1. The Medical Assessor issued a medical assessment certificate determining that the motor accident caused a post-traumatic stress disorder. The Medical Assessor noted that the claimant continued to take Lovan as well as Endep for sleep and Celebrex for pain.
2. The Medical Assessor assessed class 3 ratings for Social and Recreational Activities, Social functioning and Concentration. An allowance of 1% was made for the effects of treatment based on ongoing psychological treatment and taking an antidepressant.

1. The Panel requested and were provided with separate bundle of documents provided by the parties.

1. In June 2015 the claimant reported stress and anxiety symptoms, poor sleep and poor appetite due to the cessation of a relationship.[8] In July 2015 the general practitioner (GP) diagnosed the claimant as suffering from an adjustment disorder associated with the cessation of a relationship.[9]
2. In March 2016 the GP noted the claimant's history of bowel cancer, did not have a colostomy bag, but there was occasional incontinence at night.[10]
3. A CT scan dated 7 September 2016 showed no evidence of tumour recurrence of metastatic disease within the chest, abdomen or pelvis.[11] Further scans dated 5 March 2018 and

4 March 2019 showed evidence of previous bowel surgery but no other significant abnormality.[12]

1. The claimant attended her GP on 8 April 2019 complaining of a stiff neck and shoulders as well as right foot pain following the motor accident.[13]
2. A bone scan dated 23 April 2019 demonstrated recent fractures of the sternum and T1 vertebrae, multiple rib fractures, and mild arthropathy in the shoulders, knees, ankles and feet.[14]
3. Rosalind Dayman, psychologist, provided a report dated 18 July 2021.[15] There were 20 consultations from 19 June 2019 until 18 March 2021. The psychologist noted that the motor accident had a major impact on the claimant's lifestyle with the consequences that the claimant did not socialise, was reluctant to leave home and struggled to manage her usual household chores.
4. The psychologist noted that the claimant reported extremely severe depression, anxiety and stress which were in part due to severe financial stresses occurring since the motor accident, the uncertainty of her future in relation to capacity work, the restrictions of her lifestyle due to physical limitations and chronic pain.
5. On 29 April 2019 Dr Verma noted pain on movement and deep breathing. The bone scan showed recent fractures of the sternum, superior endplate of the T1 vertebrae and multiple rib fractures. Mild arthroplasty was noted in the shoulders and in various joints.[16]
6. The GP then noted that the claimant was "getting flashbacks, having driver anxiety" and was not able to sit in the car.[17]
7. A CT scan of the lumbar spine dated 14 May 2021 showed a small broad-based disc protrusion at L4/5 causing mild canal stenosis and at L5/S1 with no significant nerve root impingement.[18]
8. On 15 September 2021, Dr Tait, GP noted that the claimant had ongoing anxiety issues especially with driving, had returned to work part-time but was still limited by backaches to three days per week.[19] The GP noted a recent complaint of shooting left leg pain.
9. On 3 February 2022 the GP noted that the claimant was doing her best working reduced hours on Wednesday, Friday and Saturday but still had quite a lot of back pain towards the end of each day following work.[20] The GP noted that the "issues are pain with extended period standing at work or with any heavy lifting which is informed the current limits to work capacity at work" which were restricted to three days per week on non-consecutive days.[21] The GP noted that the claimant was still struggling with the mental side of the injury with extreme anxiety driving to appointments and to work.
10. On 3 May 2022 the GP noted the claimant had ongoing anxiety and depression with neck and back pain.[22]
11. On 30 June 2022 the GP noted various restrictions at work related to standing tolerance, sitting tolerance, lifting capacity and driving ability.[23]
12. On 10 October 2022 the GP reported that the claimant was feeling a bit anxious and was getting anxiety driving and getting to work. Sleep is interrupted and the claimant was taking medication to assist in sleep. Ongoing physical complaints included a sore neck and back pains.[24]
13. Ongoing complaints to the GP included "feeling drained", emotions thinking about the motor accident, poor sleep, poor concentration and physical complaints due to back and neck pain.[25]
14. The claimant suffered a work injury on 10 June 2023 when she was "taking jackets off shelf, lost balance and fell backwards on metal"[26] with complaints of pain to the left knee, ankle and left shoulder.
15. On 9 August 2023 the GP noted the recent MRI scan to the left knee and that movements caused knee pains. Sleep was disrupted due to knee pain and mood was low and the claimant was frustrated.[27]
16. On 11 October 2023 the GP noted the claimant still had pain in the left shoulder, was advised to see a shoulder specialist but was willing to commence work six hours per day, one day per week.[28]
17. Subsequent GP attendances refer to ongoing knee and shoulder pain.[29] By June 2024 the claimant was working three days per week on full hours but described her body as getting tired at the end of the week and was not able to sleep.[30]
18. On 4 July 2024 the claimant reported that the left shoulder still hurts, was in constant pain and was advised to undergo surgery.[31]
19. The claimant had consulted Renee Ferris, therapist on nine occasions since December 2022. Ms Ferris noted symptoms including agoraphobia, hypervigilance and the need to plan every variable for every outing which the claimant found immensely draining. The therapist opined that the claimant's condition was "best described as PTSD".[32]
20. A certificate of capacity in June 2022 restricted capacity to eight hours per day three days per week based on physical restrictions such as limited lifting capacity, sitting tolerance, standing tolerance and no repetitive bending or twisting.[33]
21. A certificate of capacity dated 11 May 2023 noted that the claimant felt exhausted and flat, sleep is not the best and mood was low. Depression, anxiety and stress were scored as extremely severe. The certificate also recorded physical restrictions as noted previously.[34]
22. Certificates of capacity from June 2023 to August 2024 referred to left knee and shoulder symptoms from the work injury with restricted capacity.[35]
23. An MRI scan dated 7 December 2023 showed a partial and full thickness tear of the insertional supraspinatus tendon.[36]
24. In a report dated 14 March 2024 Dr Kuo noted the moderate sized supraspinatus rotator cuff tear shown in the December 2023 MRI scan with ongoing symptoms despite physiotherapy and opined that the claimant would likely benefit from a rotator cuff repair.[37]
25. In a report dated 11 April 2024 Dr Kuo noted that the updated MRI scan of the left knee showed complete resolution of the stress reaction, there was good range of motion with some patellofemoral crepitus and that the claimant could return to activities without restriction.[38]
26. Dr Anita George, psychiatrist, provided a report dated 29 July 2024.[39] The doctor noted that the ongoing chronic pain appeared to be the main underlying contributor to sleep difficulties although post-traumatic stress disorder trauma related nightmares contributed to the sleep issue. The doctor noted that the chronic pain was significantly debilitating and had led to the current deteriorated quality-of-life.

