MOTOR ACCIDENTS - Motor Accident Injuries Act 2017; review of medical assessment; threshold injuries; median nerve injury; prior scooter accident; injury to right shoulder; cervical spine injury; ongoing neck pain; variable pain distribution; right carpal tunnel syndrome; definition of non-threshold injury; cervical spine non-verifiable radiculopathy; carpal tunnel syndrome coincidental finding; Held - no evidence of direct injury to right hand/wrist; threshold injury; certificate revoked.

Issued under s.723(1) of the Motor Accident Injury Act 2017

1. The Panel revokes the certificate of Medical Assessor Robin Fitzsimons dated

25 March 2025. 2. The Panel determines that the injuries sustained by the claimant in the subject motor vehicle accident are threshold injuries.

1. Ronald Bell (the claimant) is a 51-year-old man who was injured in a motor vehicle accident on 2 September 2022. Following the accident the claimant lodged an Application for Personal Injury benefits and thereafter sought a concession from the insurer that his injuries ought to be considered non-threshold.
2. After conducting an internal review, the insurer declined to concede that the claimant had sustained a non-threshold injury and consequently the claimant lodged an Application for Assessment of Threshold Injury.
3. The claimant was assessed by Medical Assessor Robin Fitzsimons on 11 March 2025 and in a certificate dated 25 March 2025 the Medical Assessor certified that the claimant had sustained a non-threshold injury, specifically right arm and hand with numbness and tingling - median nerve injury.
4. The insurer sought a review of this certificate and, in a decision dated 25 March 2025, President's delegate Tajan Baba, decided that there was a reasonable cause to suspect that the medical assessment was incorrect in a material respect. The matter was then referred to this medical review panel.
5. The Review Panel (the Panel) has been constituted by the President of the Personal Injury Commission (Commission) to conduct the Review of Medical Assessor Robin Fitzsimons certificate dated 25 March 2025 (the Review).
6. Pursuant to cl 128(1) of the Personal Injury Commission Rules 2021 (the PIC Rules) the Panel 'is to conduct and determine the proceedings in accordance with procedures determined by the panel'.
7. 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 14A(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.
8. The new review provision provide that a review panel consists of two Medical Assessors and a Member assigned by the Motor Accidents Division of the Commission.
9. 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.
10. Rules 127 to 130 of the 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.
11. The review of the medical assessment is by way of a new assessment of all the matters with which the medical assessment is concerned.
12. The application made by the claimant on 17 October 2024 is for an application of assessment of threshold injury noting the bodily region of injury to be cervical spine, thoracic spine, right shoulder, right arm and a consequential and overuse injury to the left shoulder.
13. The claimant was examined by Medical Assessor Michael Couch on 26 August 2025 at the Commission's Medical Suites.

Pre-accident medical history and relevant personal details

1. The claimant said that he had mostly worked as a truck driver since 2014, previously having been a forklift driver with a transport company. He went on to explain that he had lost his licence for a while in 2020 for a drink-driving offence. He said that his father had recently died and he was at a party, became distressed after an argument, and drank too much. He had intended to stay but instead drove home. He struck a gutter and fell asleep in his car but was found and breath-tested while the keys were still in the ignition. Because of this, he had gone back to forklift operating for a while but had resumed truck driving in 2022/23. Since then, he had been driving semi-trailers both locally, regionally and interstate. He worked full-time, working eight to twelve hours per day.
2. He described a more minor motor vehicle accident in 2020. He was driving a car when it was side swiped on the passenger side near an intersection. His car was towed away and apparently written off, but he denied any injuries and no ambulance attended. His son's girlfriend picked him up and took him home and he had not subsequently attended to hospital or general practitioner (GP).
3. In April 2021 he was commuting to and from his work as a forklift operator using an electric scooter, because he had temporarily lost his driver's licence. Something became caught in the front brake, locking the front wheel and throwing him off. He was wearing a helmet. He said that he "hit my helmet and a lot of things". He recalled having some blood on his nose. No emergency services attended and he did not go to hospital or consult the hospital. He called an Uber to continue his journey.
4. He recalled being a bit sore for the next few days. He consulted his GP the next day, mainly complaining of painful ribs, and was apparently off work because of this for about four weeks. He then returned to his temporary job in a transport yard, which included operating a forklift, strapping-up loads on trailers and parking B-doubles in the yard.
5. When asked, he said that he had not suffered any injuries similar to those described in the subject accident before, commenting "like I said to the physio, I couldn't understand what was going on...". He confirmed that he had never previously experienced any upper limb symptoms. When asked about any previous neck symptoms, he described occasional minor discomfort from "lying in a wrong spot - nothing like this at all".
6. When younger, the claimant had played soccer, rugby league and baseball. He described no formal exercise recently, although he was going to a gym with his son up until the 2020 accident - he said he had not returned since then. He admitted that he was "a couch potato - I get into trouble for it!" However, he confirmed that prior to the subject accident he could perform all normal activities without restrictions.
7. Socially, he lives in his own home. He described himself as "single living under one roof - still living together - on and off". He went on to say that "he had changed since the accident" and become irritable. He had asked the insurance company not to phone him. He described frustration with the claims process.

