WORKERS COMPENSATION - Workplace Injury Management and Workers Compensation Act 1998; review of Medical Assessment Certificate (MAC); psychological injury; appellant worker alleged assessment on the basis of incorrect criteria and demonstrable error in the making of assessments under one of the psychiatric impairment rating scale (PIRS) categories (travel) as well as error in applying a deduction under section 323 of two-tenths; Held - Appeal Panel found error in respect of the assessment of travel; Appeal Panel found error in the making of a deduction of two-tenths and found it should have been limited to one-tenth as the impairment from the pre-existing condition was too difficult to assess; MAC revoked.

1. On 21 November 2024 the worker [BTN] (the appellant), lodged an Application to Appeal Against the Decision of a Medical Assessor. The medical dispute was assessed by Dr Graham Blom, a Medical Assessor, who issued a Medical Assessment Certificate (MAC) on 25 October 2024.
2. The appellant relies on the following ground of appeal under s 327(3) of the Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act):
   • the assessment was made on the basis of incorrect criteria, and
   • the MAC contains a demonstrable error.
3. The delegate is satisfied that, on the face of the application, at least one ground of appeal has been made out. The Appeal Panel has conducted a review of the original medical assessment but limited to the grounds of appeal on which the appeal is made.
4. Rule 128 of the Personal Injury Commission Rules 2021 (the PIC Rules) and Procedural Direction PIC7 - Appeals, reviews, reconsiderations and correction of obvious errors in medical disputes set out the practice and procedure in relation to the medical appeal process under s 328 of the 1998 Act. An Appeal Panel determines its own procedures in accordance with r 128(1) of the PIC Rules.
5. The assessment of permanent impairment is conducted in accordance with the SIRA NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4th ed

1 March 2021 (the Guidelines) and the American Medical Association Guides to the Evaluation of Permanent Impairment, 5th ed (AMA 5).

1. The Appeal Panel conducted a preliminary review of the original medical assessment in the absence of the parties and in accordance with the Procedural Direction PIC7.
2. The appellant did not request that she undergo a re-examination. As a result of its preliminary review, the Appeal Panel determined that it was not necessary for the worker to undergo a further medical examination because although the Appeal Panel found error, there was sufficient material before the Appeal Panel to enable a determination to be made.

1. The Appeal Panel has before it all the documents that were sent to the Medical Assessor for the original medical assessment and has taken them into account in making this determination.

1. The parts of the medical certificate given by the Medical Assessor that are relevant to the appeal are set out, where relevant, in the body of this decision.

1. Both parties made written submissions. They are not repeated in full, but have been considered by the Appeal Panel.

1. The procedures on appeal are contained in s 328 of the 1998 Act. The appeal is to be by way of review of the original medical assessment but the review is limited to the grounds of appeal on which the appeal is made.
2. In Campbelltown City Council v Vegan [2006] NSWCA 284 the Court of Appeal held that the Appeal Panel is obliged to give reasons. Where there are disputes of fact it may be necessary to refer to evidence or other material on which findings are based, but the extent to which this is necessary will vary from case to case. Where more than one conclusion is open, it will be necessary to explain why one conclusion is preferred. On the other hand, the reasons need not be extensive or provide a detailed explanation of the criteria applied by the medical professionals in reaching a professional judgement.
3. The matter was referred to the Medical Assessor for assessment as follows:

"The following matters have been referred for assessment (s 319 of the 1998 Act):

• Date of injury: 5 November 2018 - deemed
• Body parts/systems referred: Psychiatric/Psychological disorder
• Method of assessment: Whole Person Impairment."

1. The Medical Assessor issued a MAC certifying as follows:

page and paragraph number in NSW workers compensation guidelines

Chapter, page, paragraph, figure and table numbers in AMA5 Guides

WPI deductions pursuant to S323 for pre-existing injury, condition or abnormality (expressed as a fraction)

Sub-total/s % WPI (after any deductions in column 6)

Total % WPI (the Combined Table values of all sub-totals)

1. The assessment was based on his assessment under the psychiatric impairment rating scale (PIRS) as required by the Guidelines as follows: (emphasis in original)

Multiple medications, intensive psychological treatment and multiple hospitalisations

She neglects her personal hygiene, in that she only showers about twice a week although isn't prompted to do this by her husband. She often remains in bed for extended periods during the day while her husband is at work and if she does get up tends to remain in her nightwear because she says it feels more comfortable. She tends to binge repetitively during the day, and this is often followed by self-induced vomiting. She is ashamed of her bingeing and vomiting and has kept this a secret from her husband. She only tends to eat nutritious meals irregularly, generally surviving on dense carbohydrate-based snacks. She doesn't cook - her husband cooks himself and occasionally she will have a meal he has cooked. Her husband does most of the cleaning and tidying around the house and is also responsible for the family food shopping.

Because of her withdrawal, avoidance and sense of shame about her situation she has lost contact with most of her friends and generally does not like to socialise at all, for example recently she missed her grandson's birthday party, even though she wished to go, because she felt overwhelmed and anxious at the thought of so many people being present. She has virtually no social life although has some interest in crocheting and also is actively engaged with [redacted]. She only occasionally goes out herself to collect injured animals but people frequently deliver them to her, and enjoys caring for them.

