8 The appellant has suffered from a number of medical conditions. The details that follow are extracted from a number of the medical reports admitted into evidence.
9 The appellant had been under the care of Dr Asawa, a general practitioner, since 1990. Dr Asawa, in a report dated 18 August 1997, noted a history of "excessive alcohol intake over the years", a heart condition diagnosed in 1990 and a referral to Dr J Strum, a psychiatrist, in July 1992 for "obsessional symptoms and paranoid about his neighbour." Dr Asawa noted that the appellant was "found unsuitable for psychotherapy as he did not seem to verbalise a lot."
10 In June 1994, the appellant was admitted to St John of God Hospital to undertake a detoxification program by reason of his "alcohol abuse" and also to deal with "obsessional personality traits."
11 In 1996, he was diagnosed with diverticulitis and a benign polyp in his colon.
12 In 1997, he was diagnosed with a duodenal ulcer and Grade III ulcerative oesophagitis.
13 Dr Asawa last saw the appellant on 13 August 1997. He noted a history of complaints by the appellant that his health had suffered a lot in the last two years and that he could not cope with stress at work and the shift work. The appellant told Dr Asawa that "he felt very depressed, hated his work, is very short tempered, angry and paranoid, unable to sleep. He feels a lot of this has to do with his job in the police force and he has had enough of it…"
14 The appellant was examined by a number of medical practitioners, seemingly at the request of the New South Wales Police Service in connection with his application for medical discharge and at the request of the respondent to these proceedings in connection with his claim for superannuation benefits.
15 As at September 1997, Dr Janne Seletto, a police medical officer, noted that the appellant said that he felt "depressed, short tempered and angry and that he worried excessively. He has had disturbed sleep for years. He stated that he has lost patience with members of the community and especially with offenders. He felt that he may not be able to control his actions if he 'does his block'. He says that he 'hates' some of the people he sees on the street. He said that he feels he can no longer cope with the stress of the police environment…". A referral letter from Dr Owen Brookes, whom I assume to be a general practitioner, addressed to Dr George Foster of 3 May 2003 noted that the appellant had both an alcohol problem and depression, and had been under his care for two years. The letter continued:
"He has had these problems for 10 to 15 years. I believe that these problems may be related to his prior work as a police officer. During this time he experienced many traumatic situations in his experience. These include exposure to the deceased, witnessing a man shoot himself in the head, searching railways for human remains, a particularly gruesome hanging. While these are part and parcel of policing I believe that his service is the primary cause of these conditions and until we start to explore these issues he will not improve."
16 Dr Margaret Gillies, a gastroenterologist, examined the appellant on 19 March 2002 referred by the respondent. In assessing the appellant, Dr Gillies said:
"I have no doubt that his emotional state at the time of discharge was an absolute indication for him to be discharged from the Police Force, and that his experiences within the Force, aggravated his already slightly paranoid and depressive personality…. I am convinced that his personality disorder was aggravated by his 31 years experience in the Police Force and if he had been allowed to continue working, there was a danger he would damage either himself or others…"
17 Dr John Lawson, consultant physician, reported to the respondent on 16 January 1998. Under the heading "Recommendation", Dr Lawson said:
"Various medical reports which have been reviewed and summarised above indicate that this man has serious and dangerous problems associated with high alcohol intake. His physical and mental health is affected by this problem. He has physical difficulties and risks associated with continued full-time police work as well as being rendered medically unfit to continue the work because of his altered mental state related to depression and hostile or paranoid ideation. Whether these mental problems reflect the effects of alcohol related brain damage or are due to some form endogenous depressive illness is not explored in the report."
18 Dr Kumar, a consultant surgeon, treated the appellant for diverticulitis. In a report to the New South Wales Police Force dated 28 July 1997, Dr Kumar commented:
"In summary, he suffers from depression, as a result of which he has indulged in excessive alcohol intake to relieve his stress factors…"
19 In addition to these reports, there are a number of reports from psychiatrists. As the appellant's claim is based on his assertion that he is suffering from a particular condition, namely post traumatic stress disorder, it is necessary to have particular regard to the psychiatric evidence. Whilst a number of reports were tendered, which I shall shortly summarise, the oral psychiatric evidence in the proceedings was restricted to that of Drs Anderson and McGrath.
Post traumatic stress disorder
20 However, before discussing the psychiatric evidence, it is necessary that I set out what appears to be the accepted diagnostic criteria for diagnosing post traumatic stress disorder. These criteria are contained in a publication entitled "Diagnostic and Statistical Manual of Mental Disorders", published by the American Psychiatric Association. The current published edition is the fourth edition and the publication is known colloquially as "DSM-IV". I should add that in referring to this disorder, most of the medical practitioners used the term "post traumatic stress disorder" ("PTSD").