1. Dr Richa Rastogi, psychiatrist, was qualified by the claimant's lawyers and provided a report dated 11 October 2021.[40] The doctor noted the claimant's work history both before and after the subject motor accident and the impact of COVID-19 to the claimant's employment.
2. Dr Rastogi noted that the claimant was diagnosed with rectal cancer in 2013 with no history of mood disorder or history of drug and alcohol abuse.
3. Having considered the claimant's history and the nature of the accident, Dr Rastogi diagnosed claimant with post-traumatic stress disorder caused by the motor accident.

"She has resumed work on suitable duties and has physical restrictions. She struggles going to work associated with driver concentration has been impacted as well with decreased ability to cope with stress and poor ability to multitask."

1. Dr Rastogi assessed permanent impairment at 14% assessing class 3 ratings for adaptation, concentration and social and recreational activities.
2. A vocational and functional assessment report dated 14 June 2022 noted ongoing physical symptoms and psychological sequalae which impacted on the claimant's social functioning (in a general sense), domestic activities and employability.
3. Dr Charles New, orthopaedic surgeon was qualified by the claimant's lawyers and provided a report dated 26 August 2021.[41] The doctor noted that normal sleep pattern was diminished, pain prevented sexual relations and seriously affected her social life and travelling by motor vehicle and public transport. Dr New described the physical examination as "unremarkable".
4. Dr Vickery, psychiatrist, was qualified by the insurer and provided a report dated

22 November 2021.[42] Dr Vickey noted that the claimant's history and presentation was consistent, there was no melancholic depression, paranoid delusions, ideation or formal thought disorder. 5. Dr Vickey noted that the claimant was working 24 hours rather than the usual 32 hours due to her pain perception. The doctor opined that the claimant suffered from post-traumatic stress disorder in partial remission and a generalised anxiety disorder with driving or being a passenger. 6. Dr Vickery recommended counselling with fine movement desensitisation and reprocessing and opined that there was reasonable prognosis for recovery. 7. A functional and capacity report was prepared by Dr Farag and Mr Raue dated 11 May 2023 (the VACC report).[43] The authors concluded that the claimant's performance was "affected by pain behaviour and self-limitation" and stated:[44]

"The inconsistency in Ms Shorrock's performance relates to the lack of a physical basis for the extensive level of self-limitation in the manual handling tests of this assessment. Her exaggerated self-limitation is support for the impact of behavioural factors on her presentation."

1. The authors concluded that the inability to upgrade hours was due to "issues of anxiety and her generalised psychological state".
2. A vocational assessment report dated 3 April 2023 commented on the claimant's skills as part of assessing the claimant's capacity.[45] It is necessary to refer to this report in some detail given the insurer's submission that the report was relevant to the assessment of the claimant's concentration, persistence and pace.
3. The vocational psychologist noted the following under the heading "Education":[46]

"Ms Shorrock said she is competent at everyday computer functions such as sending emails and documents and the like. She has ordered stock and is able to monitor when stock levels are down and identify other stores where excess stock might be available. She has had to organise rosters for staff. The actual sales processes in the store she works in now are programmed centrally for all stores so that the process of charging customers involves scanning items to calculate the cost of goods, and taking point-of-sale payments by credit or debit card. If cash is used then the store cash registers do the calculations of costs and change automatically. She said that since the car accident she has found she is slower to learn how to do things when there are changes in the computer systems used in the store, however."

1. Later in the report the author noted that the claimant has also worked as a Retail Store Manager and Retail Supervisor and listed activities relevant to that job description.[47] When read in the context of the employment history that work related to pre-accident duties.
2. Dr Anand was qualified by the insurer and provided a report dated 15 May 2023.[48] The doctor diagnosed that the claimant has a post-traumatic stress disorder noting the presence of nightmares, flashbacks, avoidance phenomena, hypervigilance, irritability and hyper-arousal.
3. Dr Anand opined that from a psychological perspective the claimant's future incapacity for work was restricted to her current part-time hours. The doctor found class 3 ratings for the psychiatric impairment rating scale (PIRS) categories of social and recreational activities and concentration. The other categories were rated as class 2.
4. Dr Anand assessed a treatment effect at 2% which resulted in overall assessable impairment at 9%.
5. Dr Anand provided a supplementary report dated 3 November 2023 which commented on the VACC report, and the opinion expressed by Dr Shatwell.[49] In response to the observations contained in the VACC report, Dr Anand stated:

"After my extensive examination, I identified that Ms Shorrock meets the DSM-5 criteria for post-traumatic stress disorder. I noted the current burden of the psychiatric symptomatology and the mental state on my assessment. After a comprehensive assessment, considering her medical history, the progression and the stability of her condition, the functional limitations and the limitations over an extended period, I was able to provide an accurate and holistic view of Ms Shorrock's disability.

I respectfully acknowledge the information that has been provided to me, however it does not cause me to change my assessment of the WPI."

1. Dr Anand otherwise confirmed that his assessment of the PIRS was with reference to the psychological injuries and not with respect to the functional incapacity arising from the physical injuries.

Claimant's submissions dated 14 November 2023[50]

1. These submissions opposed leave being granted to review the medical assessment certificate. The submissions provided little guidance on the Panel's function in determining a new assessment of all the matters with which the medical assessment is concerned.
2. The claimant noted the similar assessments of Medical Assessor Canaris, Dr Rastogi and

Dr Anand and the importance of the "third Class 3 assessment". It was submitted that Medical Assessor Canaris provided very detailed reasoning in relation to the PIRS categories. 3. The claimant noted that the further report of Dr Anand dated 2 November 2020 assisted the claimant's case when he opined that he did not find the further documentation provided by the insurer (the VCC report and the report of Dr Shatwell) as "an accurate and holistic view of Ms Shorrock's [psychiatric] disability". 4. The claimant otherwise referred to the medical assessment certificate in detail and submitted that there was no merit to the review.