She is able to drive reasonably lengthy distances, for example over an hour to [redacted] however avoids this if possible because of anxiety. Nevertheless, her capacity is intact and lies within the normal range

She continues to have a reasonably close relationship with her husband, although it is strained and tense. There is no intimacy in the relationship nor has there been for some time, since the injury. There has been no violence nor has there been any separation. Her relationship with her children however is much more problematical. Whilst she is close to her only daughter, her two sons are resentful and angry about the impact of her illness. She has lost contact with her youngest son [redacted], not having spoken to him for about two years. She also only has limited contact with her son [redacted]. This is particularly distressing for her because she wishes to have a relationship with her grandson, but her son has blocked her from this because he feels that she is too impaired and unsafe to care for or be around an infant. She has lost contact with her friends.

1. Her concentration, focus and memory are all impaired. She said that she struggles to watch TV and is unable to read. Her memory is unreliable due to her frequent dissociative episodes and an incapacity to maintain a sense of continuity of her chronological experience. She also struggles to maintain focus. In my interview with her, which was very extended given the complexity of her history, lasting 140 minutes, whilst she was able to persist, she had significant difficulties in recalling chronological events and the times that significant events occurred. She said that previously she also used to do all the bills and accounts for the home but now she cannot focus sufficiently and her husband has had to take over these tasks.

She has not worked since her injury in late 2018. She is severely impacted by a range of serious psychiatric disorders which cause difficulties in managing her personal hygiene marked avoidance and withdrawal so that she avoids most social events and certainly any, where there are many people likely to be present. She suffers from severe anxiety and is repetitively suicidal. All of this would likely become much worse were she placed in a position of having to interact with others such as in a workplace, or the requirements of even irregular work.

There is a 20% deduction for her pre-existing impairment.

1. The Medical Assessor made a deduction of two-tenths under s 323 in respect of a pre-existing condition, abnormality or injury, leaving the total whole person impairment (WPI) assessed as a result of injury as 19%.
2. The worker appealed.
3. In summary, the appellant submitted that the Medical Assessor made assessments on the basis of incorrect criteria and/or made demonstrable errors in the assessments he made, as follows:

(a) in assessing Class 1 for travel when he should have assessed a mild impairment at Class 2, and

(b) in making a deduction of two-tenths under s 323 when he should have made no deduction.

1. In summary, the respondent employer, the Secretary, department of Education submitted that the Medical Assessor did not err or made an assessment on the basis of incorrect criteria and the MAC should be confirmed.
2. The role of the Medical Assessor is to conduct an independent assessment on the day of examination. The Medical Assessor is required to take a history, conduct a mental state examination, make a psychiatric diagnosis and have due regard to other evidence and other medical opinion that is before the Medical Assessor. The Medical Assessor must bring his clinical expertise to bear and exercise his clinical judgement when making an independent assessment of impairment under the PIRS categories. The assessment is not to be based upon self-report alone. An appeal panel cannot disturb ratings under the PIRS scale for mere difference of opinion but must be satisfied as to error.
3. The path of reasoning disclosed by the Medical Assessor must be adequate. This is also dependent on the extent of the history taken and a thorough examination of the worker so that self- report can be properly evaluated in the context of other evidence before the Medical Assessor.
4. The Medical Assessor took a history which he recorded as follows: (emphasis in original)

"Brief history of the incident/onset of symptoms and of subsequent related events, including treatment:

• [BTN] began teaching in [redacted]. In [redacted] she undertook a psychology degree and was subsequently appointed as a school counsellor in the [redacted] cluster of schools in [redacted]. She said that whilst she sometimes found her job as a counsellor difficult, and occasionally struggled with the degree of damage that the children had experienced, which often resulted in very disturbing behaviour, suicidal ideation and deliberate self-harm, nevertheless she found the work overall extremely enriching and rewarding. She said "I loved my job." She had occasional episodes of anxiety and stress but this appears to have been within the bounds of reasonable normality. In about 2015, she moved from the [redacted] cluster of schools to the [redacted] and continued there until she left school because of her work injury.

[redacted] As a result, not surprisingly there was a great deal of distress amongst both the staff and students at the school. As a result [BTN] was called on to counsel several students who were extremely distressed and also to counsel several of her teacher colleagues. She found this distressing and difficult, but at least initially felt that she was coping with the situation. However after about a week she noted that she began to feel down and increasingly overwhelmed. She became tearful and anxious and began having episodes of panic. Her symptoms became so severe that she attended her general practitioner and took time off work. As it was close to the end of the school year she did not return at all in 2018.

During the school vacation her symptoms of anxiety were complicated by a deterioration in her pre-existing eating disorder. She began to develop restrictive anorexic symptoms associated with significant anxiety and some panic. She was admitted to [redacted] clinic, a mental health unit in [redacted], and felt that she improved, however when her return to work in late January 2019 approached, she began to experience worsening panic attacks to the point that she felt unable to return to work. Around this time she also began to have nightmares, associated with markedly disturbed sleep as well as repetitive daytime rumination about the teacher who had disappeared but also about several of the students whom she had counselled who had been suicidal or who had self-harmed. With this increasing anxiety she again became focused on her weight and began exercising as an attempted to control her anxiety and mounting distress. She also became increasingly avoidant. Her husband is a [redacted] and normally they spoke frequently about work, but as her symptoms deteriorated [BTN] found it increasingly distressing and intolerable to be reminded of school in any way. Her running exercise previously had taken her past the school but now she avoided it because of its triggering effect. Along with the increasing exercise, anxiety and deteriorating depression she also began to again experience restrictive anorexic symptoms characterised by caloric restriction and an excessive focus on food and calories.