1. The claimant said that on 2 September 2022 at about 12.30pm, he was driving to work in his 2012 Holden VE Commodore. He was proceeding along Woodville Road in Villawood at approximately 60 kmph, travelling in a southerly direction. He recalled that a McDonalds store was to the right. Traffic had built up ahead. He was in the outer lane. An Australia Post van pulled out from the left lane, pushing his car onto the median strip and almost into the oncoming traffic. He thought that the van had been going faster than him.
2. He was wearing a seatbelt but airbags did not activate. He recalled hitting his head on the driver's window and hitting his right shoulder, either on the window or the door pillar. He recalled that he did not get out of the car immediately and "just sat there". Two women from the offending van approached him and were apparently very vociferous and insulted him - he said that he had filmed this incident on his dashcam.
3. The claimant said that police did not attend the scene but came to see him at home later, watched the footage on his dashcam, and said that "they could see that she didn't look". His car remained driveable and he continued on to work. His car was repaired and he said it was off the road for quite a long time.
4. The clinical records from Dr Bin David Sun, GP of Medical and Fitness Centre, Kingswood, from April 2021 until May 2023 have been reviewed. On 21 April 2021, Dr Sun recalled the scooter accident, when he had apparently landed face first and was complaining of pain in the face, chest and elbows. Examination showed mild tenderness over the cervical spine, pain and tenderness over the lower anterior ribs, and bilateral elbow pain. There was a comment, "Imaging request printed to Kingswood Imaging...MRI cervical (had MVA last year in May, numbness and pain in R hand, x-ray cervical showed severe stenosis, for MRI further investigation)". He was certified fit to return to work five weeks later on 27 May 2021. At subsequent attendances, there was no further mention of symptoms related to the scooter accident.
5. On 12 July 2022 (two months before this accident), Dr Sun recorded "forklift accident on last Friday night, was travelling 15-20 kmh, head and shoulder hit steel frame of forklift, drives manual and difficulty changing gears, pain in L temporal head". Examination showed left temporal and paracervical tenderness, restricted neck movements due to pain, and difficulty elevating the left upper limb because of shoulder pain. Because he had had hit his head he was referred for CT scan of the head and neck and also X-ray and ultrasound of the left shoulder. The claimant returned three days later, describing improved shoulder symptoms, but the CT scan apparently showed a small cerebral aneurysm on the circle of Willis. He was referred to a specialist for this. Three weeks after the forklift incident on 1 August 2022,

