues with menstruation or bowels, and also

vitamin D deficiency. Faecal occult blood testing was also negative. She had various other investigations done including full blood count, thyroid studies, B12, folate and MDA lipid glucose, C-reactive protein. 3. There were no abnormalities apart from the iron studies and vitamin D. At that stage she was prescribed Ferinject 500mg/10mL and had one injection. 4. On specific questioning she denied having used the oral contraceptive pill or any other hormone preparation. There was no history of any prior episodes of clotting, in particular prior DVT's or pulmonary embolic disease. 5. She thinks she may well have had COVID-19 in 2020, as she recalled some respiratory symptoms at the time, but she hadn't been very unwell. She couldn't recall having any positive testing for COVID-19. She had two Pfizer COVID-19 vaccines, the last a few years ago. 6. She denied any history of smoking or vaping. 7. There was no known history of any work exposures to airborne agents or other contaminants, and she said the lab was well ventilated and they always wore PPE. 8. Prior to the subject accident she was taking no regular medications.

1. Ms Rexhepi lives with her husband and three children, age 9, 12 and 14, in a detached dwelling in Western Australia. She said her husband helps with all chores including laundry and cooking, however this related to her musculoskeletal symptoms, rather than any current respiratory complaints.
2. She said she tries to keep active with regular walking and swimming at the local pool.

1. On 20 May 2022 she had been a front seat passenger in an LDV 7-seater 4 WD which her husband was driving. Their three children were in the back seat. They all had their seat belts fastened. Their car was stopped at traffic lights on Pennant Hills Road in the kerbside lane. It was then their car was hit on the right rear side by a Mazda sedan that had turned left from a side street without adequately judging the distance.
2. Police attended, but no ambulance arrived. They had driven the car back home.
3. She said she returned to work the following week, with no time off. But had later taken some a few sick days. She had later moved to part-time hours.
4. When asked about her overseas trip, she said they had gone to visit her husband's family in early August 2022. Her GP had recorded on 5 August 2022 that she was travelling overseas. Ms Rexhepi said that they had in fact travelled to Kosovo, rather than Albania, although Kosovo is also Albanian speaking. They were overseas for six weeks. They had stayed in the town, not on a farm or in a rural area.
5. She added that they had done a lot of outdoor activities. When asked about her flight, she said she travelled from Sydney to Bangkok, about eight to nine hours, then from Bangkok to Istanbul, about 10 hours, then from Istanbul to Pristina, Kosovo, about an hour. She said she had taken reasonable precautions, including wearing compression stockings on the flight and moving about the plane.
6. She said that in late 2022 her colleagues were commenting that she had a bit of a cough. She thinks at that stage she had a RAT test and PCR, but these were negative and at the time her husband and children were not suffering from any respiratory issues.
7. In April 2023, she said she had become very short of breath and unwell. It seems she had visited the GP, and as her oxygen saturations were reduced, so was referred urgently to Bankstown Hospital. There she was investigated before being discharged home.
8. She had taken a month off work as she was feeling so unwell.
9. She was also referred to a cardiologist in Bankstown and no abnormality was identified.
10. She was referred to respiratory physician, Dr David Freiberg. She had visited him on

"She has had episodes of shortness of breath that she has presented to hospital with. She has had a normal D-dimer and negative CTPA and a normal cardiac assessment. These episodes the most recent occurring two days ago are not associated with wheeze, cough, or chest pain. At the time of today's examination, she is asymptomatic. Her chest is clear to auscultation; Her enclosed detailed lung function tests are normal. However, her fraction of expired nitric oxide is elevated at 31 pp indicating an underlying asthmatic or eosinophilic inflammation which certainly points to the most likely cause of these episodes being asthma, I have therefore commenced her on Breo Ellipta 100/25 once daily. I reviewed her CTPA from 2 months ago which shows patchy areas of ground glass opacification which could possibly be due to asthmatic inflammation, but small vessel pulmonary emboli is a possibility. Occasionally these are present with a negative CTPA. I have arranged for a ventilation perfusion lung scan."

"I enclose this woman's ventilation perfusion lung scan which suggests multiple bilateral subsegmental small vessel pulmonary emboli contributing to her dyspnoea.

I have given her a screen for thrombogenic status although the most likely cause of her pulmonary emboli is the immobility from her back injury that she experienced from a motor vehicle accident last year, I have commenced her on Eliquis 10 mg b.d reducing in 1 week to 5 mg b.d and in 6 months time she will have a progress ventilation perfusion lung scan. She also continues on Breo Ellipta for the confirmed asthmatic component."

