Certificate issued under Division 7.5 of the Motor Accident Injuries Act 2017

1. The Review Panel revokes the certificate of Medical Assessor Geoffrey Stubbs dated

26 July 2024 and issues a new certificate as follows:

(a) the Review Panel certifies the followng injuries were caused by the motor accident:

(a) pelvis - comminuted fractures to right side of pelvis requiring operative fixation with right sacroiliac joint screw and external fixation, and subsequent removal of external fixation;

(b) hip - minimally displaced comminuted fracture of the right superior pubic ramus extending into the acetabulum and right hip joint;

(c) lumbar spine - lumbosacral spine -soft tissue injury, and

(d) sacrum/coccyx - right sacrum soft tissue injury, and

(b) the Review Panel finds that the above injuries result in a whole person impairment of 20%.

Certificate issued under Division 7.5 of the Motor Accident Injuries Act 2017

The Review Panel combines the following assessments:

1. Certificate of the Review Panel dated 11 December 2025:

(a) the degree of permanent impairment in relation to the following injuries caused by the motor accident is 20%:

(i) pelvis - comminuted fractures to right side of pelvis requiring operative fixation with right sacroiliac joint screw and external fixation, and subsequent removal of external fixation;

(ii) hip - minimally displaced comminuted fracture of the right superior pubic ramus extending into the acetabulum and right hip joint;

(iii) lumbar spine - lumbosacral spine -soft tissue injury, and

(iv) sacrum/coccyx - right sacrum soft tissue injury.

1. Certificate of Medical Assessor Edward Korbel dated 6 March 2025:

(a) the degree of permanent impairment in relation to the following injuries caused by the motor accident is 8%,

(i) urinary tract including bladder-urinary incontinence. Pseudomonas UTI, moderate rectocele, mild cystocele, significant detrusor overacting and decreased bladder capacity, hypotension secondary to dehydration;

(ii) bladder-urinary incontinence. Pseudomonas UTI, moderate rectocele, mild cystocele, significant detrusor overacting and decreased bladder capacity, and

(iii) body-scarring.

1. Certificate of Medical Assessor Geoffrey (Paul) Curtin dated 28 February 2025:

(a) the degree of permanent impairment in relation to the following injury caused by the motor accident is 1%,

(i) body-scarring.

1. Certificate of Medical Assessor Nigel Ackroyd dated 25 August 2024:

(a) the degree of permanent impairment in relation to the following injury caused by the motor accident is 0%,

(i) transient hypotension.

1. Certificate of Medical Assessor Philip Truskett dated 25 June 2024:

(a) the following injuries caused by the motor accident have resolved:

(i) abdomen - soft tissue injury, contusions, abrasions, injury and pain to the hypogastric region of the abdomen.

1. Using the Combined Values Chart at page 322 of the American Medical Association Guides to the Evaluation of Permanent Impairment, fourth edition, the combined permanent impairment is 27% and IS GREATER than 10%.

1. Michelle Annette Doyle (the claimant) was involved in a motor accident on 25 May 2021. She was then an 80-year-old pedestrian that was knocked over by a reversing truck with a trailer. The truck then moved the trailer over her up to three times.
2. As a result of the motor accident, the claimant suffered multiple injuries to her body including fractures to her right pelvis requiring surgery.
3. The claimant made a claim for personal injury benefits with Insurance Australia Limited t/as NRMA (the insurer), the third-party insurer of the vehicle that she says caused the accident.
4. A medical dispute arose about whether the degree of the claimant's whole person impairment (WPI) is greater than 10% WPI. If there is a dispute about the degree of a claimant's WPI, damages for non-economic loss[1] cannot be awarded and disputes must be referred to a Medical Assessor/s for determination.
5. Due to the nature of the claimant's injuries, the medical dispute was referred to multiple Medical Assessors whose assessments were captured in a combined certificate issued by Lead Medical Assessor Edward Korbel. The combined certificate found that the claimant's injuries caused by the motor accident gave rise to a permanent impairment of 9% which was not greater than 10%.
6. The present proceedings relate to the medical assessment of Medical Assessor Geoffrey Stubbs dated 26 July 2024. The Medical Assessor found the injuries referred to him for medical assessment had all resolved and therefore did not provide an assessment of the degree of permanent impairment.
7. The claimant lodged an application with the Personal Injury Commission (Commission) seeking a review of Medical Assessor Stubbs' assessment.
8. On 7 May 2025, a delegate of the President (Ms Melinda Drew) accepted the application for review and referred the matter to this Review Panel (the Panel) to conduct the Review proceedings.