Dr Sun certified him fit to return to pre-injury duties, and two weeks later he was said to be having no difficulty with these. 6. On the day of the accident, Dr Sun recorded "another car changed into his lane, crashed onto the passenger side of his car, happened in the morning, didn't notice pain until the afternoon, pain mostly over the lower back and lower thoracic...". On examination he recorded "inspection normal, normal neck movement, no midline tenderness along the spine, pain in paralumbar areas". He was referred for X-rays of the lumbar, thoracic and cervical spine. One week later on 9 September 2002, Dr Sun recorded "neck still really sore, one more week of rest and review, CT neck no fracture, back 50% better, review next week". Three weeks after the accident on 23 September 2002, Dr Sun recorded a Telehealth consultation: "patient happy to close case and go back to work on Monday, wants to finish off remaining physiotherapy sessions". 7. A Certificate of Capacity/Certificate of Fitness from Dr Sun, dated 16 September 2022, certified Mr Bell unfit for work for the following week because of neck and back pain. On

23 September 2022, he was certified fit for pre-injury duties, with a stated plan to close his case at next review. 8. The claimant said that soon after the accident he drove back to the home he had recently purchased on the Central Coast. He recalled that he eventually returned to work as a forklift operator after two to three months (this is inconsistent with Dr Sun's records), stating "my GP wanted me to go back on suitable duties...my boss and doctor agreed I should have a break every 10 minutes off the forklift". The Assessor discussed his work conditions further with

Mr Bell - he said that he did not have to look up to work on high racks/shelves, and that this particular workplace was very conscious of OHS issues. 9. A return to work and recovery assessment report from Sarah Hough, Exercise Physiologist and Rehabilitation Consultant of IOH, performed on 15 September 2022, diagnosed neck and back pain and mentioned medication, physiotherapy. She stated that he would benefit from counselling. One week later, a letter from John Ruzick physiotherapist to Dr Sun, stated that he had just assessed the claimant for the first time following his accident and he was reporting intermittent low back pain and neck pain, "both of which have improved greatly since the accident". He stated "I have diagnosed Ronald with a Grade 2b whiplash associated disorder (WAD) and non-specific low back pain (NSLBP) centred at L4. Both are recovering at the expected rate...". 10. Two months after the subject accident, Dr Sun conducted another Telehealth consultation and noted that the claimant had moved and would now find it easier to see any specialists in Newcastle. He noted that he needed referral "to see brain vascular surgeon and that it would be better for him to get a referral locally". In January 2023, at another Telehealth consultation, Dr Sun noted that the claimant had seen a Dr Tang and been referred to Gosford Hospital, who had advised him in fact to attend Royal North Shore Hospital (apparently in relation to the previously discovered cerebral aneurysm). 11. The claimant next attended Dr Sun in person on 24 February 2023:

"Came in today saying last day at workplace, will have new job on Monday, wants to reopen the previous Workcover case, happy to work to full pre-injury duties capacity at his new job, said has been seeing physiotherapy despite last claim closed and said the pain hasn't gone away, physio advised to get an MRI, given three weeks to do this, as he said it's hard to get in to do one".

He was referred for MRI of the cervical spine. Three weeks later Dr Sun recorded "ongoing neck pain despite conservative management, referred to neurosurgeon".

1. He in fact subsequently saw Dr Crimmins, neurologist, who considered that MRI scan showed definite right C4 nerve root compression. He arranged an epidural injection and

Mr Bell gave a convincing history of prolonged relief from this, with some recurrence in the months prior to the Panel re-examination. He coincidentally diagnosed right carpal tunnel syndrome, confirmed by his nerve conduction study, (see Dr Crimmins letter of 26 October 2023). 2. The claimant was asked further about his symptoms over the three years since the accident. He said that the main problem had continued to be pain in his neck and right upper limb. He said that he had had an epidural injection some two years earlier with benefit but thought that this had been wearing off for the past few months. He confirmed that he had returned to work as a semi-trailer truck driver, commenting "I push myself to work - I had an epidural to stop the pain - everything, the neck pain, tingling in my arm and numbness". 3. The claimant said that because his symptoms were gradually recurring, he would eventually see Dr Crimmins again but did not currently have an appointment. He continues to attend

Dr Sun at the Kingswood Medical Centre for any symptoms related to the subject accident, rather than a local GP on the Central Coast. (The records provided to the Panel from the medical centre in Kingswood were printed on 27 June 2023 and documented a last attendance with Dr Sun on 18 May 2023 - this was apparently to cease the alcohol interlock program on his car). Mr Bell thought that he might have seen Dr Sun during 2024.