[BTN] had been consulting a psychiatrist and a psychologist prior to her injury (from about July 2018) and they continued to consult her. She was trialled on various antidepressants and other medication although she is unclear which, although according to the notes it appears she was taking the antidepressant fluoxetine as well as the sedative antipsychotic agent quetiapine. In late January 2019, she was again admitted to [redacted] Clinic for both her anorexia as well as for treatment of her quite severe anxiety. Between 2019 and late 2021 she did not improve despite intensive psychological treatment, ongoing psychiatric management and trials of multiple different drug combinations and several admissions to various hospitals.

In late 2020, or early 2021, her psychologist, Ms Suzie Luchette undertook a thorough review because of [BTN]'s failure to respond to significant evidence-based therapy. Eventually following considerable testing and review she made a diagnosis of dissociative identity disorder (DID). Subsequently she was referred to [redacted] Hospital in Brisbane. This is a hospital which specialises in the management of dissociative disorders. She was consulted and managed by Prof Middleton whilst there. Unfortunately, her admission did not assist her overall symptomatology or impairment and if anything she deteriorated. When I asked [BTN] to describe the experience of DID she described the experience of multiple "voices "in her head which she felt reflected different personalities within her, she also described significant disruption in her memory and loss of considerable periods of time which could not be explained by her other symptomatology. She was told by Ms Luchette that she had also witnessed [BTN] presenting at different sessions in ways that showed a remarkable variation in her apparent personality. I note that Prof Middleton supported this diagnosis, as did Dr Madden, her treating psychiatrist. As a result of this diagnosis Ms Luchette changed aspects of her psychological treatment, focusing particularly on dissociative treatments along with the standard DBT and CBT that she had been previously administering.

Despite all of this, not only was there no improvement in [BTN]'s symptoms and impairment if anything there was further deterioration. [BTN] felt, and I am inclined to agree that the restrictions around movement as a result of the Covid epidemic, added to her difficulties. This was further complicated by the fact that [BTN] was medically retired at the end of 2022. While realistically it is very highly unlikely that she could ever return to counselling, nevertheless this was an enormous blow to her self esteem and her hope for the future. Over the last 2 to 3 years she unquestionably has become increasingly more withdrawn and avoidant and as a result was also unable to exercise. This was of great import as exercising was the most effective method she had of managing her anxiety and coincidently assisted in her weight control. As she increasingly was unable to manage her weight her eating disorder morphed from weight loss to increasing episodes of bingeing and vomiting. This, as is commonly the case, was associated with substantial feelings of shame and even greater avoidance and anxiety. Whilst [BTN] had previously experienced some low mood, this had not been as substantial an issue as it became now. Her mood dropped markedly, she struggled with motivation and was increasingly fatigued and lacking in drive and energy. Furthermore, she began to experience increasing feelings of hopelessness and helplessness which culminated in ongoing and severe suicidal ideation. This was associated with multiple low-grade, and some quite significant suicide attempts. She has had multiple admissions to public hospitals following suicide attempts and has had several stays of multiple days in ICU because of the severity of her suicide attempts. Suicide attempts in her case usually consist of the ingestion of excess amounts of paracetamol. Unfortunately, this is complicated by the fact that she describes 'alter personalities' which she says drive her to suicide. Moreover on several occasions she believed that she had only ingested a small overdose of paracetamol but almost certainly had dissociated and in fact had taken a much larger overdose - she described a situation where she thought that she had taken about five tablets of paracetamol, that is 2.5 g when in fact in hospital they determined that the dose was in fact approximately 10 times that - i.e. 25 g, a potentially lethal dose.

Since the onset of her injury she has continued to have intensive, evidence-based and appropriate treatment although there has been little overall improvement. She said that she has trialled multiple different antidepressants - reviewing the notes it is clear that these are from virtually all classes, as well as a variety of antipsychotic agents, and a variety of sedative and other agents to manage various of her symptoms. She has had multiple admissions to private psychiatric facilities, she thought about 14, since her injury as well as multiple admissions to public facilities usually following overdoses. She consults her psychologist twice-weekly and has been doing this from about the time of her injury. Suffice to say that even though there has been only modest improvement, if any, she has reached maximum medical improvement and it is unlikely that she will experience substantial improvement in her level of impairment in the foreseeable future, whatever treatment she has.

• Present treatment: [BTN] consults her psychiatrist, Dr Sloan Madden, approximately once every month. He manages her medications and monitors her especially for suicidality. Her current medications are:

quetiapine - 150 mg XR and and 100 mg IR/night. (These are powerful sedative medications of the antipsychotic class).

prazosin - 4 mg/night (this is used to manage nightmares and associated anxiety).

Lisdexamphetamine (Vyvance) - 70 mg/morning. (This is being used to assist her bulimia).

Topirimate - 100 mg/night (this is also used for her bulimia, although she is uncertain of its effectiveness.)

She was previously trialled on a multitude of antidepressants but said that she has never found any that have been helpful and so has stopped them all. There is no plan to restart antidepressants.

[BTN] continues to have reasonably frequent admissions to Mental Health Units. Most recently she was admitted to [redacted], mental health unit (MHU) in August, 2024, for about three weeks. This was a planned admission following an admission to a [redacted] public hospital following an overdose. She spent several days in the public hospital receiving treatment for paracetamol overdose and was then transferred to the MHU only being discharged when a further admission to a private hospital had been organised.

She consults her psychologist , Ms Luchette twice weekly. Ms Luchette uses a variety of treatments based around management of dissociative disorder, DBT and CBT.

• Present symptoms: [BTN] has a wide variety of symptoms which I shall group into their diagnostic clusters, although understandably there is a considerable degree of overlap.