1. Medical Assessor Stubbs was referred multiple injuries for assessment including contusion type injuries to her bilateral arms, elbows, hands, feet and left ankle.
2. Of more significance to the referral for permanent impairment assessment were the following injuries:

(a) pelvis - multiple fractures to right side of pelvis. Superior and inferior pubic rami fracture to the right side of the pelvis. Open book pelvic fracture requiring operative fixation with right sacroiliac joint screw and external fixation, and subsequent removal of external fixation. Pelvic fracture requiring open reduction and open fixation surgery. Peripheral neuropathy. Extraperitoneal haematoma. Bony injury, nerve injury musculoskeletal injury, soft tissue injury. Complex comminuted pelvic fractures involving right ilium, pubic rami right hip and right sacroiliac joints;

(b) hip - right hip - bony injury, multiple fractures, musculoskeletal injury, soft tissue injury, nerve injury, contusions, abrasions;

(c) lumbar spine - lumbosacral spine - musculoskeletal injury, soft tissue injury, disc injury, radiculopathy, nerve injury, and

(d) sacrum/coccyx - right sacrum fracture, bony injury, musculoskeletal injury, soft tissue injury, disc injury.[2]

1. Medical Assessor Stubbs documented that the claimant had a past history of right hip and abductor muscle/tendon rupture which was treated conservatively eight years ago. There was also some osteoarthritis of the left hip. She was, however, fully independent in personal care and could drive, walk long distances and do the housework.
2. The Medical Assessor diagnosed the claimant with an open book pelvic injury on the right side when she was run over by a double axel box trailer. The pelvic fractures were assessed as fractures that are healed without displacement and without residual signs at 0% WPI. The Medical Assessor concluded that the accident-related injuries had all resolved.

1. The claimant says she had a right total hip replacement due to the extensive damage sustained in the subject accident.
2. The claimant also says there is residual impairment arising from the multiple fractures to the claimant's pelvis, including the hardware fixed into her sacroiliac joint.

1. The insurer submits that the Medical Assessor was correct to find no impairment to the injuries caused by the motor accident.
2. Specifically, the insurer says the claimant had not provided any report regarding the right total hip replacement including when and why it was undertaken for the purposes of the Commission assessment. The insurer says the medical evidence present at the time of lodgement of the claimant's application for Commission assessment (7 May 2024) did not verify that the claimant had undergone a right total hip replacement and that it was due to the motor accident. The insurer refers to other reports on file that suggest the right total hip replacement actually occurred in August 2024.

1. At its preliminary conference on 11 July 2025, the Panel advised the parties of its preliminary view that the contusion type / soft tissue injuries to the following injuries would have resolved since the motor accident and would attract nil % WPI. These were:

(a) arm - left arm - musculoskeletal injury, soft tissue injury, contusion;

(b) elbow - left elbow - musculoskeletal injury, soft tissue injury, contusions;

(c) arm - right arm - musculoskeletal injury, muscle wasting, soft tissue injury, contusion;

(d) elbow - right elbow - musculoskeletal injury, soft tissue injury, contusions;

(e) hand - left hand - soft tissue injury, contusions, abrasions;

(f) hand - right hand - soft tissue injury, contusions, abrasions;

(g) right leg - musculoskeletal injury, soft tissue injury, nerve injury, contusions. right femur - musculoskeletal injury, soft tissue injury, contusions;

(h) right foot - musculoskeletal injury, soft tissue injury, nerve injury, contusions. right hindfoot - musculoskeletal injury, soft tissue injury, nerve injury, contusions;

(i) left ankle - musculoskeletal injury, soft tissue injury, contusions, and

(j) left foot - musculoskeletal injury, soft tissue injury, nerve injury, contusions.

"subject to submissions, the Panel intends to narrow its assessment to the real issues in dispute which concern the following claimed injuries:

(a) pelvis - multiple fractures to right side of pelvis. Superior and inferior pubic rami fracture to the right side of the pelvis. Open book pelvic fracture requiring operative fixation with right sacroiliac joint screw and external fixation, and subsequent removal of external fixation. Pelvic fracture requiring open reduction and open fixation surgery. Peripheral neuropathy. Extraperitoneal haematoma. Bony injury, nerve injury musculoskeletal injury, soft tissue injury. Complex comminuted pelvic fractures involving right ilium, pubic rami right hip and right sacroiliac joints;

(b) hip - right hip - bony injury, multiple fractures, musculoskeletal injury, soft tissue injury, nerve injury, contusions, abrasions;

(c) lumbar spine - lumbosacral spine - musculoskeletal injury, soft tissue injury, disc injury, radiculopathy, nerve injury, and

(d) sacrum/coccyx - right sacrum fracture, bony injury, musculoskeletal injury, soft tissue injury, disc injury."

1. The Panel notes that neither party made any objection to the above course proposed.
2. The Panel also advised that the claimant would be re-examined by Panel Medical Assessor Margaret Gibson and that it would occur on 15 August 2025.