Details of any relevant injuries or conditions sustained since the motor accident

1. The claimant denied any such injuries or conditions but added "but it (the subject accident) has given me really bad anxiety". He said that he had been attending a psychologist because of this. He said that now when driving, particularly in the truck, he gets very anxious about possible accidents and is very aware of how much damage his 35-tonne semi-trailer could do.

1. The claimant said this is the worst, and he has some soreness most of the time - he notices it every day, although it varies in severity. He pointed to the cervicothoracic junction in the midline, and also to the region of the right trapezius muscle.

1. The claimant described pain radiating from the cervical region to the extensor aspect of his right upper arm and the whole forearm, with tingling in all fingers - he clarified this, clearly pointing to all four fingers and the thumb. If he is driving, he intermittently rests his right upper limb and moves the limb and hand around to relieve symptoms. Although he is right-handed, he tends to rely on his left upper limb more. He described pain in the same area. When asked more about how the pain behaved, he replied "it's hard to explain - it has a mind of its own".

1. The claimant said he did not have pain in this area at present but had previously felt pain in this area since the accident.

1. The Medical Assessor asked the claimant if he had had any pain localised to the shoulder joint proper (rather than the radiating pain described above). He replied that he sometimes experienced this, but not currently. On further questioning he did not seem to localise pain specifically to the glenohumeral joint and pointed more to the right deltoid and upper arm - probably more consistent with radiating/radicular pain than specific shoulder joint pain.

1. The claimant recalled using some stronger analgesics earlier after the accident, particularly before the successful epidural injection. He said that he still had some prescription medication in reserve but now only takes Paracetamol if pain is worse.

1. The claimant said that he smokes a cigarette only when having a beer and will drink a six-pack of beer only at weekends, when not working.

1. The claimant presented as a stocky middle-aged man with short greying hair and a few days' stubble of beard. He had a lot of tattoos on his upper body and a ring in his left ear. Height was 173cm and weight 80kg.
2. He gave a clear history in a straightforward manner. He appeared to be of only average intelligence and was not particularly articulate - the Medical Assessor found that he needed to be patient to obtain a clear history, but the claimant was able to give this. There was no suggestion of exaggeration or dramatization of symptoms. He showed excellent effort during examination, with no evidence of abnormal pain behaviours, self-limitation or inconsistency. Consistent with his description of being "a couch potato", he did look somewhat deconditioned. He was able to sit during the interview and climb on and off the examination couch to lie supine. He removed a T-shirt for examination but kept tracksuit pants, sneakers and socks on.

1. Posture of the head and neck was within normal limits. On palpation he reported moderate tenderness at the cervico-thoracic junction in the midline and to the right of the midline. The right trapezius muscle was moderately tender but not significantly tense to palpation. Active range of movement (AROM) of the cervical spine was full and symmetrical in all directions. Spurling's provocation test for radicular symptoms was negative on both sides.
2. The findings were tenderness, and Mr Bell was clearly describing non-verifiable radicular complaints in the right upper limb. As can be seen below under "Upper Extremities" there were no objective physical signs of radiculopathy.

1. Posture of the thoracic spine both when standing and sitting was normal, and there was no tenderness reported to palpation. Spinal rotation (which mainly occurs in the thoracic spine) was tested with the claimant seated to stabilise the pelvis and was full and pain-free bilaterally. He was not reporting any non-verifiable radicular complaints in relation to the thoracic spine.