1. She said she sought a second opinion from Dr Penny Motum, a haematologist, a colleague of hers at Liverpool Hospital, and is continuing to have six monthly follow-ups with the doctor. Another consultation is planned toward the end of this year.
2. She said she has bloods performed prior to each visit. She said Dr Motum had given her a letter which had suggested immobility after the accident had caused the pulmonary embolus. When asked she thought she may have mentioned the flight, but she wasn't entirely sure.
3. She was also referred to breast screen and ultrasound.
4. She said that in late 2023, her GP had prescribed Endep and Cymbalta and she had taken these for about six months. This was because she was depressed due to the diagnosis of pulmonary embolism. She had also seen a psychologist at that time as there was also a lot of pressure at work.

1. Ms Rexhepi denied any current respiratory symptoms, in particular there was no shortness of breath, cough, chest pain or fevers and she reported normal exercise tolerance.
2. Her sleep is generally okay, but disturbed at times, she generally manages about six hours a night. Apart from feeling fatigued, there were no symptoms suggestive of sleep apnoea.
3. There was neck and low back pain and stiffness in both shoulders (she indicated trapezius and infrascapular regions).
4. She remains very anxious, in particular as she is worried as she understands she will need to remain on the Apixaban for an indefinite period, as there is uncertainty in relation to the cause of the pulmonary embolus.

1. Ms Rexhepi said that her regular GP is Dr Aruj in Bankstown. Her last visit was in January of this year, and she had a telehealth appointment in April 2025.
2. She takes apixaban 2.5mg twice a day and uses Breo Ellipta one inhalation per day. She also takes Maltofer for iron deficiency, but no longer takes vitamin D.

1. Ms Rexhepi had not brought any imaging studies with her for the assessment.

1. Ms Rexhepi was pleasant and cooperative, but quite anxious. She was 1.66cm tall and she weighed 58kg. She was right hand dominant. There were no peripheral signs suggestive of respiratory disease. There were no palpable neck nodes. There was no shortness of breath at rest and no cyanosis.
2. On examination of the chest there was normal expansion and no adventitious sounds on auscultation. Heart sounds were dual with no murmurs.

1. Ms Rexhepi is a 43-year-old woman who was involved in the subject accident on

20 May 2022. She hadn't required any immediate medical attention and there was no suggestion of any chest injury. There was no air bag deployment, and their car was driveable, so they headed back home. 2. She had visited her GP the following day but said this was mainly around concerns for her son, but she had mentioned some low back symptoms to the doctor at the time. The doctor noted (clinical notes 21 May 2022) the accident the preceding day and Ms Rexhepi's complaints of back pain and had prescribed paracetamol. She was reviewed again on

12 June 2022, and at that stage there was also neck pain. On 19 June and 30 June 2022, the GP records ongoing musculoskeletal symptoms and also conducts a general systems review, in particular recording that there was "no cough/CP/SOB/sweats/palpitation." On 1 July 2022 there is iron and vitamin D deficiency identified. 3. The last review prior to her travel is on 5 August 2022, when some routine travel advice is discussed. When asked about the lack of any mention of any respiratory symptoms

Ms Rexhepi responded that she thought she had mentioned it. However, there was clearly no mention of any respiratory complaint, and furthermore the GP had made specific enquiry regarding any such symptoms and recorded this in the negative. 4. She then embarks on a long-haul international flight, which is known risk factor for thromboembolic disease. It is not until the following year that she visits Dr David Freiberg, well over a year after the subject accident and he records a history of respiratory complaints since the subject accident and immobility due to her injuries. However, the contemporaneous notes from the GP do not indicate any such respiratory complaints and Ms Rexhepi had in fact resumed work after the subject accident, and whilst she may have had some limitations as a consequence of her musculoskeletal complaints, there was no immobility to the extent that the Panel could regard this as being a risk factor for the later diagnosis of pulmonary embolus. 5. The Panel does not consider that the CT SPECT scan is an investigation which arises from the injuries caused by the motor vehicle accident. Single-photon emission computed tomography (SPECT) is a nuclear imaging modality used to assess tissue perfusion and function, so is valuable in confirming a diagnosis of pulmonary embolus, even involving smaller emboli. 6. The Panel considers that the requirement for the CT SPECT scan does not relate to the injuries caused by the motor accident. Whilst, given the diagnosis, the scan is appropriate in the clinical context, it is not reasonable and necessary in the circumstances as it does not arise from any injuries caused by the motor vehicle accident.