She continues to have active and severe chronic PTSD marked by nightmares most nights of the week, associated with substantially disturbed sleep. She said that she frequently wakes from nightmares in tears although on some occasions she is also very anxious. She has great difficulty returning to sleep and often is unable to, because of her fear of having further nightmares. This also makes initiating sleep difficult for her. She has daytime flashbacks and intrusive ruminations about the events that occurred at school. She is very easily triggered into panic for example by media reporting of abuse, violence or deliberate self-harm and suicidality, and this results in considerable anxiety even at home. She is avoidant and withdrawn as she becomes even more anxious if she leaves the house and is very fearful of being triggered particularly by seeing children or teachers or parents from her school, seeing the school or indeed any school. She is startled and triggered by loud noises. Generally she remains on edge and is hypervigilant.

Her mood now is persistently down, although she said that she has developed ways to try to 'cover this up' especially from her children as her symptomatology and impairment has caused considerable difficulties in her relationship with them. She describes generally feeling helpless, hopeless and despairing. She said that she struggles to do things because of low motivation, low energy and feelings of fatigue. only partly related to her disturbed sleep. She struggles to get out of bed each morning and very often spends much of the day in her nightgown, although she made a point that she had gotten dressed for this interview and had also had a shower - something that she said that she only occasionally manages. She struggles with focus, attention and memory all of which is made worse by her dissociative disorder.

She continues to struggle with her eating disorder which now presents primarily as bulimia complicated by regular and repetitive vomiting. She said that she tends to binge and vomit approximately six times/day. Because of her sense of shame and her anxiety about weight gain her diet otherwise is exceptionally poor. She tends to eat sugary calorie dense foods even when not bingeing, and only occasionally eats a proper meal. Her weight is currently approximately normal, or perhaps slightly high. She said her weight is 65 kg and her height has been measured at 1.58 m, giving a current BMI of 26.

She continues to experience regular dissociative episodes which includes altering into separate personalities. She is sometimes, but not always aware of switches into alternative personalities and describes regular periods where she is unable to account for her behaviour or describes periods of loss of time. This naturally seriously impacts her memory and her capacity to maintain persistence. As mentioned unfortunately her dissociation also complicates her active suicidality. It also generally disrupts any sense of continuity of her 'Self' which further exacerbates and complicates her symptom complex and her level of impairment.

• Details of any previous or subsequent accidents, injuries or condition: [BTN] has a complex and difficult psychological history. She was adopted by her parents at about the age of two weeks. From about the age of three years through to 9 years of age she was subjected to repetitive childhood sexual abuse by a priest who was a friend of her mother. This is documented in the brief of evidence and I only touched on this to confirm the basic outline with [BTN] as she remains very vulnerable to these memories.

She never disclosed the abuse at the time and so was never protected from it. She appears to have managed her way through this, presumably unconsciously, with a process of denial stating that she felt "it didn't affect me at all". In any case there is no evidence of any significant childhood symptomatology and [BTN] herself denied it. However during her late teens she did begin to develop some symptoms of disordered eating, in particular bingeing, reasonably regularly and very occasionally vomiting although this was not a substantial feature at this time. She said that the bingeing tend to occur when she felt overwhelmed. She did not feel that it got in the way of her life in any particular way, and she did not seek treatment.

During her 20s and into her 30s she said that she "ate a lot" and while she was a bit vague about this, my sense was this was associated with some preoccupation with food. She was moderately overweight but denied any other significant disordered eating. She denied symptoms of anxiety or depression during these years. She gave birth to her first child at the age of 26 and subsequently had two further children. She denied any history of postnatal depression and nor is there any evidence that she experienced any particular symptomatology during her children's early years.

In 2016 [BTN] had become increasingly concerned by her weight. She said that over the years her weight had increased, presumably because of her focus on eating, to 90 kg - a BMI of over 36 and well into the obese range. She began exercising in an increasingly obsessional way, and also restricted her calories to the point that she lost 30 kg in weight total, over a period of about 12 months. She emphasised that this was 'intentiona' and did not reflect disordered eating. Comment - this is a very substantial amount of weight loss within a relatively brief period of time and had she consulted a psychiatrist, I suspect one might have been concerned about the possibility of an eating disorder especially given [BTN]'s history of trauma and some previous disordered eating.

This situation was unfortunately severely complicated when in [redacted] she travelled to the [redacted] and whilst there was sexually assaulted on at least two occasions by her tour guide. Following this she her eating began to "get out of control". She began increasingly exercising and her thinking was markedly focused on weight, calories and eating. She was diagnosed with anorexia nervosa and consulted a psychologist and a dietician. Despite this treatment her symptoms did not significantly improved and as 2018 progressed, that is before the injury at work, she began to lose substantial amounts of weight and her eating deteriorated to the point where she was admitted to hospital, [redacted] clinic, eating disorders unit. She had two admissions to the hospital within a relatively short time between June and August 2018. The second admission was necessitated because following her discharge from the first admission she was engaged in an outpatient program and was found to be losing weight whilst on the program. It was noted at the time of her second admission although [BTN] denied memory of this, that not only was her weight low but that she also was experiencing a degree of mood disturbance - transient euphoria was noticed when she lost weight and significant drops in mood occurred when she gained weight.