1. There were moderate callouses on the palms of both hands, consistent with his truck driving duties - he did say that he is not required to do any manual loading or unloading of trucks. The right (dominant side) upper arm measured 35 cm in circumference, the left 34, the right forearm 29 cm and the left 28. Biceps, triceps and brachioradialis reflexes were all slightly less brisk than average, but within normal limits and symmetrical.
2. While the Medical Assessor was examining power of the upper limbs, the claimant commented that earlier he had dropped things because of perceived weakness in the right upper limb, including dropping his dinner a few times after the accident, and not being able to pick up his young granddaughter. He indicated that this improved, but the right upper limb still felt somewhat weak.
3. On testing there was full and symmetrical power of flexion and extension in both elbows and wrists and normal grip strength bilaterally. There was no wasting of intrinsic muscles and power was normal and symmetrical. Power was normal around both shoulder girdles. Light touch sensation was preserved in both upper limbs, including all five fingers bilaterally. Pinprick was also preserved in all fingers bilaterally, although Mr Bell was slightly hesitant reporting pinprick on the right.
4. Because of the previous diagnosis of carpal tunnel syndrome, provocation tests were performed. Phalen's test bilaterally was negative but on Tinel's test (percussion over the median nerve at the wrist), Mr Bell said that he definitely had slight tingling in all the fingers of the right hand (this would be consistent with mild carpal tunnel syndrome, in the absence of detectable weakness). The Panel notes that at assessment in March 2025, Medical Assessor Fitzsimmons found some impaired sensation in the tips of the fingers of the right hand, a strongly positive Tinel's sign on the right, and a mildly positive Phalen's sign. (The Panel is aware that symptoms and signs of carpal tunnel syndrome can vary from time to time.)
5. Turning to the shoulders, there was no muscle wasting around either shoulder girdle. AROM of both shoulders was measured with a goniometer with repetition as tabulated - these were completely full apart from flexion being 170 degrees bilaterally, as opposed to a full 180 degrees. The examining Medical Assessor did not consider this to be clinically significant, particularly in a middle-aged man who appeared to be somewhat deconditioned.

1. There was no pain on any active shoulder movement. Power was full and symmetrical and impingement signs were negative. The examining Medical Assessor considered that both shoulders were clinically normal.

1. Knee jerks and ankle jerks were normal and symmetrical and gait and general mobility were normal.

1. CT cervical spine, 12 July 2022 (after striking head on forklift). This was reported: "There are mild degenerative changes at the uncovertebral C3/4. However, there is no high grade spinal canal stenosis or neural foraminal exit narrowing". No other abnormality was noted.

1. This was reported to be normal apart from a prominent 5 mm density in the region of the ACOM (anterior communicating artery), suspicious of an aneurysm. Assessment of the circle of Willis with CT angiogram was recommended.

1. This confirmed a small aneurysm of 3.4 mm diameter on the anterior communicating artery, suggestive of a fusiform aneurysm.
2. Imaging following the subject accident included:

X-ray cervical spine, thoracic and lumbar spine, 5 September 2022

1. These were reported as normal apart from the anatomical variant of partial sacralisation of the L5 vertebra and mild degenerative disc disease at the L2 and L3/4 levels.

1. This confirmed sacralisation of the L5 vertebral, circumferential disc bulges at three levels without canal stenosis, and mild bilateral L2 and left L3 foraminal stenosis.

1. This was reported to show a mild to moderate broad-based right paracentral disc protrusion at C3/4 causing mild indentation of the thecal sac and right lateral recess, with normal appearance of the uncovertebral joints and facet joints. There was also a small, broad-based posterior disc bulge at C4/5 not causing significant central canal or neural exit foraminal stenosis, and also a small broad-based, left paracentral disc protrusion at C5/6, not causing central canal stenosis or foraminal stenosis.

"Conclusion: Osteo-discal protrusion C3/4 narrowing the AP diameter to the canal, as described. There is also narrowing of the right C4 neural exit. Close clinical correlation will assist. Comparison with previous CT scan of 9 September 2022 shows similar changes at C3/4 that are only found in retrospect, after reviewing the MRI examination."