1. The Panel issued a direction for the parties to provide the following:

(i) any pre-accident reports of Dr Richard Boyle or any other treating surgeon;

(ii) any pre-accident imaging of the right hip, and

(iii) general practitioner (GP) notes or other orthopaedic reports one year before the subject motor accident of 25 May 2021.

1. Following the re-examination, the Panel reconvened at a teleconference on 12 September 2025. The Panel referred to its directions issued on 15 July 2025 and noted that no further documentation with respect to the pre-accident GP's notes, surgeons' reports or imaging of the right hip had been received.
2. The Panel noted the specific wording of the referral of the right hip injury did not include any mention of a right total hip replacement, which took place at Royal Prince Alfred Hospital by

Dr Richard Boyle on 14 August 2024. As the initial application for medical assessment (dated 7 May 2024) was lodged before the right total hip replacement operation, the parties' understanding of the dispute may not extend to its inclusion for medical assessment. 3. The Panel was cognisant of the Mandoukos v Allianz Australia Insurance Limited [2023] NSWSC 1023[3] where Chen J states,

"it is not, in my view, the function of the medical assessor to somehow divine a case, particularly of the kind that is covered by this court, and it is certainly not for this Court [...] to 'ferret around and construct a claim'[4] where none has been made."

1. Given the claimant is elderly (born 1940) and that the right hip was an injury referred for medical assessment, the Panel felt that inviting submissions to address causation of the now expanded injury description to include the right total hip replacement, which took place just three months after the application for medical assessment, was consistent with the objects of the Act, namely in facilitating the quick, cost effective and just resolution of disputes[5] and is appropriate in the circumstances.

Parties' submissions on right total hip replacement

1. The insurer refers again to the original application for medical assessment (dated

7 May 2024) which made no reference to the claimant's intension for impending right total hip replacement. Or that the need for such an operation was due to the effects of the motor accident. The insurer also refers to the claimant's statement dated 24 May 2024 which was also silent on the issue. 2. The insurer refers to recently obtained clinical records from Dr Rachael Cordina. Specifically, a report dated 1 February 2024 that was addressed to Dr Amar Ahmed. The insurer says this report referred to the claimant's past history which included mild polymyalgia rheumatica which had required several courses of steroids and osteoarthritis of the right hip. The insurer submits that Dr Cordina reported that the claimant "had been advised by Dr Ahmed to seek a surgical opinion on the need for a hip replacement". A referral to Dr Boyle was made for the procedure. 3. The insurer's position is that the right total hip replacement is not causally related to the motor accident. The insurer argues that the claimant knew of consideration was being made to undergo the surgery when she saw Dr Cordina in February 2024 but made no attempt to change the list of injuries which were the subject of the Commission assessment. 4. The insurer says the claimant did not approach the insurer to support payment of the right total hip replacement procedure. 5. The insurer further notes that Medical Assessor Stubbs was not provided with the report of Dr Richard Boyle dated 14 August 2024 which reported that the claimant underwent a right total hip replacement on 14 August 2024.

1. The claimant disputes the insurer's contention that she was required to include in her original application for medical assessment, "an exhaustive list of all treatment received or proposed to be received by the claimant for each listed injury under the 'Injury Description' column". The claimant says,

"the Commission M01 Medical Assessment form under the 'Injury Description' column states that you need only 'Describe location and type of injury'. References to treatment related to a pleaded injury such as, for example, physiotherapy, acupuncture, radiological scans, or surgery is not required to be listed."

1. The claimant notes the original application for medical assessment was lodged on

7 May 2024, several months before her right total hip replacement which occurred on

14 August 2024. 2. The claimant says the insurer's contention that additional documentation was not provided to Medical Assessor Stubbs is unfounded as such additional documentation was not in the claimant's possession at the time. The material is now provided to the Panel because the Panel has allowed for "all other documents" in its initial direction issued to the parties dated 13 May 2025. 3. The claimant clarifies that the correct date of the claimant's right total hip replacement surgery is 14 August 2024, as per the records and reports of Dr Richard Boyle. Any previous reference to the surgery occurring in December 2023 is incorrect. 4. The claimant says she did not approach the insurer for approval to pay for the right total hip replacement procedure because Dr Boyle was willing to perform the surgery at the Medicare rate with no out-of-pocket cost to the claimant. The claimant submits that by her not approaching the insurer is not determinative of causation for the surgery. 5. The claimant relies on a report of Dr Boyle dated 18 September 2025 where Dr Boyle confirmed that the right hip injury was caused by the motor accident of 25 May 2021. 6. The claimant notes Dr Boyle stating further:

"...the residual evidence remains including the DI screw. Preoperatively the hip was completely obliterated with degenerative (=post traumatic) arthritis.

One surmises that she suffered an impact injury, resulting in early degeneration of the joint, and thus required arthroplasty. Her left hip is not affected, and to my knowledge remains asymptomatic."