21 The diagnostic criteria for this disorder as contained in that manual (which became evidence in the proceedings) are as follows (at 427 - 429):
A The person has been exposed to a traumatic event in which both of the following were present:
1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criterion A1); (at p 424)
2) the person's response involved intense fear, helplessness, or horror.
B The traumatic event is persistently re-experienced in one (or more) of the following ways:
1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
2) recurrent distressing dreams of the event.
3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).
4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
2) efforts to avoid activities, places, or people that arouse recollections of the trauma
3) inability to recall an important aspect of the trauma
4) markedly diminished interest or participation in significant activities
5) feeling of detachment or estrangement from others
6) restricted range of affect (eg, unable to have loving feelings)
7) sense of a foreshortened future (eg, does not expect to have a career, marriage, children, or a normal life span)
D Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
1) difficulty falling or staying asleep
2) irritability or outbursts of anger
3) difficulty concentrating
4) hypervigilance
5) exaggerated startle response
E Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.
F The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor
The psychiatric evidence
22 The appellant was examined by four psychiatrists, two of whom gave oral evidence. I shall first deal with those reports that were admitted into evidence whose authors were not called to give oral evidence.
23 Dr Selwyn Smith examined the appellant on 11 December 2002, referred by the respondent. He had available to him a number of medical reports. The appellant told Dr Smith of some of the incidents (described as "distressing experiences") narrated by the appellant. Dr Smith said that "as a method of coping with his distress he reported that he began to consume alcohol in increasing quantities. He stated that he had not consumed alcohol prior to joining the Police Service."
24 During the course of his examination, Dr Smith was not able to detect any signs or symptoms of any psychiatric disorder. He noted, however, that the appellant complained of "episodic depression and irritability. At the time of my examination his affect of expression was blunted and flat…"
25 Dr Smith diagnosed "a mixed clinical picture" demonstrating chronic alcohol dependence. He thought that there was evidence of "a number of paranoid personality traits" including distrust and suspicion of others. Dr Smith was of the opinion that the appellant demonstrated evidence "of chronic dysthymia or depression secondary to his alcohol dependence. He displays episodic depression with a loss of self confidence and at times feelings of inadequacy…" He was of the opinion that the appellant's medical conditions "were causally connected to his incapability to perform police duties." He was of the opinion that the appellant was not fit at that stage to work as an operational police officer.
26 The appellant was examined by Dr Klaas Akkerman on 5 April 2005, having been referred by the New South Wales Police Legal Services. Dr Akkerman was specifically retained to give an opinion about whether the appellant's employment with the New South Wales Police Force "was a substantial contributing factor to the onset of the psychiatric injury" which he appears to have considered was "alcohol dependence, depression and paranoid personality traits."
27 In the history taken by Dr Akkerman, the appellant referred to three significant incidents which occurred during his time with the police force being the suicide of a person in front of him who had killed eight members of his family, a train accident where a woman had lost half of her brain and a suicide where the appellant's body had been sprayed with maggots which had covered the body of the deceased.
28 The appellant told Dr Akkerman of a number of symptoms including insomnia, lack of concentration, problems with short-term memory and energy levels, that he was irritable, tearful, "gets flashbacks nightly" and "gets nightmares occasionally."
29 Dr Akkerman diagnosed the appellant as suffering from alcohol abuse with secondary depression and said that his paranoid traits were part of his depression.
30 In terms of causation, Dr Akkerman noted that "the cause of his alcohol abuse is constitutional. I do not believe that it is associated with the police force. His employment is not a substantial contributing factor to the condition."
31 Dr Peter Anderson, consultant psychiatrist, was engaged to examine and give an opinion concerning the appellant by his solicitors initially in connection with the "hurt on duty" aspect of his claim against the New South Wales Police Service. Dr Anderson had access to a number of medical reports. He examined the appellant in May 2005 and saw him for a second time on 25 November 2005. Dr Anderson's reports were admitted into evidence.
32 When Dr Anderson first saw the appellant in May 2005, he elicited symptoms of waking during the evening, being disorientated about twice a week, flashbacks to motor accident scenes and other incidents, a feeling of distrust and concerns that the Police Service had not been supportive after he had been involved in traumatic incidents. The appellant told Dr Anderson that he was "not a drinker" when he joined the Police Service but that he rapidly became a drinker as a means of dealing with the emotional trauma which he experienced at work. Drinking became a regular pattern at the end of a morning or afternoon shift "as a way of escaping from reality."