While [BTN]'s DID was not diagnosed until 2021, she acknowledged that in hindsight she had long-standing symptomatology reflective of dissociative disorder. Comment dissociative identity disorder is frequently a long-standing condition and often diagnosed late. She said that at least from her adolescence she had regularly experienced 'voices arguing in my head' which were clearly not psychotic phenomena and appeared to reflect as she saw it different aspects of her personality. She also had many episodes of 'lost time' where she could not recall what she had done and had no memory of events for periods often lasting many hours. She emphasised however that this was as she saw it 'normal for me' and she assumed that it did not reflect any form of psychological disturbance_. Comment - it is likely that this reflects a significant degree of denial and disavowal, which had the positive impact of supporting her capacity to function through what one might consider concerning symptoms._

• General health: [BTN]'s general health is reasonably good. She currently does not take any medications beside those prescribed for her psychiatric symptomatology.

She was diagnosed with Systemic Lupus Erythematosus in the early 2000s but only had one episode and has had no further problems.

• Work history including previous work history if relevant: [BTN] was adopted as a baby. She denied any great difficulty in her relationship with her parents although I note that in the documentation and to some degree confirmed by [BTN] her relationship with her father is not close as he tends to be a distant and somewhat emotionally unavailable man. He is currently in his 90s now and unwell but she has little contact with him. She feels some guilt about this, not because she wishes to have a relationship with him but she feels responsible for his care. This seems to reflect a burden of guilt that appears to be intrinsic in [BTN]'s manner of functioning.

[BTN] left school in [redacted] and undertook a Bachelor of [redacted] Education as well as a teaching degree. She graduated and began teaching in [redacted] initially at [redacted], for about 12 years and then at a variety of schools such as [redacted]. In [redacted] she decided to undertake a psychology degree. She said that this was to some degree influenced by her mother's death. She did well in her degree, despite continuing to work full-time as a [redacted] teacher. From [redacted] she began working as a school counsellor initially at the [redacted] cluster of schools and subsequently at the [redacted] cluster of schools. She experienced her injury in October 2018 and left work in November 2018. She has not returned to any form of work since then.

• Social activities/ADL: [BTN] lives with her husband in their home at [redacted]. She neglects her personal hygiene, in that she only showers about twice a week although isn't prompted to do this by her husband. She often remains in bed for extended periods during the day while her husband is at work and if she does get up tends to remain in her nightwear because she says it feels more comfortable. She tends to binge repetitively during the day, and this is often followed by self-induced vomiting. She is ashamed of her bingeing and vomiting and has kept this a secret from her husband. She only tends to eat nutritious meals irregularly, generally surviving on dense carbohydrate-based snacks. She doesn't cook - her husband cooks for himself and occasionally she will have a meal he has cooked. Her husband does most of the cleaning and tidying around the house and is also responsible for the family food shopping.

She does not like to leave the house but does go to the shops reasonably regularly, alone, in order to get snack foods for bingeing. She is able to drive longer distances (outside the local area), although prefers not to. However, she has driven as far as [redacted] on several occasions. She has done this alone.

Because of her withdrawal, avoidance and sense of shame about her situation she has lost contact with most of her friends and generally does not like to socialise at all, for example recently she missed her grandson's birthday party, even though she wished to go, because she felt overwhelmed and anxious at the thought of so many people being present. She has virtually no social life although has some interest in crocheting and also is actively engaged with [redacted]. She only occasionally goes out herself to collect injured animals, but people frequently deliver them to her and she enjoys caring for them although this, somewhat like her eating can become somewhat obsessive and out of control. For example, she told me that currently she had [redacted] that she was caring for and that this was becoming somewhat problematical.

She continues to have a reasonably close relationship with her husband, although it is strained and tense. It is complicated by the fact that she is aware that she lies to him about her bingeing and feels great shame about this. There is some distance certainly in the relationship in that she has been able to keep secret not only her bingeing but her poor hygiene. Nevertheless, there has been no violence, nor is there been any separation. Her relationship with her children however is much more problematical. Whilst she is close to her only daughter her two sons are resentful and angry about the impact of her illness. She has lost contact with her youngest son [redacted], not having spoken to him for about two years. She also only has limited contact with her son [redacted]. This is particularly distressing for her because she wishes to have a relationship with her grandson, but her son has blocked her from this because he feels that she is too impaired and unsafe to care for or be around an infant. She has lost contact with her friends.

Her concentration, focus and memory are all impaired. She said that she struggles to watch TV and is unable to read. Her memory is unreliable due to her frequent dissociative episodes and an incapacity to maintain a sense of continuity of her chronological experience. She also struggles to maintain focus. In my interview with her, which was very extended given the complexity of her history, lasting 140 minutes, whilst she was able to persist, she had significant difficulties in recalling chronological events and the times that significant events occurred. She said that previously she also used to do all the bills and accounts for the home but now she cannot focus sufficiently, and her husband has had to take over these tasks.

She has not worked since her injury in late 2018. She is severely impacted by a range of serious psychiatric disorders which cause difficulties in managing her personal hygiene marked avoidance and withdrawal so that she avoids most social events and certainly any, where there are many people likely to be present. She suffers from severe anxiety and is repetitively suicidal. All of this would likely become much worse were she placed in a position of having to interact with others such as in a workplace, or the requirements of even irregular work. She is unable to work now or in the foreseeable future."

1. The Appeal Panel is satisfied that an adequately detailed history was taken, which is broadly consistent with the other evidence before the Medical Assessor. Medical Assessors have to obtain a focussed history and undertake a mental state assessment within a finite appointment time.
2. The Medical Assessor recorded his findings on mental state examination as follows:

"[BTN] was seen via a teleconferencing application. She managed the application with no difficulties. The quality of the streaming was quite good, and I had no difficulty in undertaking my review.