1. The claimant states that the records of Dr Rachael Cordina, the claimant's treating cardiologist, acknowledge the "early degeneration" of the claimant's right hip caused by the subject accident. Such records, it is submitted, do not refer to a complete obliteration of the right hip due to post-traumatic injury, namely the subject accident when the claimant was repeatedly run over by a heavy and large double axle trailer. The claimant attaches a photograph of such a trailer which was obtained from the liability expert report of Barringtons dated 19 July 2021, commissioned by the insurer.
2. Consistent with Dr Boyle's opinion, the claimant refers to the certificate of Medical Assessor Geoffrey (Paul) Curtin dated 28 February 2025 (who assessed the claimant's scarring). At paragraph 19 under causation and reasons, the Medical Assessor states:

"...The history given by Ms Doyle together with the documents supplied indicate that the motor vehicle accident did cause the referred injuries. As the pelvic fracture extended into the right acetabulum, it is possible that the injury was a contributing factor to the subsequent hip replacement surgery, and therefore the scar resulting from that surgery has been included in the assessment."

1. On 13 May 2025, the Panel issued a direction to the parties requiring indexed and paginated bundles of the information they relied upon. Both parties duly responded with the claimant's bundle comprising of pages 1-705 and the insurer's bundle comprising of pages 1-204.
2. The Panel has read the documentation relied upon by the parties. This includes the additional documents and submissions detailed above which were lodged pursuant to the Panel's further directions.
3. Below is a summary of the material that is relevant to the resolution of the permanent impairment dispute and the issues in dispute.

Claim documents, clinical records and treating reports

1. Ambulance report dated 25 May 2021 - "...pelvis initially pain free. Long bones intact. Pt with limited rom in lower limbs, but due for right thr soon. Pt helped to feet, reported increased pelvic pain on weightbearing with inability to move right leg. Initial assessment = hip pain. Secondary survey - right femur pain described as aching.

1. Discharge referral John Hunter Hospital - admitted 25 May 2021, discharged 14 July 2021. Run over by car trailer x 2 times. Injuries - L) hip pain + abrasions to bilateral hands. Underwent successful operative fixation on 27 May 2021 with right SIJ screw and pelvic external fixation - removed with no complications on 5 July 2021.
2. Discharge summary MetroRehab Hospital - transferred from John Hunter Hospital. Admitted 14 July 2021, discharged 3 August 2021. Run over by 4WD and trailer three times. Open book pelvic fracture requiring operative fixation on 27 May 2021 with right SIJ screw and external fixation. External fixation removed on 5 July 2021. Medical issues: hip pain, hip external fixator wounds: mild, superficial infection of wound on the left. Premorbidly independent.

Notes: 15 July 2021 = "ET poor, reportedly limited by (r) hip pain (which has resolved since #) + SOB." (ref Insurer 60 of 204).

1. Dr Richard Boyle, orthopaedic surgeon, patient registration form dated 28 May 2024 - Past surgery "torn tendons R hip 8 years ago". 14 August 2024 - right THR surgery.
2. X-ray Pelvis dated 25 May 2021 - Mildly displaced fractures of the right superior and inferior pubic rami. The right acetabulum may be involved. No dislocation.
3. X-ray Left Elbow dated 25 May 2021 - No acute fracture. Alignment is normal. No joint effusion.
4. CT Abdomen and Pelvis with IV contrast dated 25 May 2021 - Extraperitoneal haematoma in pelvic sidewalls bilaterally. This is more so on the left to the presence of ipsilateral right sacral ala, iliac, sacroiliac, acetabula, superior pubic ramus and inferior pubic ramus fractures.

Complex comminuted pelvic fractures involving the right ilium, superior and inferior pubic rami, right hip and right sacroiliac joints as described. There is high density free fluid in the pelvis, centred adjacent to the right superior pubic ramus fracture, in keeping with blood product / early haematoma.

1. CT Angio Chest, Abdomen and Upper Limbs dated 26 May 2021 - Clinical history: Trailer ran over pelvis 3x at low speed. R sacrum fracture + pubic rami fractures. Complex right pelvic fracture stable in position, involving right superior and inferior pubic rami, right ilium body extending to the joint, and involving both surfaces of the right sacroiliac joint.
2. X-ray Pelvis dated 28 May 2021 - referral notes: post op SIJ screw and pelvis fix. The internal and external fixateurs maintain alignment in anatomical position.
3. Police report dated 2 June 2021 - "trailer rear wheel reversed over the top of her abdomen hip area."
4. X-ray Pelvis dated 17 June 2021 - External fixator pins in the iliac bones and right SI joint internal fixation are unchanged in position. No complication seen. The right superior and inferior pubic rami fractures are unchanged in position.
5. Claimant's statement dated July 2021 - "trailer wheel ran over my hips and pelvis three times..."
6. Report of Jordan D'Ermilio, physiotherapist, Progressive Physiotherapy dated