Claimant's submissions dated 4 December 2024[51]

1. These submissions were in response to the insurer's further submissions dated

18 November 2024. 2. The claimant disputed the insurer's contention that the claimant's mental health had been substantially affected by the workplace injury on 10 June 2023. It was noted that the insurer's description of the mechanism of the injury was incorrect in that claimant sustained injury to the left knee and left shoulder as a result of that fall. 3. The claimant submitted that the entries in the various certificates of Dr Verma referring to sleep disruption due to pain, low mood frustration and increased anxiety relate to the motor accident as opposed to the workplace injury. It was submitted that these symptoms are a continuation of the claimant's ongoing complaints since the motor accident and are referenced in Dr Verma's clinical notes. 4. The claimant noted that she had consulted Ms Dayman, psychologist from 2019 to 2022 and transferred for further therapy with Ms Ferris after that time. All this treatment related to the symptoms caused by the motor accident. 5. The claimant referred to the medical opinion of Dr Kuo, orthopaedic surgeon, who concluded there was a complete resolution of the left knee injury by April 2024 with ongoing left shoulder symptoms which will require surgery. It was noted that the claimant resumed her employment in October 2023 and had worked continuously from that date. 6. The insurer referred to the VCC report dated 11 May 2023 which noted the claimant's performance was affected by pain behaviour and suggestions of exaggerated self-limitation in the claimant's performance.

Insurer's submission dated 11 April 2022[52]

1. These submissions were provided prior to the provision of the records of the GP practice.
2. The insurer referred to the opinion of Dr Vickery in a report dated 22 November 2021 who diagnosed post-traumatic stress disorder in partial remission and a generalised anxiety disorder. Dr Vickery opined that the condition had not stabilised and recommended further treatment.
3. The insurer submitted that the opinion provided by Dr Rastogi on various PIRS assessments were either inconsistent with the treating psychologist or not properly explored by that doctor.

Insurer's submission dated 24 October 2023[53]

1. These submissions were filed seeking leave to review the medical assessment.
2. The insurer disputed the assessment made by the Medical Assessor for social functioning, social and recreational activities and concentration.
3. In respect of the assessment of social functioning the insurer referenced:

(a) the claimant distanced herself from most of her friends but the relationship with the family was quite good (Dr Anand);

(b) strong relationships with her family (Medical Assessor Canaris);

(c) loss of long-term relationship in 2015 which led to an adjustment disorder (clinical records), and

(d) socialising was limited due to reliance on other people driving in the claimant did not wish to drive herself (VCC report).

1. In respect of concentration, the insurer submitted that the Medical Assessor relied on self-reporting and failed to consider the history in the VCC report that the claimant was confident with everyday computer functions such as sending emails and documents and the like and was able to monitor stock levels and organise rosters for the staff. The insurer submitted that there was a history of rectal cancer which otherwise influenced fatigue, and this was relevant to pre-accident capacity.

Insurer's submission dated 18 November 2024[54]

1. These submissions related to the effects of the workplace injury in June 2023.
2. The insurer noted that the claimant injured her left shoulder and left knee and referenced the opinion of Dr Kuo dated 15 November 2023. It further submitted, by reference to the clinical records that the claimant's mental health declined significantly after the work injury.
3. The insurer referred to cl 6.34 of the Guidelines and submitted but it would be appropriate to assess the effects of the work injury under the PIRS "similar to as required for a pre-existing diagnosis".

1. The Panel determined that the claimant be re-examined by both Medical Assessors. The examination report is as follows:

Ms Shorrock is a 51-year-old woman who lives alone in her own home in Western Sydney suburb. She is working 25 hours/week over 3 days as a fashion retail sales assistant with Glue store in both Penrith and Rouse Hill. She is not in relationship and does not have children.

She was born in Nepean Hospital Penrith and described a normal birth and development. Her 83-year-old father worked as a truck driver. Her mother died of breast cancer when Ms Shorrock was 21 years of age. She has a 55-year-old sister. She described a good childhood and grew up in a nearby suburb. She said she was a happy child who suffered no form of abuse. She attended Penrith South primary school and then Jamieson high school where she completed year 12 in 1991 with a slightly above average result. She said she was a well engaged student who had friends at school and was never in trouble.

After leaving school she commenced working in fashion retail. She said she did various TAFE courses with regard to her work. She was initially employed as a casual and then progressed to working full-time as a sales assistant. She eventually worked as a store manager and was involved in buying merchandise. She has spent 17 years working for the Glue store outlets, mainly in Penrith but more recently in Rouse Hill while the Penrith store was being refurbished. She said she now does 2 days/week in Penrith and 1 day/week in Rouse Hill.

Ms Shorrock said she was involved in a relationship with a now 49-year-old man for 16 years. They were living together and buying a house together. They separated in 2016 because he had cheated, and she ended the relationship. In 2017 she was briefly involved in another relationship for 9 months, but the man lived in Queensland and the relationship ended. There have been no relationships since then.

Leisure activities prior to the motor accident consisted of gardening, tennis, yoga, craft activities and painting. Ms Shorrock denied any history of problems with the law and said there had been no previous motor accidents or worker's compensation claims. She denied any past or family history of psychiatric illness.

Medical history consisted of the diagnosis of rectal cancer in 2013. She underwent chemotherapy and radiotherapy and then proceeded to surgery for resection. Subsequently she had an ileostomy for 6 or 8 months. This was then closed and replaced with a J-pouch. She said she now has the management of the J-pouch 'down Pat' and rarely gets caught short or has an accident. During the course of treatment, she was off work for approximately 12 months. Her GP at the time was Dr M Tait of the Penrith Medical Centre. She said she did not require psychological or psychiatric treatment or psychotropic medication at that time and was entirely managed by Dr Tait. When asked how she was affected psychologically by the cancer diagnosis she said she had to fight for her life so she 'took the bull by the horns' and simply dealt with it. She denied becoming anxious or depressed.