[BTN] appeared as a woman who was older than her stated age. She appeared tired, worn and somewhat haggard. She was slightly unkempt, for example she had no makeup, and her hair was not done, although appeared to be neatly and cleanly dressed. She was a reasonably warm woman who engaged with the interview actively and presented as an honest witness. I did not feel that she was dissembling or attempting to prevaricate even at times when she had difficulty answering questions.

She had a reasonable range of affective responses and in particular, there was no flattening of her affect. She was repetitively tearful in the interview sometimes spontaneously and sometimes due to the nature of the material she was talking about. She expressed suicidal ideation on multiple occasions which was concerning particularly given her history of multiple suicide attempts. Unquestionably she remains a very high long-term risk of completed suicide. She however reassured me that at this time she would not act on her suicidal ideation because she was hoping that she could prove to her son that she was safe and responsible and therefore could have some contact with her grandson.

There was no evidence in this interview, that I could discern of her experiencing a dissociative episode nor did I believe that there was any alteration in her personality, such as the appearance of an 'alter personality'.

She was not psychotic and there was no evidence of delusions, hallucinations or formal thought disorder. The 'voices in her head' did not appear at all to be psychotic phenomena.

She had difficulties at times with focus and there were gaps in her memory. She nevertheless persisted through a long and somewhat arduous interview. She struggled with pace and concentration, however. All of this was consistent with her several diagnoses and did not appear to reflect organic disorder."

1. The Medical Assessor summarised the injury and diagnosis as follows:

[BTN] was confronted with a close colleague being removed from her school because of alleged sexual abuse of students. Subsequently she was engaged in counselling both students and staff. Some of the students expressed suicidal ideation and in her long history as a counsellor she had had to deal with many students who were suicidal or had inflicted deliberate self-harm upon themselves. Following this she began to experience anxiety which developed into clear-cut PTSD this was associated with a deterioration in her pre-existing atypical eating disorder (marked at times by caloric restriction and excessive exercise and at other times by bingeing). Furthermore, as treatment progressed, it became apparent that she was experiencing substantial dissociative phenomena which while these experiences had been pre-existing for some time, had never been formally diagnosed. All of the above was complicated by significant and deteriorating depression which is now chronic and associated with significant active suicidality.

She had a pre-existing eating disorder and a pre-existing dissociative disorder although the latter had never previously been diagnosed.

She currently meets the diagnostic criteria for the following disorders: -

1. PTSD - chronic.
2. Persistent Depressive disorder with ongoing Major Depressive disorder - severe.
3. Dissociative Identity Disorder.
4. Bulimia Nervosa. This is Her current diagnosis although in the past she clearly met the criteria for Anorexia Nervosa. Her eating disorder is and somewhat fluid in its presentation.

The diagnosis of PTSD is made because of the presence of exposure to a seriously disturbing and violent event, the likely suicide of a close colleague and suicidal ideation from several students which led to the development of substantial anxiety and panic associated with intrusive re-experiencing phenomena, avoidance of triggering stimuli overwhelmingly negative beliefs and cognitions about herself, marked hypervigilance and increase startle with unquestionable and significant impairment.

The diagnosis of PDD with ongoing MDD is made because of the present of persistently low mood with marked feelings of hopelessness, suicidal ideation and despair. This is associated with reduced motivation, drive and energy, disturbed appetite (although this is impacted by her eating disorder) impaired sleep and disturbed concentration and memory. The severity of her depression is such that it warrants a diagnosis separate to the mood disorder implicit within PTSD.

The diagnosis of DID is made because of the historical description of marked disruption of identity characterised by several, distinct personalities. This has been associated with significant trauma both as a child and subsequently as an adult. She has recurrent gaps in recall of everyday events. I should note that this diagnosis is made based on the documentation that I received. This is not a diagnosis that can be made in a cross-sectional single interview.

The diagnosis of bulimia nervosa is made because of the presence of binge eating, vomiting and significantly disturbed and disordered thought processes and beliefs around eating and weight. This occurs on the background of previous anorexia.

[BTN]'s presentation was consistent with the documentation that I reviewed, the history that I took and my clinical examination."

1. The Medical Assessor made an assessment of WPI in accordance with his assessment under the six PIRS categories as set out above.
2. When explaining his assessment of permanent impairment he gave detailed reasons about the contribution of the pre-existing psychological conditions suffered by the appellant as follows:

"My opinion and assessment of whole person impairment

A history of a traumatic series of events involving both, deliberate self-harm and likely suicide of a close colleague. As a result, the worker developed typical symptoms of PTSD complicated by an atypical eating disorder. Subsequently it became apparent that she had suffered from a dissociative identity disorder that likely had been long-standing but that had also been substantially exacerbated by her PTSD and associated trauma. As these conditions have become more chronic and associated with increasing levels of avoidance and withdrawal, resulting in loss of an ability to exercise the worker has become increasingly depressed and actively suicidal.

The degree of impairment has been increased significantly because of the pre-existing conditions of anorexia/atypical eating disorder as well as the pre-existing dissociative disorder.

In making that assessment I have taken account of the following matters:-

I have determined her whole person impairment at 22%. She has pre-existing diagnosed atypical eating disorder and undiagnosed dissociative identity disorder both of which have contributed significantly to her level of impairment. I have deducted 20%.

There is no evidence of any significant improvement considerable, evidence-based treatment. It is not clear that withdrawal of treatment would have any significant impact on her current impairment although it most likely would lead to a significant increase in the risk of completed suicide. Therefore, no addition for treatment effect is warranted.

Her final level of impairment is therefore 19% after rounding."