6 August 2021 - physiotherapy to manage open book pelvic fracture open fix on 27 May 2021 and right SU screw and ex fix. Ex fix removed on 5 July 2021. Claimant reported slight right anterior hip pain although mostly general weakness. 7. Report of Dr Patrick, general surgeon, dated 23 October 2023 - diagnosed pelvic fractures, lumbosacral muscular guarding, right trochanteric bursitis and right hip flaring and left ankle motion and right hindfoot. WPI - lumbosacral spine 5%, right trochanteric bursitis 3%, right hip flared 95 degrees 2%, Right hindfoot 2%, Left ankle loss of ROM 6%. Total WPI = 17%. 8. Report of Dr Andrew Keller, occupational physician, dated 19 December 2023 - Diagnosed complex fracture of the pelvis that has healed in anatomical position after surgical fixation. Impairment: healed fracture without displacement, 0% WPI. Normal gait, no wasting of limbs. Full symmetrical range of motion in both hips. No assessable WPI. 9. X-ray right hip and pelvis dated 22 May 2024 - Previous fractures would appear to have united without significant residual deformity. There has been progression in the degenerative changes in the right hip. Some less marked degenerative changes in left hip. 10. Report of Dr Richard Boyle, orthopaedic surgeon, dated 28 May 2024 - recommendation right total hip replacement. 11. Right total hip replacement - performed by Dr Boyle on14 August 2024. 12. X-ray right hip dated 15 August 2024 - Comparison made to 17 June 2021. Post new hip arthroplasty with cemented femoral stem component. Acetabulum has two fixation screws superiorly. No periprosthetic fracture or hardware complication. Femoral head is concentrically positioned within the acetabular cup without dislocation. 13. X-ray pelvic girdle; x-ray right hip dated 24 September 2024 - six weeks post THR. Right-sided hip prosthesis in satisfactory position. No complication demonstrated.

1. The Panel determined that the claimant be re-examined by Medical Assessor Gibson. This occurred in-person on 15 August 2025 with a further telephone conference on

8 December 2025. The re-examination report is below:

"Ms Doyle attended and was accompanied for the initial part of the assessment by husband Richard and then by daughter Rebecca.

Ms Doyle had conservative treatment for a right hip abductor rupture 9 years ago. She said that at the time she was under the care of specialist, Dr Michael Walsh. She said there was no problems subsequently. She was unsure what if any imaging had been done at the time.

In relation to the left hip, she said there had been no imaging or any symptoms prior to the subject accident.

She has been diagnosed with hypertension and an aortic aneurysm. She said she was taking a number of medications prior to the accident, and has continued most of these.

There were no prior motor vehicle accidents and no significant injuries over the years.

Ms Doyle lives with her husband in a single-storey house in Cranebrook. They have four bedrooms, an office, and an ensuite and main bathroom. There are no steps.

She is independent in all activities of daily living. She has no problems dressing and undressing or donning or removing shoes and socks.

She said that they have a cleaner in on a fortnightly basis to clean the bathrooms and floors. She said she had received no commercial domestic assistance prior to the accident. On specific questioning she said that prior to the subject accident, at least one of her six daughters would come over and do some of the odd jobs around the house, such as cleaning the pantry and stove or hanging out washing. They would stay overnight on a weekly basis.

Ms Doyle said she has never driven a car. She said there are no buses near to home, however she does feel she would be able to get on and off a bus, as there are handrails and other supports. She prefers to travel by train, as she finds this easier.

Ms Doyle said she used to walk everywhere, but now she uses a walking stick at times, particularly in unfamiliar territory or over any distance. She can manage shorter distances without a stick, for instance if she walks to the end and back of their cul de sac, of about 12 houses or if she visits the local shops. She said that when she visits the supermarket she leans on a shopping trolley for support and then walks up and down the aisle for exercise. If she ventures into areas with uneven ground or where more walking would be required, she would need to use a stick. She is restricted in her walking tolerance with or without a stick and could manage a few blocks at most, but certainly not six blocks.

She can negotiate stairs, but will use the railing for support or a family member will assist.

If she is watching a 2-hour movie at home, she has to get up at times, she thinks she could manage about 1 ½ hours of sitting before she would have to get up. She finds she is quite stiff when rising if she sits doo long. She prefers to use a chair with arm rests on the side so she can support herself when getting to her feet, but she doesn't require special seating. She finds she has a "bit of a waddle" when walking.

Ms Doyle and her husband had been staying in in a cabin in a caravan park in Gloucester. Her husband had been playing veterans' golf. On the day of the accident, he had been out playing golf and so she had walked into the village centre to do some shopping.