The panel pointed out the ending of her relationship occurred following cancer treatment and she was asked if this added stressor resulted in any psychological symptoms. She said the separation was a shock and there were economic consequences which meant she was struggling to maintain ownership of her home. She acknowledged it was a difficult time but said she did not need psychological help or psychotropic medication.

After Dr Tait retired, she consulted Dr Verma in the Penrith Medical Practice. She said he goes overseas a lot, so she currently attends GP Dr Ban Abdulabas at the same practice regarding the subsequent worker's compensation injury. She has transferred her care for the CTP claim to Dr Coral Shaw of Blaxland.

Celebrex 200 mg 1 or 2 in the evening for pain arising from the motor accident.

CBD oil 4 mL morning and night. This had been prescribed by Dr Coral Shaw commencing in January for anxiety, pain and insomnia arising from the motor accident.

Ms Shorrock denied the use of cigarettes, alcohol, recreational drugs and gambling. She drinks 2 or 3 cups of coffee per day.

On 7 April 2019 Ms Shorrock had been visiting local plant nurseries with 2 friends. One was in the front passenger seat and the other in the middle of the rear seat. All were wearing seatbelts. They were travelling on the great western highway at Emu Plains. She said there was congestion with heavy traffic on both sides. Cars were parked on the left-hand side and there was heavy traffic in the right lane. She had been stationary at traffic lights when she noticed a vehicle in her lane coming towards her at speed. She realised she was about to be hit and was unable to move to the left or the right. A head-on collision ensued. Airbags were not fitted in Ms Shorrock's car. She said she did see the airbags deploy in the other vehicle and heard the female driver screaming.

Ms Shorrock said she smelled smoke and fumes. She was able to self-extricate. She described being in flight mode and feeling shaky; she was fearful the car would catch fire. She assisted her friends to get out of the car. She continued to hear the woman in the other car screaming. Passersby began to lend assistance, and they were all able to move to the side of the road. She phoned her sister. The police and ambulance services attended and helped to extricate the driver of the other car. She said they sat at the accident site for hours in shock.

Ms Shorrock said she had a bull bar on the front of her car which she believes saved her and her friends from more serious injury. She was not transported to hospital and was taken home by a tow truck driver. She said the car was written off by the insurer.

History of symptoms and treatment following the motor accident

Ms Shorrock described pain during the night following the motor accident. She said her chest was extremely sore and she was unable to sleep because of both pain and psychological stress arising from the accident. She attended her GP the following day. Dr Tait was away so she consulted Dr Verma who ordered x-rays which reported no fractures. Pain management consisted of opiate patches and Panadol. She subsequently attended Dr Tait who ordered a bone scan which revealed a fractured sternum, 7 fractured ribs and the undisplaced fracture of the transverse process of the T1 vertebra. Pain from the fractures continued for many months. She said currently she continues to experience chronic pain in the back and on the right side of her neck. She also experiences bilateral sciatic nerve pain during winter.

Psychological symptoms initially consisted of feeling numb. She said the insurer provided her with a hire car, but she was not able to even get inside it. She said she became claustrophobic. She described being unable to trust anyone. If she sat in the car, she had to get out of it. She said she just wanted to stay at home because of anxiety. She said she was unable to drive for a long time but could not remember exactly how long. She said she did not even have a car for a long time. If she was transported by her father, she panicked if he drove faster than 20 kph.

She described disturbed sleep. She said she was having flashbacks during which she could see and hear the woman screaming. She said she constantly ruminated on the motor accident and could not shut her mind down. She also described dreams of the lady screaming. She said in the dream she hits her car and is unable to get out of the car. She went on to say if someone goes fast on the road or cuts her off, she freezes. She said she has to stop and get out of the car to calm herself down. These events were panic attacks. She described being "freaked out" at the thought of going to the city for a physical IME examination. She said it was necessary to use an Uber and have her sister travel with her. She had to ask the driver to pull over on a number of occasions.

She said 'bad thoughts' started after the motor accident. She said everything was hard and she could not turn off the thoughts. She was asked if they included thoughts of suicide. She said she did not want to be around anymore and thought it would be easier not to be alive. The bad thoughts were continuous. When asked if she had any plans for suicide she said she was looking at the beams in her garage as a means of hanging herself but had not made any attempts. She denied any deliberate self-harm.

Ms Shorrock complained of being constantly tired and stressed out because of the anxiety. She said she does not have a life and feels like she is just existing.

When asked about treatment she initially consulted psychologist Ms Rosalind Dayman on a weekly basis and then later on a fortnightly basis. She said she was also able to telephone her in an emergency. After consultation with Dr Vickery who suggested eye movement desensitisation response (EMDR) she was referred to psychologist Ms Renee Ferris who works in the same practice. She initially saw her fortnightly and then monthly. She said she is also able to telephone and email her here in an emergency. She believes she had approximately 20 sessions of EMDR. She said this was not helpful in reducing nightmares and flashbacks.

On the advice of Ms Ferris, she consulted psychiatrist Dr Anita George. She said the main reason she wanted to consult Dr George was to enquire about the use of CBD oil but this was not available from Dr George. She prescribed prazosin for nightmares and flashbacks which resulted in diarrhoea and was discontinued. She also recommended the use of fluoxetine, melatonin and amitriptyline. Dr George considered pain was a significant cause of her distress.

Subsequently Ms Shorrock consulted GP Dr Carol Shaw of Blaxland in January 2025 because she heard Dr Shaw prescribed medicinal cannabis. She currently uses 4 mL of CBD oil in the morning and in the evening. She said this has been effective in dealing with anxiety, pain and insomnia and had also stopped bad thoughts of self-harm. She said she feels less fuzzy, and it has taken the edge of her anxiety. Ms Shorrock said she needs CBD oil and does not believe she could do without it. She obtains the prescriptions legally and does not feel she is at risk of testing positive for cannabis if she is tested while driving.