1. The claimant presents as a generally healthy but not very physically active 51-year-old truck driver who was involved in a significant "side swipe" crash when a van hit the passenger side of his car, pushing it sideways onto the median strip, some three years prior to the Panel's re-examination. He described the onset on the same day of neck, right upper limb and back symptoms. He attended his usual GP the same day, apparently mainly complaining of lower back and lower thoracic back pain but returned mentioning that his neck was still sore one week later. He required about three weeks off his employment as a forklift operator.
2. There is a history of an electric scooter accident 18 months earlier. The most troublesome injury seemed to be to the chest wall/ribs and he was off work for about four weeks.
3. At that time his usual GP, Dr Sun, noted that there was a history of a motor vehicle accident in May 2020 with numbness and pain in the right hand and an X-ray showing severe foraminal stenosis in the cervical spine. The claimant mentioned the 2020 accident to the examining Medical Assessor but denied injuries, although he did say that his car was towed away and written off.
4. Dr Sun recorded neck pain after the scooter accident but there is no record of right upper limb radicular symptoms. There is no further history of musculoskeletal symptoms until the subject car accident in September 2022. Both Dr Sun and the treating physiotherapist described rapid improvement of back and neck symptoms during September 2022, such that Mr Bell was cleared to return to his pre-injury forklift duties three weeks later and subsequently resumed driving a truck when he regained his licence.
5. In 2023, he returned to Dr Sun with persistent neck and right upper limb symptoms. He subsequently saw Dr Crimmins, neurologist, who considered that MRI scan showed definite right C4 nerve root compression. He arranged an epidural injection and the claimant gave a convincing history of prolonged relief from this, with some recurrence in the months prior to the Panel's re-examination. He coincidentally diagnosed right carpal tunnel syndrome, confirmed by his nerve conduction study.
6. At the Panel's re-examination, the only findings in the cervical spine were tenderness, but the claimant was convincingly describing non-verifiable radicular complaints in the right upper limb. Examination showed no objective signs of radiculopathy but possible right carpal tunnel syndrome with minimal reported changed to pinprick sensation in the right fingers and positive Tinel's sign. The thoracic spine and both shoulders were clinically normal.
7. The claimant definitely had right upper limb symptoms immediately after the subject accident. However, these apparently resolved quite quickly, although they recurred the next year.

Dr Crimmins, neurologist, confidently considered that these related to C4 nerve root compression, although the description of symptoms at the Panel's re-examination was more distally. 8. The claimant has developed symptoms and some signs of right carpal tunnel syndrome, confirmed by nerve conduction studies since the accident, but a causal relationship is very uncertain. 9. The claimant did say that he had struck his right shoulder on the inside of the car. There had been no imaging of the right shoulder and clinically both shoulders are normal. 10. Section 1.6 of the MAI Act defines a non-threshold injury to be an injury to nerves or a complete or partial rupture of tendons, ligaments, menisci or cartilage. The Panel is satisfied that the injuries to the claimant's cervical spine, thoracic spine and right shoulder are soft tissue injuries and accordingly, pursuant to the definition in the legislation, constitute a threshold injury.

1. Of the injuries referred to the panel:
   • cervical spine injury - this was caused. The diagnosis is Whiplash-associated Disorder Grade II (WAD II). There are symptoms of non-verifiable radiculopathy. This is a threshold injury;
   • thoracic spine injury - this was caused and has fully resolved;
   • right shoulder - he reports striking it on the inside of the car. Injury may have been caused but has certainly fully resolved;
   • left shoulder - not caused. There is no evidence of such injury, and
   • "Arm-Upper limb-injury to the right arm and hand associated with numbness and tingling"- some of the right upper limb symptoms are part of injury 1 above (cervical spine). They are non-verifiable radicular complaints. They are not a separate injury.
2. In addition, when he was being assessed by Dr Crimmins (neurologist), nerve conduction study on 26 October 2023 showed right carpal tunnel syndrome. Medical Assessor Fitzsimons confirmed this diagnosis clinically in March 2025. The claimant still had some symptoms and signs of this at the Panel's re-examination.
3. Carpal tunnel is a very common condition in the general middle-aged population. Symptoms often wax and wane over time. In the claimant's case it was a coincidental finding by a neurologist more than one year after the accident. There is no evidence of a direct injury to the right hand/wrist or arm in the accident. It was NOT caused by the subject accident.

1. The Panel has determined that the Injuries caused by the motor accident are threshold injuries for the purposes of the Act.