She said she had been walking along the footpath. She was standing on the left side of a large telegraph pole and she had seen a truck with a long trailer enter a petrol station on her side of the road. The vehicle had then proceeded to back out of the petrol station towards the telegraph pole where she was standing.

She remembered being knocked out, and finding herself lying flat on the ground with her head on the footpath and her shoulders in the gutter. It was then that the driver's trailer ran over her lower abdomen and then reversed back, such that it rolled over her again. A bystander called out and the driver then parked the car. Police and ambulance arrived. Ms Doyle said at the time she had accidentally called her daughter and after that called her husband.

She was assessed by paramedics, placed in a pelvic binder and then transferred via ambulance to the helipad at Gloucester Hospital. She was then airlifted to John Hunter Hospital. She was hypotensive in accident and emergency. The trauma admission sheet recorded no other injuries, apart from the pelvic fracture, but the tertiary survey noted bruising left upper arm and right knee. CT Abdomen and Pelvis was reported as "Complex comminuted pelvic fractures involving the right ilium, superior and inferior pubic rami, right hip and right sacroiliac joints as described. There is high density free fluid in the pelvis, centred adjacent to the right superior public ramus fracture, in keeping with blood product /early haematoma. Likely focal haematoma in the right side of the pelvis." Imaging of left elbow and chest were unremarkable.

She was reviewed by a trauma surgeon and underwent surgery to reduce a fractured pelvis. She had worn an external fixator for 6 weeks for the pelvic fracture. She was eventually discharged on a walking frame after 7 weeks. She said the physiotherapist in the hospital had assisted her with mobility and had also provided some strategies to assist her to safely get in and out of a car.

The discharge summary from John Hunter Hospital was dated 25 May 2021 and noted she "was admitted under Professor Zsolt Balogh (orthopaedics) for a lateral compression pelvic ring injury after being run over by a low speed double axel trailer. She underwent successful operative fixation on 27/5/21 with a right SIJ screw and pelvic external fixation which was removed with no complications on the 5th of July." Issues listed were pelvic ring fractures, urinary incontinence, hypotension and urinary tract infection.

She was then admitted to MetroRehab in Petersham where she spent the next two weeks. There she was having physiotherapy three times a day and hydrotherapy daily. She was then on Canadian crutches on discharge. She said she used a walking stick for at least 14 months and still uses this at times. Once discharged from the rehab hospital, she had attended Progressive Physiotherapy in Penrith where she was having physiotherapy twice daily for 4-5 weeks, then daily. She has telehealth follow-ups with Dr Balogh, the trauma surgeon at John Hunter Hospital.

Two years ago, she had an aneurysm repair. She said that this had been an incidental finding on imaging and she had been under the care of Dr Rachael Cordina, who had been undertaking yearly follow-ups with MRI scans.

She had a right hip replacement in August 2024 at Royal Prince Alfred Hospital which was performed by Dr Richard Boyle. On clarification she said she hadn't visited the doctor before the subject accident, nor could she recall that any recommendation had been made that she have a right hip replacement prior to the subject accident. In particular she could not account for this being mentioned in the ambulance report. She said that ever since the subject accident there had been some right hip pain and as she became more mobile, and despite physiotherapy the pain just kept getting worse, such that her general practitioner referred her to Dr Boyle, who arranged for the surgery under Medicare.

On 19 June 2025, she had a gastroscopy/colonoscopy which identified Helicobacter pylori. She was commenced on therapy. The gastroscopy was repeated two weeks ago and she is still awaiting the results. The gastroenterologist is Dr Martin Grehan at Nepean Hospital, Penrith. She said she has also been diagnosed with peripheral neuropathy and has been prescribed B12 injections every three months and has been using them for some years.

There is pain in the right hip most of the time, which she categorised as being "slight - moderate". The pain increases significantly if she sits for long periods. Also, there is pain if she turns over in bed at night.

On specific questioning there were no other complaints.

Ms Doyle confirmed that all the referred injuries had resolved apart from there being ongoing symptoms in right hip and low back.

X-ray of right hip and pelvis performed 22 May 2024 and reported as "The right sacroiliac Joint is transfixed by a screw as demonstrated previously. Unchanged in position. There was no residual widening of the sacroiliac joints. No residual fracture line in this region. The fracture of the right inferior pubic ramus has united. The fracture of the lateral aspect of the right superior pubic ramus has united. There was no significant residual deformity. There are more advanced degenerative changes in the right hip. More marked narrowing of the joint space. More extensive cystic changes. Larger osteophytes are present. Some areas of ossification adjacent to the greater trochanter. Some chondrocalcinosis at the pubic symphysis. There is curvature in the lower lumbar spine convex to the left and there are marked degenerative changes with narrowing of the disc spaces and gas in the disc spaces and sclerosis and prominent osteophytes. Some less marked degenerative changes also appeared to be present in the left hip."