She said she returned to work some months after the motor accident initially doing 1 day/week and gradually increasing to 2 days and then 3 days. She said she had no alternative but to work because she needed the income.

Injuries or Conditions Sustained since the Motor Accident

In June 2023 Ms Shorrock suffered a work accident at the Rouse Hill store. She was reaching with a hook to get a jacket down from a high rail. She said another employee had placed a metal rack under some clothing behind her. When she stepped back, she tripped on the metal rack and fell backwards sustaining an injury to her shoulder and leg. She said the shoulder injury consisted of a torn tendon which may or may not require surgery. The leg injury consisted of a stress fracture of the tibia at the left knee which should heal spontaneously. She continues to have a problem with her shoulder and is being treated by orthopaedic surgeon Dr Warren Kuo. GP Dr Abdulabas is the NTD and has suggested obtaining a second opinion which she will do in May 2025. When asked about the psychological impact of this injury she described it as a 'hiccup' compared to the motor accident. She said she did not discuss it with her psychologist, but it did cause her to miss an appointment. She denied any other injuries or conditions. The panel accept that this condition did not add to her psychological distress.

When asked to describe her current symptoms Ms Shorrock said she feels the motor accident controls her life. She said she is constantly upset, angry and frustrated. She described double checking herself and feeling tense all the time. She said nightmares regarding the motor accident continue weekly or fortnightly. She said in these nightmares she is hit by the other car and gets trapped in her car. She said she is now unable to go into confined spaces such as elevators, small rooms and scans (CT or MRI) without anxiety. She described constantly ruminating on the motor accident and said it never goes away. She said she feels trapped in it and does not know how to get out of it. Flashbacks continue but less frequently. She said she still has to pull over to settle panic symptoms if she is cut off on the road or if a car or truck gets too close.

She was asked about work, and she said she continues to do only 3 days/week because her mind is not right. Her mood is low, she is anxious, and she has persistent suicidal ideation. She said she must be bright while working in fashion retail and does not believe she could put on a happy face for more than 3 days. Prior to the motor accident she described herself as a happy, bubbly person who could easily engage with customers but now finds this a significant effort. When asked about the impact of her physical injury on her ability to work she said there are lifting restrictions and pushing and pulling restrictions, but it is not the physical condition that prevents her from working 5 days/week.

Ms Shorrock is a 51-year-old right-hand-dominant woman whose appearance is consistent with her stated age. She was located alone in a room in her home in Western Sydney; her sister was present in another room in the house. She was identified from her photograph on her NSW driver license. She was interviewed using the Microsoft Teams application with a good internet connection. The interview commenced at 9 AM and concluded at 10:45 AM.

Ms Shorrock was cooperative with the interview and provided information in a straightforward manner. She described significant anxiety associated with driving which appears to have spread to other activities such as being in confined spaces such as elevators and small rooms. She described the development of panic attacks. She also described nightmares relating to the subject motor accident and flashbacks if she was exposed to cues while driving. She noted hypervigilance and an exaggerated startle response, especially in relation to motor vehicles. She described constant rumination about the impact of the motor accident on her life. She was depressed in appearance and described intermittent ongoing thoughts of self-harm. She was frequently tearful throughout the interview while discussing matters relating to the subject motor accident. Some pain behaviour was evident throughout the interview in that she needed to stand and stretch because of right-sided back and rib pain. Her speech was normal in rate, form and prosody.

Ms Shorrock was fully oriented in time, person and place and displayed no evidence of organic or psychotic psychopathology.

When asked to describe a normal day Ms Shorrock said she normally goes to bed about 8:30 PM but can take hours to get to sleep. She wakes around 3 AM. She said she often gets up to have a shower and then moves from one lounge to another. She denied sleeping throughout the day. She described doing very little on the days she is not working and confined herself to home.

Self-care and personal hygiene: Ms Shorrock said she does shower regularly and usually each day. She makes an effort to wear clean clothing, especially when she is working. She said she neglects her nutrition because of poor motivation to attend to herself. She has gained 10 kg. She is mildly impaired.

Social and recreational activities: Ms Shorrock said she has stopped seeing all friends because they no longer invite her out to events or sport and no longer come to visit. She said they have given up because of her constant refusal to accept invitations. She described not being able to participate with them because of anxiety. She said she does not go out for coffee or for a meal. She does not attend clubs, hotels or entertainment venues because of anxiety. She is moderately impaired.

Travel: Ms Shorrock drives to work on 1 day per week from Emu Heights to Rouse Hill, a journey of approximately 1 hour. She said this involves frequent panic attacks and the need to pull over if she encounters a fast car or a large truck. If it is raining she cannot travel and needs her sister or father to drive her. She is unable to travel as a passenger in a vehicle unless her father or sister are present. She is unable to use public transport because of anxiety. She is similarly unable to travel via air. She is mildly impaired.

Social functioning: Ms Shorrock was not in relationship prior to the motor accident and has not been in a relationship since. She said the relationships with her father and sister are strained because of her dependence on them with regard to travel. She reported losing all friends because of anxiety. Prior to the motor accident she was interested in meeting another partner but now is unable to do this because of anxiety. Because of the loss of all her friendships she is moderately impaired.

Concentration, persistence and pace: Ms Shorrock said she is unable to watch anything on television because it can trigger anxiety or panic attacks. She is unable to watch the news because it is negative and involves exposure to too many car accidents. Prior to the motor accident she was able to read but now is not able to read more than 1 page of a book. She said she struggles to use a computer and needs assistance from her sister because she is indecisive. She said she is unable to persist and jumps from a task to task. She is slower in completing tasks. She is moderately impaired.

Adaptation: Ms Shorrock is working 3 days/week. She said she is less meticulous about housework and has let things slide. She relies on her father to mow her lawn, but this is because of pain. She is not motivated to maintain the house as she previously did. She is mildly impaired.

Ms Shorrock's presentation was internally consistent, consistent with the documentation provided and consistent with the diagnosis made.