1. The Medical Assessor made brief comment on the other opinions as follows: (emphasis in original)

"My brief comments regarding the other medical opinions and findings submitted by the parties and, where applicable, the reasons why my opinion differs:

I have noted the extensive documentation relating to her multiple admissions to Mental Health Units, as well as the considerable number of letters from Dr Madden to [BTN]'s GP and reports and letters by her psychologist Ms Luchette. I have taken all of this into account and considered it in determining both the validity of her diagnoses, the existence of pre-existing disorder and its impact upon her permanent impairment.

The report of Dr Anthony Dinnen dated 20 February 2023. Dr Dinnen makes a diagnosis of complex PTSD with major depressive disorder and an Eating disorder with DID. I agree with this diagnosis which is conceptually the same as mine. Dr Dinnen rates [BTN] as having 24% WPI. I agree with all of his ratings except for that of travel where he rates [BTN] as having mild impairment and I rate her as having no impairment. She clearly stated that she is able to drive lengthy distances, for example to [redacted] if needed although she prefers not to. This nevertheless is within the normal range and should be rated class I. Dr Dinnen adds 3% for Treatment Effect. I am at a loss as to why he does this as he does not describe any significant overall improvement in her impairment and certainly [BTN], and indeed her treating psychologist acknowledge that there has only been marginal if any improvement in overall symptoms and impairment.

The report of Dr Anwar dated 20 April 2023. Dr Anwar makes a diagnosis of PTSD and anorexia nervosa with bulimia. He does not address the diagnosis of DID and indeed does not seem to have been aware of it - this could account for his failure to make any deduction for either the pre-existing, diagnosed Eating Disorder or for her DID. For the reasons I have outlined elsewhere in my report I think that this is an error, and a deduction is warranted. Dr Anwar rates [BTN]'s at 19% I have rated her level of self-care higher. Dr Anwar's descriptors are somewhat limited but given her impairment in both hygiene, nutrition and her ongoing risk of suicidality I believe that moderate impairment and class 3 is appropriate. Dr Anwar also rates her class 2 for travel. For the reasons that I have stated above, I believe class 1 is more appropriate.

The reports of Dr Martin Allan, dated 14 May 2019 and 6 May 2020. In his first report Dr Allan makes a diagnosis of PTSD with a pre-existing atypical eating disorder. At the time of his reports the diagnosis of DID had not been entertained. He addresses the need for further treatment but does not address the issue of WPI.

1. The Medical Assessor gave the following reasoning for making a deduction of two-tenths under s 323 as follows:

(a) Is any proportion of loss of efficient use or impairment or whole person impairment, due to a previous injury, pre-existing condition or abnormality? Yes

(b) If so, please indicate which body part/system is affected by the previous injury, pre-existing condition or abnormality. Psychological disorders - both a pre-existing eating disorder, primarily anorexia as well as a pre-existing although undiagnosed dissociative identity disorder. Neither of these were causing significant impairment at the time of the injury - in that [BTN] was able to continue her work and function as a wife and parent, however as a result of these pre-existing impairments, associated almost certainly with her childhood trauma and subsequent sexual abuse in 2016, her current impairment is considerably worse than it would otherwise have been were it not for these pre-existing conditions.

1. He reasoned further in respect of the pre-existing conditions and how they have contributed to the overall level of permanent impairment assessed as follows:

"DEDUCTION (IF ANY) FOR THE PROPORTION OF THE IMPAIRMENT THAT IS DUE TO PREVIOUS INJURY OR PRE-EXISTING CONDITION OR ABNORMALITY

1. DEDUCTION (IF ANY) FOR THE PROPORTION OF THE IMPAIRMENT THAT IS DUE TO PREVIOUS INJURY OR PRE-EXISTING CONDITION OR ABNORMALITY

(a) In my opinion the worker suffers from the following relevant previous injuries, pre-existing conditions or abnormalities:

1. Bulimia nervosa currently on a background of previous anorexia nervosa, albeit with atypical features.
2. Dissociative Identity Disorder, which had not been diagnosed prior to the injury but where there is sufficient evidence that the disorder was pre-existing, prior to the injury.

(b) The previous injury, pre-existing condition or abnormality directly contributes to the following matters that were taken into account when assessing the whole person impairment that results from the injury, being the matters taken into account in 10a, and in the following ways:

(i) [BTN]'s eating disorder contributes to impairment in her level of self-care, her social functioning and her social and recreational activities. It would impact on her capacity to be employed in any position.

(ii) Her DID impacts her CPP, her social and recreational activity and her social functioning. It also has impacts on her capacity for self-care. It would be significantly detrimental were she to attempt to return to any form of employment.

Whilst the extent of the deduction is difficult or costly to determine the available evidence is that the deductible proportion is large and a deduction of one tenth is at odds with the available evidence. In my opinion the deductible proportion is 2/10 for the following reasons:

In my opinion the deductible proportion is 2/10 for the following reasons:

Whilst she did not have substantially impairment from either of these disorders at the time of the injury, it is very clear that these pre-existing disorders have interacted with her later trauma experience to result in significantly greater impairment than would have occurred were it not for the pre-existing injury. As I have outlined above these have impacts on self-care, social and recreational activity, social functioning, CPP and employability. Nevertheless, she has significant PTSD which is directly and only caused by her injury and were it not for the injury and the PTSD it is likely that the other disorders would not have had the impact that they had had. In my clinical judgement I believe that a deduction of 20% is both appropriate and fair."