Plain x-ray pelvic girdle and right hip performed 24 September 2024 as "The right-sided hip prosthesis is in a satisfactory position. No complication was demonstrated."

Ms Doyle was 168cm tall and weighed 84kg. She was right hand dominant. She had a mild antalgic limp due to right hip joint pain.

On examination the neck, movements were ¾ normal in all planes. There was no asymmetry, muscle spasm or guarding.

On examination of the lower back, she was tender over the lower lumbar spine. Flexion and extension were to three-quarters normal. Lateral flexion was to three-quarters normal bilaterally with some complaints of catching when leaning to the right. Rotation was normal bilaterally. There was no asymmetry, muscle spasm or guarding.

On examination of the upper limbs, circumferential measurements were consistent with right hand dominance, 29cm at the arms measured 10cm proximal to the olecranon and right forearm measured 25cm, 10cm distal to the olecranon, left forearm measured 24cm 10cm distal to the olecranon. There was normal power, sensation and reflexes bilaterally.

On examination of both shoulders there was no deformity, swelling or scarring. There was no tenderness or impingement. Active shoulder movements were as follows:

Elbow and wrist movements were symmetrical and normal range bilaterally.

On examination of the lower limbs, thighs measured 47cm bilaterally, 10cm proximal to upper pole patella, maximal calf circumference was 39cm bilaterally. There was no significant leg length discrepancy. There were normal lower reflexes and power but some dysaesthesia below the knee in a non-dermatomal distribution.

There was 120° knee flexion bilaterally and full extension bilaterally. There was no crepitus or instability demonstrated.

On examination of the hips, there was no specific pelvic tenderness. Hip flexion 100 degrees on right, and 110 degrees on the left. Internal rotation 20 degrees on the right, 30 degrees on the left. External rotation 25 degrees on the right, 40 degrees on the left. Abduction 20 degrees on the right, 40 degrees on the left. Adduction 20 degrees on the right and 30 degrees on the left."

1. The assessment of the degree of permanent impairment is to be made in accordance with the Guidelines.[6]
2. Version 10 of the Guidelines applies to the Review. Part 6 deals with the assessment of permanent impairment.
3. The Guidelines were issued pursuant to Division 10.2 of the MAI Act and adopt the American Medical Association's Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides). The Guidelines are definitive with regard to the matters they address by where they are silent on an issue, the AMA 4 Guides should be followed.

1. It is necessary for the Panel to consider whether the accident caused or contributed to the claimant's physical injuries.
2. The provisions regarding causation of injury are contained in cls 6.5 to 6.7 of the Guidelines.
3. The provisions state:

"6.5 An assessment of the degree of permanent impairment is a medical assessment matter under clause 2(a) of Schedule 2 of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident. A determination as to whether the injured person's impairment is related to the accident in question is therefore implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA 4 Guides, as well as the common law principles that would be applied by a court (the Commission) in considering such issues.

6.6 Causation is defined in the Glossary at page 316 of the AMA 4 Guides as follows:

Causation means that a physical, chemical or biological factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following;

(a) the alleged factor could have caused or contributed to the worsening of the impairment, which is a medical determination, and

(b) the alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.

This therefore, involves a medical decision and a non-medical informed judgement.

6.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes."

1. Further, the provisions of the Civil Liability Act 2002 apply, in particular ss 5D and 5E.

1. The review of the medical assessment is not limited to a review of only that aspect of the assessment that is alleged to be incorrect and is to be by way of a new assessment of all the matters with which the medical assessment is concerned.[7]
2. The Panel should only consider the impairment as it is at the time of the Panel's assessment.[8]
3. The Panel may confirm the certificate of assessment or revoke that certificate and issue a new certificate as to the matters concerned.[9]
4. The Panel refers to the above re-examination report of Medical Assessor Gibson. The Panel reconvened on 12 September 2025 and discussed the re-examination report findings before collectively making the below determinations.