Assessor Christopher Canaris issued a certificate dated 3 September 2023 diagnosing post-traumatic stress disorder and assessing whole person impairment of 14%. The claimant was a 49-year-old single woman working 3 days/week in fashion retail. She denied previous psychiatric history. He noted rectal cancer in 2013 requiring colostomy, radiotherapy and chemotherapy which she claimed she simply 'dealt with'. There was no family history of psychiatric illness. She denied the use of substances and gambling. Her father was a truck driver and her mother was a housekeeper; she died when the claimant was 21 years of age of brain cancer; again the claimant said she 'dealt with' it. She described a good childhood. She completed year 12 and then studied retail and fashion design at TAFE; she worked in fashion retail, sometimes managing stores. A 16-year relationship ended in 2015 when her partner cheated. There was a subsequent relationship for 1 year which ended when her partner moved interstate. She has no children. She was physically active and outgoing prior to the motor accident. The motor accident consisted of a head-on collision. She was driving and had 2 friends in the car. Her vehicle did not have airbags but the airbags in the other vehicle deployed. She smelled smoke and fumes and was afraid the car might explode. She focused on getting her passengers out. The other driver was screaming and could not get out. Police and ambulance attended and extricated the other woman. Injuries consisted of 7 fractured ribs, a fractured sternum and a fracture of T1 vertebra. She consulted her GP and had x-rays which were declared okay. Due to ongoing pain she had a bone scan 2 weeks later which detected the fractures. Symptoms consisted of back and neck pain which were unbearable and worse in cold weather. She is unable to sleep, maintain the house or do the garden. She relied on her sister for support. She was off work for 6 months. She gradually returned to work but can manage only 3 days. She is anxious while driving. She has nightmares and flashbacks about the face of the woman driving the oncoming vehicle. She worries about the future. Sometimes she was unable to get in the car. She described low mood and feels like she is going backwards. She has gained weight because of inactivity. She does not feel safe away from home and is hypervigilant for danger. Her concentration is reduced. Social activities are reduced. She has not attempted to establish another relationship. She is irritable. Medications consist of fluoxetine 20 mg and amitriptyline 25 mg. She consults a psychologist fortnightly and has had 10 sessions of EMDR which has not helped. She uses Celebrex. He diagnosed post-traumatic stress disorder which included her depressive symptoms. He also diagnosed a somatic symptom disorder with predominant pain. He assessed whole person impairment at 13% (132332). He made a 1% treatment effect allowance taking the total to 14%.

Psychiatrist Dr Richa Rastogi provided an IME report dated 11 October 2021. She diagnosed post-traumatic stress disorder with anxiety. She assessed whole person impairment at 14% (132233).

Treating psychologist Ms Rosalind Dayman provided a report dated 18 July 2021 following 21 counselling sessions between June 2019 and March 2021. She noted the claimant has an ileostomy following rectal cancer treatment. DASS 21 scores were all extremely severe on 11 March 2021. She described symptoms consistent with PTSD and a chronic pain disorder. There were 3 AHRR's.

Occupational therapist Dr Horace Ting of the Vocational Capacity Centre provided a vocational and functional assessment report dated 14 June 2022. He noted she was working 3 days per week in her preinjury role as a sales assistant but her work performance has been compromised due to pain and inability to handle stress. He recommended work as a sales assistant or customer service representative.

Treating psychologist Ms Renee Ferris provided report dated 23 May 2023 noting the claimant had attended nine EMDR therapy sessions since November 2022. She diagnosed stagnant PTSD and chronic pain.

Clinical record of Penrith Medical Centre is dated 8 July 2024 and commences on 15 October 2014.

15/10/2014 CA rectum diagnosed. Ileostomy March 2014 by Professor Cartmill. Now has colostomy bag and plan for reversal.

30/06/2015 referred to Cancer Care Centre. Anxious because partner left after 16-year relationship with no proper explanation. He was withdrawing money from accounts and pushing her to sell the house. Booked with psychologist through Cancer Care. Referred to oncologist Dr Jenny Shannon.

02/07/2015 feeling numb and in shock due to separation; denied depression; query adjustment disorder.

07/03/2016 colostomy reversed, has J-pouch, occasional incontinence at night.

08/04/2019 seen with sister following subject MVA yesterday.

29/04/2019 whole-body scan indicate fractures of the sternum, superior endplate of T1 vertebra and fractures of the right 2nd, bilateral 3rd and left 4th-6th ribs anteriorly. Mild arthropathy in shoulders. No evidence of bony malignancy. Referred for physiotherapy and psychological counselling. Norspan (buprenorphine) 5 mcg/h transdermal patch. Flashbacks and driving anxiety; not able to sit in the car.

06/10/2021 return to work part-time 3 days/week limited by back aches. Appointment with psychologist next week regarding anxiety and fear of driving cars in rainy weather. 03/02/2022 Works on Wednesday, Friday and Saturday with a lot of back pain towards the end of each day. Was previously a manager but now works as an assistant. Seeing psychologist Ms Rosalind Dayman monthly.

03/03/2022 seeing both personal psychologist and psychiatrist. Anxiety while driving is being exacerbated by poor weather such as threats of floods.

10/05/2022 Dr Vickery recommended EMDR for anxiety. Referred to psychologist.

05/09/2022 anxiety symptoms remain the same, not worse. Sleep disrupted. EMDR booked.

05/12/2022 EMDR in process, sessions heavy, no good effect noticed.

11/05/2023 EMDR continuing, no change in symptoms, not much improvement. Sleep not the best, mood low. DASS 21 scores all extremely severe. Working 3 days/8 hours/week.

10/06/2023 fell backwards onto metal at work 2 weeks ago taking jackets from shelf. Pain in ankle and foot. Diagnosis left shoulder tendinitis and left ankle sprain. Celebrex 100 mg twice daily as needed.

29/06/2023 bone scan indicated suspicion of fracture of left tibia.

03/07/2023 pelvic CT scan indicates well-defined lucent lesion in the left ilium measuring 12 mm in diameter. Likely metastatic deposit.

26/07/2023 worker's compensation claim regarding fall at work. PET scan normal. Soft tissue injury left knee and left leg. Referred for physiotherapy.

16/10/2023 referred to orthopaedic surgeon Dr Warren Kuo.