33 The appellant told Dr Anderson of some of the significant traumatic events which had occurred during his time in the Police Service, details of which I have previously set out. The appellant also gave evidence of being irritable and was described by Dr Anderson as being "episodically depressed."
34 Dr Anderson concluded that in giving his history the appellant was "anxious and agitated, although not a person likely to admit to being so." He diagnosed the appellant as suffering from alcohol dependency but did not think that this was constitutional as found by Dr Akkerman. It was the opinion of Dr Anderson that the appellant's alcohol dependency was "secondary to his own attempts to use the alcohol as a treatment, a method of handling the disturbed emotional states with which he was visited as a result of his work." Dr Anderson regarded any signs of paranoia as a symptom of "a post traumatic state". He was of the opinion that the appellant was "hypervigilant, constantly scanning his environment for trouble or threats." Dr Anderson diagnosed the appellant as suffering from depression but disagreed that this was secondary to alcohol dependency.
35 Furthermore, Dr Anderson was strongly of the view that the appellant was suffering from a chronic post traumatic stress disorder as described in the DSM-IV, to which I have previously referred. Such diagnosis applied as at the date of the appellant's discharge from the Police Service.
36 In explaining his reasoning, Dr Anderson said, in his initial report:
"He has had more than his share of exposure to trauma, the threat of likely attack and death, the viewing of deceased bodies with all sorts of disfigurations, the viewing of actual shooting and suicide. He has reacted on his history in a disturbed manner to this and indeed has tried to treat himself with alcohol at the time. Subsequent symptoms which have developed in a gradual manner, difficult to specify from the non-chronological history available, but certainly now chronic, include the re-experiencing of the traumatic events in nightmares and in flashbacks and intrusive thinking. The symptoms include a state of high arousal, waking with a startle, being hyper-vigilant. The symptoms included at one time an avoidance of thoughts and feelings to do with his traumatic experiences, a wish not to talk about them, not to pursue them. Clinical picture continues to include an exacerbation of his difficult thoughts and feelings by reminders of the various traumatic scenes of accidents etc, and a wish to avoid same.
His symptoms have led to highly significant levels of impairment, both directly and through his secondary use of alcohol."
37 It followed that the PTSD, alcohol dependence and depression were caused, in the opinion of Dr Anderson, by the appellant's police service.
38 When re-examined in November 2005, the appellant presented to Dr Anderson with the same general symptoms. This led to a reinforcement of the opinion previously expressed by him.
39 The final report of Dr Anderson, dated 8 April 2008, traversed the symptoms that were indicative of the diagnosis of PTSD according to the DSM system of classification of psychiatric disorders. Dr Anderson repeated his opinion by reference to those symptoms that the appellant was indeed suffering from chronic PTSD which he thought was directly related to traumatic events experienced by the appellant whilst in the New South Wales Police Service.
40 In oral evidence, Dr Anderson emphasised that a psychiatric diagnosis principally, but not exclusively, depended upon the history taken by the examining doctor from the patient. If there was a failure to direct questions about certain matters or a reluctance on the part of the patient to deal with those matters, this could lead to the examining psychiatrist not receiving sufficient information or receiving incorrect information which would in turn lead to an incorrect diagnosis.
41 For example, Dr Anderson was asked about whether any innate defence mechanisms used by the appellant might mask the effect of any traumatic event. Dr Anderson said: "I would say that he wanted to avoid thinking about trauma and wanted to avoid introspection, he wanted to get on with his job as best as possible. The very avoidance of thinking about it is a symptom of post traumatic stress disorder but it leads to difficulty in obtaining a history." Furthermore, Dr Anderson believed that the effects of alcohol, which resulted in a masking of the appellant's symptoms, resulted in the other psychiatrists retained to give evidence in the proceedings overlooking the diagnosis of PTSD.
42 It was Dr Anderson's evidence that the diagnosis of PTSD was dependent upon an identification of "a constellation of symptoms which can be seen as clustering and therefore diagnosable." This would prevent a diagnosis of PTSD necessarily being possible following any particular traumatic event which occurred in 1969 or 1977. He said: "…the injury is seen as the effect on the brain of what had gone before…"
43 During the course of his evidence, I asked Dr Anderson a series of questions about the mechanism that applied so as to produce the aggregation of symptoms which, in a cluster, allow the diagnosis to be made. The following evidence was given:
"Q. Would I be wrong, in medical terms, in assuming though that each of these events, these psychologically traumatic events is in some way a trigger for what occurs? I mean, it has to by way of the definition I assume?
A. Yes, yes that is true.