1. The extent of the deduction is complained about on appeal, the appellant submitting that should have been no deduction.
2. The Medical Assessor explained his reasons for assessment under each of the PIRS categories as set out in the table above. The appellant complains that the Medical Assessor has erred in respect of one out of the six categories assessed, namely Travel. The appellant submitted that the assessments should not have been of no deficit or Class 1 but rather a mild impairment at Class 2 should have been made based on correct criteria.
3. The MAC must be read as a whole. The Appeal Panel cannot interfere with these ratings absent error by the Medical Assessor. The Appeal Panel cannot interfere with the rating because opinions might differ as to the best fit in each category. There must be error or assessment on the basis of incorrect criteria.
4. In respect of Travel Table 11.3 of the Guides provides as follows:

Table 11.3: Psychiatric impairment rating scale - travel

No deficit, or minor deficit attributable to the normal variation in the general population: Can travel to new environments without supervision.

Mild impairment: can travel without support person, but only in a familiar area such as local shops, visiting a neighbour.

Moderate impairment: cannot travel away from own residence without support person. Problems may be due to excessive anxiety or cognitive impairment.

Severe impairment: finds it extremely uncomfortable to leave own residence even with trusted person.

Totally impaired: may require two or more persons to supervise when travelling.

1. The Medical Assessor assessed no deficit Class 1 with the following reasoning:

"She is able to drive reasonably lengthy distances, for example over an hour to [redacted] however avoids this if possible because of anxiety. Nevertheless, her capacity is intact and lies within the normal range."

1. The appellant submitted that a Class 2 or mild impairment should have been assessed.
2. The respondent submitted that there was no error.
3. The Appeal Panel considers that an error has been made. There is no history either taken by the Medical Assessor or in the other reports in evidence that the appellant is able to travel to new environments. When she is travelling to [redacted] to see her son she suffers anxiety and tries to avoid it if possible but as it is a familiar environment she is able to complete the trip if it cant be avoided. On assessment on the basis of correct criteria her impairment is the domain of travel is a mild impairment or Class 2.
4. This means the calculations become as follows:

1. The appellant complained on appeal that about the deduction made by the Medical Assessor under s 323 of two-tenths and submitted that no deduction should have been made because on the Medical Assessor's own findings the pre-existing conditions were not causing impairment at the time of injury, noting he found that she suffered from "both a pre-existing eating disorder, primarily anorexia as well as a pre-existing although undiagnosed dissociative identity disorder" but that:

"Neither of these were causing significant impairment at the time of the injury - in that [BTN] was able to continue her work and function as a wife and parent..."

1. The respondent submitted that no error was made in making the deduction of two-tenths.
2. A deduction can only be made if the pre-existing condition abnormality or injury has contributed to the overall level of permanent impairment assessed. If the deduction is too difficult or costly to determine, the deduction should be one-tenth if that is not inconsistent with the available evidence.
3. The Appeal Panel considers that there has been an error made by the Medical Assessor in assessing a deduction of two-tenths. The Medical assessor has considered that a deduction would be too difficult or costly to assess but has not made a deduction of one-tenth because he has considered that at odds with the available evidence. However the Panel notes the recent case of Matheson v Baptistcare NSW & ACT [2025] NSWSC213 (18 March 2025) directing a Medical Assessor to paragraph 11.10 of the Guidelines.
4. Paragraph 11.10 of the Guidelines provides as follows:

11.10 To measure the impairment caused by a work-related injury or incident, the psychiatrist must measure the proportion of WPI due to a pre-existing condition. Pre-existing impairment is calculated using the same method for calculating current impairment level. The assessing psychiatrist uses all available information to rate the injured worker's pre-injury level of functioning in each of the areas of function. The percentage impairment is calculated using the aggregate score and median class score using the conversion table below. The injured worker's current level of WPI% is then assessed, and the pre-existing WPI% is subtracted from their current level, to obtain the percentage of permanent impairment directly attributable to the work-related injury. If the percentage of pre-existing impairment cannot be assessed, the deduction is 1/10th of the assessed WPI."

1. The Appeal Panel notes that the Medical Assessor determined that the pre-existing condition was not causing impairment at the time of injury, however the Medical Assessor recorded two admissions in 2018 arising from the appellant's pre-existing eating disorder indicating that the appellant must have had some impairment in aspects of self-care over those months, and presumably was unable to work as a teacher whilst an inpatient, that continues and is in part attributable solely to that pre-existing condition. These admissions over 2018 make the accurate ascertainment of a pre-existing WPI as required by paragraph 11.10 impossible. Accordingly, as per paragraph 11.10 "the percentage of pre-existing impairment cannot be assessed", and the deduction should therefore have been limited to one-tenth.
2. This means that the calculations become 24% WPI less one-tenth equal 21.6 % or 22% after rounding.
3. For these reasons, the Appeal Panel has determined that the MAC issued on

25 October 2024 should be revoked and a new MAC issued. The new certificate is attached to this statement of reasons.

This Certificate is issued pursuant to s 328(5) of the Workplace Injury Management and Workers Compensation Act 1998.

The Appeal Pane revokes the Medical Assessment Certificate of Medical Assessor Graham Blom and issues this new Medical Assessment Certificate as to the matters set out in the table below:

page and paragraph number in NSW workers compensation guidelines

Chapter, page, paragraph, figure and table numbers in AMA5 Guides

WPI deductions pursuant to S323 for pre-existing injury, condition or abnormality (expressed as a fraction)

Sub-total/s % WPI (after any deductions in column 6)

Total % WPI (the Combined Table values of all sub-totals)

The above assessment is made in accordance with the SIRA NSW Guidelines for the Evaluation of Permanent Impairment for injuries received after 1 January 2002.