10/01/2024 sleep disrupted, mood stable, seeing psychologist on Monday. Able to work 2 days/week.

04/04/2024 saw specialist, torn tendon left shoulder, surgery advised.

11/06/2024 seeing psychologist monthly, mood low, psychologist advised her to see psychiatrist. Refer to Dr Anita George.

Orthopaedic surgeon Dr Charles New provided an IME report dated 26 August 2021. He noted she can lift only very light weights, walk for approximately 1 km and sit for approximately 30 minutes. Sleep is diminished to 4 hours. Pain prevents intercourse and has seriously affected her social life and travel by motor vehicle in public transport. He recommended a functional and vocational assessment.

Psychiatrist Dr Anita George provided a report dated 29 July 2024 following face-to-face consultation. She indicated chronic pain was the main contributor to sleep difficulty and recommended pain management consultation. She noted traumatic nightmares and flashbacks related to the subject MVA. She recommended treatment with prazosin, fluoxetine, melatonin and amitriptyline.

Dr Graham Vickery provided an IME report dated 22 November 2021. He noted medication is fluoxetine 20 mg in the morning along with Celebrex and Pariet. She attends psychological counselling with Ms Rosalind Dayman. He diagnosed post-traumatic stress disorder in partial remission and generalised anxiety disorder along with anxiety while driving or as a passenger in a car. He recommended antidepressant medication for further 12 months and 10 sessions of EMDR. He did not believe stabilisation had occurred and did not provide a WPI assessment.

Psychiatrist Dr Ashwinder Anand provided an IME report dated 15 May 2023. Current treatment was fluoxetine, amitriptyline and Celebrex plus psychological treatment from Ms Renee Ferris which includes EMDR. He diagnosed post-traumatic stress disorder and assessed whole person impairment at 7% (232232). He made a 2% treatment effect allowance taking the total to 9%.

Psychiatrist Dr Ashwinder Anand provided a supplementary IME report dated 2 November 2023. He reviewed the Vocational Capacity Centre report and the report of associate Professor Michael Shatwell and declined to change his previous opinion.

Vocational Capacity Centre provided a report dated 11 May 2023 authored by physiotherapist Ms Inez Farag and psychologist Mr John Raue. They wrote 'Ms Shorrock's performance at this assessment was affected by pain behaviour and self-limitation. The clinical assessment identified evidence of the constitutional effects on spinal function at the cervical, thoracic and lumbar spine levels. The inconsistency in Ms Shorrock's performance relates to the lack of a physical basis for the extensive level of self-limitation in the manual handling tests of this assessment. Her exaggerated self-limitation is support for the impact of behavioural factors on her presentation'.P43-44 'Ms Shorrock should be capable of upgrading her working hours to her pre-injury hours of 32 hours per week, working eight-hour days over the course of four days. Her limitations in upgrading her working hours are, it is opined, not associated with physical constraints but with issues of anxiety and her generalised psychological state. She has potential for eventually undertaking full-time employment if that were a goal that she particularly aspires to.' Recommendations for employment included retail supervisor, sales assistant, order clerk, information clerk, call centre operator and retail manager.

Treating orthopaedic surgeon Dr Warren Kuo provided a report on 11 April 2024. He noted the left knee stress reaction had completely resolved. If the left shoulder continued to be painful he recommended review in 2 months.

Ms Shorrock was involved in a head-on motor accident on 7 April 2019. She had been able to stop but said the other vehicle was travelling at significant speed. Ms Shorrock suffered significant physical injuries consisting of a fractured sternum, 7 fractured ribs and a fracture of T1 vertebra. She developed both anxiety and depressive symptoms consistent with post-traumatic stress disorder. There is some indication that the anxiety has spread into other areas and is now causing difficulty in confined spaces.

She meets DSM-5-TR criteria for post-traumatic stress disorder (chronic) as follows:

Criterion A. She was involved in a potentially life-threatening motor accident.

Criterion B. She experiences intrusive distressing memories, dreams and flashbacks. She described intense distress at internal and external cues and marked physiological reactions.

Criterion C. She attempted to avoid external reminders of the event.

Criterion D. She described negative beliefs about herself and others, a persistent negative emotional state, diminished interest and participation in significant activities, feelings of detachment from others and restricted ability to experience positive emotions.

Criterion E. She described being hypervigilant, having an exaggerated startle response and sleep disturbance.

Criterion F. Duration has been greater than 1 month.

Criterion G. There has been impairment in social and occupational functioning.

Criterion H. It is not attributable to a substance or another medical condition.

While Ms Shorrock described both depressive symptoms and panic symptoms, the panel members agreed these symptoms were components of post-traumatic stress disorder and did not require separate diagnoses.

Ms Shorrock was involved in a potentially life-threatening head-on motor accident. She felt she and her passengers were in danger of being engulfed by fire. She was aware of the screaming of the driver of the other vehicle and continues to experience her screams in nightmares.

The panel concluded the accident was capable of causing post-traumatic stress disorder and in fact has done so.

It is now 5 years and 11 months since the subject motor accident. Ms Shorrock has had appropriate evidence-based treatment including EMDR with little effect. She noted some benefit from the recent introduction of CBD oil. However, she remains significantly impaired. We are of the opinion that her condition is unlikely to change by more than 3% in the next 12 months with or without further treatment. Her condition has stabilised.

The Following Injuries Were Caused by the Motor Accident

Degree of permanent impairment psychiatric impairment rating scale

The determination as to permanent impairment is made in accordance with the American Medical Association's Guides to the Evaluation of Permanent Impairment (Fourth Edition) and Part 6 of the Motor Accident Guidelines.

Ms Shorrock said she does shower regularly and usually each day. She makes an effort to wear clean clothing, especially when she is working. She said she neglects her nutrition because of poor motivation to attend to herself. She has gained 10 kg. She is mildly impaired.

Ms Shorrock said she has stopped seeing all friends because they no longer invite her out to events or sport and no longer come to visit. She said they have given up because of her constant refusal to accept invitations. She described not being able to participate with them because of anxiety. She said she does not go out for coffee or for a meal. She does not attend clubs, hotels or entertainment venues because of anxiety. She is moderately impaired.