1. Ms Doyle is currently 85 years of age who was involved in the subject accident on 25 May 2021.
2. The Panel accepts that the mechanism of the injury, namely a heavy double axle box trailer running over the claimant's abdomen/hip area multiple times could have caused an injury to the right hip. Initial imaging taken at the hospital had, in particular revealed a minimally displaced comminuted fracture of the right superior pubic ramus extending into the acetabulum and right hip joint. Immediate attention concerned the open book pelvic fracture which required operative fixation (on 27 May 2021) with a right SIJ screw and external fixation.
3. The Panel were of the opinion that involvement of the right hip joint, as demonstrated on the early radiology, would have caused worsening and acceleration of the pre-existing degenerative changes and so later contributed to the requirement for surgery.
4. Following removal of the hardware on 5 July 2021, the claimant reported pain in her right hip. The Panel was of the view that since the pelvic fracture extended into the right acetabulum, it was more likely than not that the initial insult and the insertion and removal of the external fixation hardware rendered her symptomatic and accelerated the need for a right total hip replacement in December 2023. The Panel thus shares the views of the claimant's operating surgeon Dr Boyle and Medical Assessor Curtin.
5. The Panel considered the insurer's submissions in the original application, the review application and the further submissions pursuant to the Panel's direction. The Panel did not accept the insurer's view that because the claimant did not amend the list of injuries in the original application for assessment document that this should result in a finding that the right hip injury should not be assessed as it is at the time of the Panel re-examination,[10] which would include the impairment from the right total hip replacement surgery.
6. The submissions pointed to a past history of mild polymyalgia rheumatica and osteoarthritis of the right hip, however the Panel notes that the claimant was 80 years of age at the time of the accident and while some degenerative features are expected, they do not interrupt the flow of causation from the heavy impact injury described above and the subsequent operative procedures in close proximity to the right hip, the symptoms of which is the claimant's chief complaint as she presents to the Panel now.
7. The Panel accepts the claimant's history that she had not seen Dr Boyle before the subject accident. Even if the claimant was considering a total right hip replacement at the time she saw Dr Cordina in February 2024, there was no evidence to suggest she was definitely proceeding with the surgery at that time. The Panel notes that such surgery is not without risks, particularly at the claimant's advanced age, but may nevertheless be inevitable due to the claimant's increasing pain as a consequence of her right hip injury and following the repair of her pelvis.
8. The Panel also accepts that the claimant sustained an injury to the lumbar spine and sacrum/coccyx given the mechanism of the accident and the close proximity to the pelvis and hip.
9. The other injuries referred for assessment have resolved by the account of the claimant's history given at the Panel's re-examination.
10. In summary, the Panel was satisfied that the following injuries were caused by the motor accident:

(a) pelvis - comminuted fractures to right side of pelvis requiring operative fixation with right sacroiliac joint screw and external fixation, and subsequent removal of external fixation;

(b) hip - minimally displaced comminuted fracture of the right superior pubic ramus extending into the acetabulum and right hip joint;

(c) lumbar spine - lumbosacral spine -soft tissue injury, and

(d) sacrum/coccyx - right sacrum soft tissue injury.

1. The claimant's injuries have reached maximum medical improvement and stabilised for the purposes of permanent impairment evaluation.

1. In reference to Table 3.4 page 131 AMA4. Fractures that have healed without displacement and without residual signs attract 0% WPI.

1. Lumbar [Lumbosacral] spine there were complaints of pain or symptoms, but without vertebral body compression or vertebral fracture. There were no clinical findings as detailed in Table 6.8, SIRA Motor Accident Guidelines. Therefore the lumbar spine injury would be assessed at DRE Impairment Category I, thus 0% WPI,

1. The Panel notes clause 6.113 of the Guidelines which states:

6.113 The assessment of spinal impairment is made at the time the injured person is examined. If surgery has been performed, then the effect of the surgery, as well as the structural inclusions, must be taken into consideration when assessing impairment. Refer also to clause 6.20 in these Guidelines.

1. While cl 6.113 of the Guidelines refers to the assessment of spinal impairment, the Panel is of the view the clause can apply to other regions of the body, including the hip.
2. Hip arthroplasty in reference to Table 64, p 85 = 20% WPI. In reference to Table 65 (p87 AMA4) there was 71 points, which is a fair result. 30 points as there was slight to moderate pain. 20 points for function as there was slight limp (8 points). Cane for long walks (7 points), distance up to three blocks (5 points). 11 points for activities as she uses railing when climbing stairs (2 points), can put on shoes and socks (4 points), sitting any chair one hour (4 points), and able to use public transport (1 point). There were 5 points for deformity as no significant fixed deformity or leg length inequality and 5 points for range of motion.

1. The claimant's WPI as a result of accident-related injuries to her right pelvis, right hip, lumbar spine and sacrum/coccyx is 20%.
2. The Panel revokes the certificate of Medical Assessor Stubbs dated 26 July 2024.
3. A new certificate and combined certificate are issued at the front of these reasons.

[2] Also taken to be the injuries referred to the Panel for assessment.

[3] The Panel notes that the judgement of Chen J was affirmed by the Court of Appeal in Mandoukos v Allianz Australia Insurance Limited [2024] NSWCA 71.

[4] Using the words of Bromwich J in COE17 v Minister for immigration, Citizenship and Multicultural Affairs [2023] FCA 669 at [9].

[7] Section 7.26(6) of the Motor Accident Injuries Act 2017 (MAI Act).

[10] As directed in cl 6.21 of the Guidelines.