Ms Shorrock drives to work on 1 day per week from Emu Heights to Rouse Hill, a journey of approximately 1 hour. She said this involves frequent panic attacks and the need to pull over if she encounters a fast car or a large truck. If it is raining she cannot travel and needs her sister or father to drive her. She is unable to travel as a passenger in a vehicle unless her father or sister are present. She is unable to use public transport because of anxiety. She is similarly unable to travel via air. She is mildly impaired.

Ms Shorrock was not in relationship prior to the motor accident and has not been in a relationship since. She said the relationships with her father and sister are strained because of her dependence on them with regard to travel. She reported losing all friends because of anxiety. Prior to the motor accident she was interested in meeting another partner but now is unable to do this because of anxiety. Because of the loss of all her friendships, her strained family relationships and that she has not formed a new relationship, she is moderately impaired.

Ms Shorrock said she is unable to watch anything on television because it can trigger anxiety or panic attacks. She is unable to watch the news because it is negative and involves exposure to too many car accidents. Prior to the motor accident she was able to read but now is not able to read more than 1 page of a book. She said she struggles to use a computer and needs assistance from her sister because she is indecisive. She said she is unable to persist and jumps from a task to task. She is slower in completing tasks. She is moderately impaired.

Ms Shorrock is working 3 days/week to the best of her ability. She said she is less meticulous about housework and has let things slide. She relies on her father to mow her lawn, but this is because of pain. She is not motivated to maintain the house as she previously did. She is mildly impaired due to an inability to work extra hours due to her psychiatric condition.

Apportionment - pre-existing/subsequent impairment

There is no requirement for apportionment for pre-existing or subsequent impairment.

There is no evidence that treatment has been particularly effective. No treatment effect allowance is made.

Degree of permanent impairment caused by the motor accident

1. The Panel conducts a new assessment of all the matters with which the medical assessment is concerned.[55]
2. The Panel, comprised of two specialist medical practitioners, is not required to choose between competing medical opinions and is required to form its own opinion: Insurance Australia Group Ltd v Keen[56] and Insurance Australia Ltd v Marsh.[57]
3. The Panel adopts the detailed examination findings made by both Medical Assessors with the additional further short observations.
4. Clauses 6.214 and 6.215 of the Guidelines note that the assessment of psychological injury does not include any allowance for "impairment due to physical injury" and "impairments due to somatoform disorders or pain". We have considered the effects of pain and expressly have not included any allowance for these effects in our assessments of the PIRS categories.
5. We are satisfied that the motor accident caused a psychiatric condition, diagnosed by the Medical Assessors as post-traumatic stress disorder.
6. The insurer provided submissions on the relevance of the VCC report dated 11 May 2023 which included comments on exaggeration of her physical symptoms. The insurer did not refer to the observations in that report that the "limitations in upgrading her working hours are, it is opined, not associated with physical constraints but with issues of anxiety and her generalised psychological state."[58]
7. The Panel formed a view that the claimant was consistent with respect to psychological symptoms and do not consider the observations of the authors of that report as impacting on the clinical impression formed by the Medical Assessors on this Panel.
8. We observe that Dr Anand expressed a similar response when this report was raised by the insurer for the doctor's comment.
9. We add some further comments on our assessment of concentration, persistence and pace. The claimant stated that she had various limitations which are set out by the Medical Assessors.
10. We note the submissions raised by the insurer which are summarised earlier in these Reasons.[59]
11. We have earlier referred to aspects of the vocational assessment report produced by Vocational Capacity Centre.[60]
12. We do not accept the insurer's submission accurately reflects the claimant's ability post-accident. Portions of that report refer to skills the claimant has attained, particularly in a managerial role performed in her pre-accident employment history. Whilst these are skills, we do not read the author's comments as suggesting that these tasks have been undertaken since the motor accident.
13. The Medical Assessors, and the Panel, formed the view that the claimant was a reliable witness. Her employment history, including returning to work as best as she can supports our favourable view of the claimant's credit.
14. Ms Shorrock's claimed symptomatology is consistent with a chronic psychological condition from a very serious motor accident. We accept that the claimant's description of her loss of concentration is due to her psychological condition in an inability to focus. The matters raised by the insurer relating to computer tasks is the claimant's pre-existing skills which is not reflective of her current ability to concentrate.
15. The insurer referenced the subsequent work injury and submitted that any assessment under cl 6.34 should be undertaken in a similar way as that required for a pre-existing diagnosis.[61] The submission is incorrect.
16. Clause 1.34 of the Guidelines referable to the Motor Accidents Compensation Act 1999, which is identical to cl 6.34 of the Guidelines, was discussed by Wright J in Slade v Insurance Australia Ltd.[62] His Honour determined that the principles discussed by Malcolm CJ in State Government Insurance Commission v Oakley[63] apply in respect of the assessment under that clause. This test is different from the application of test provided by cl 6.31 of the Guidelines.
17. We have considered the claimant's evidence and the various medical evidence relating to the injuries sustained in the work accident. We are not satisfied that the post-accident work injury caused or contributed to any aggravation of the psychological injury. We are also not satisfied that there is objective evidence that the work injury resulted in permanent impairment of the underlying psychiatric condition caused by the motor accident.
18. We are not satisfied that there is objective evidence of pre-existing impairment within the meaning of cl 6.31 of the Guidelines prior to the motor accident. There is evidence of some psychological symptoms in July 2015 when the claimant was diagnosed by the GP with an adjustment disorder. However, that condition was of short duration and not referenced in later years prior to the accident in the clinical records. The claimant's ongoing functionality and employment status after that time and prior to the motor accident is otherwise inconsistent with both the existence of an ongoing psychological condition and any impairment.

1. The medical assessment certificate is confirmed.

[1] See Division 7.5 and Schedule 2 cl 2 of the MAI Act.

[56] [2021] NSWCA 287 at [40], [41] and [45].

[57] [2022] NSWCA 31 at [11], [21], [64].

[62] [2020] NSWSC 1031 (Slade).