Medical and allied assessments
27The plaintiff attended Liverpool Hospital for initial treatment of his injuries. The plaintiff's legal representatives did not tender any records or a discharge summary from that hospital.
28The plaintiff was referred to Dr Antonio Fernandez, a plastic and reconstructive surgeon, who diagnosed the plaintiff to have sustained a deep laceration to the proximal portion of his forearm with exposure of the muscle bellies. Dr Fernandez also diagnosed an area of altered sensation in the plaintiff's right radial nerve distribution. Arrangements were made for a surgical repair of those injuries.
29On 11 November 2005, Dr Fernandez operated upon the plaintiff at Sydney Southwest Private Hospital, for repair of his laceration and the damage to the underlying tissues. On 22 November 2005, Dr Fernandez undertook a post-operative review of the plaintiff. He removed the dressing and referred the plaintiff to physiotherapy for mobilisation of his fingers. The plaintiff was then required to maintain his arm in an elevated position for a time.
30On 29 November, 6 and 22 December 2005, 16 January, 21 March and 2 May 2006, Dr Fernandez undertook further reviews of the plaintiff. He initially reported that the plaintiff's progress was very slow, and he noted the emergence of complaints in the right arm and neck, which were possibly linked to disuse. Those problems receded over time, but the plaintiff continued to experience pain, especially when making a fist with his right hand. He also continued to experience neck pain.
31In March 2006, Dr Fernandez advised the plaintiff to consult his general practitioner, Dr Truong, for pain management. The plaintiff was also referred for a CT scan of the neck, and he was referred to a pain clinic. When Dr Fernandez discharged the plaintiff from his care, he considered that the plaintiff's complaints of intermittent pain had improved to a degree.
32On 24 March 2006, at the request of Dr Fernandez, the plaintiff underwent x-ray and CT imaging of his cervical spine, which revealed no significant abnormality apart from mild degenerative changes.
33On 6 July 2006, at the request of Dr Truong, the plaintiff was seen by Dr Darryl Salmon, a pain management specialist. Dr Salmon was of the opinion the plaintiff had persistent pain in his left arm following extensor tendon and neurovascular injury, which involved a permanent impairment. He thought there might be improvement in this condition over time. Remedial exercises were prescribed.
34On 16 August 2006, the plaintiff was re-examined by Dr Salmon. Little change was observed in the plaintiff's condition.
35On 30 August 2006, at the request of Dr Salmon, the plaintiff underwent an MRI scan of his right wrist, which produced a degraded image due to patient movement. Some relative thickening of the triangular fibrocartilage was observed to be present, which was taken to be a possible injury to that area.
36On 31 August 2006, Dr Troung referred the plaintiff to Dr Khahil, to assess the plaintiff's left elbow which had been causing him pain over the preceding months since the accident. It was recorded that the plaintiff had tried physiotherapy, acupuncture and NSAIDs with only minimal improvement in his condition.
37On 4 September 2006, the plaintiff was reviewed by Dr Salmon, who thought that the plaintiff's restricted range of arm movement and altered sensation remained unchanged. He suggested an orthopaedic opinion for the left elbow symptoms, and suggested an MRI scan of the right wrist.
38On 18 October 2006, At the request of Dr Truong, the plaintiff underwent an ultrasound study of his left elbow, which was reported as showing a combination of extensive tendonosis and tear involving the common extensor tendon of the elbow, with an associated tendon defect.
39On 24 October 2006, at the request of his solicitor, the plaintiff was examined by Dr Clive Sun, a consultant in rehabilitation and pain medicine. Dr Sun confirmed the need for the plaintiff to be referred for rehabilitation and pain management treatment. He also recommended analgesia, a sympathetic block in the neck to treat the plaintiff's chronic regional pain syndrome, along with regular hand therapy. Dr Sun placed significant restrictions on the plaintiff concerning work activities.
40On 26 October 2006, the plaintiff was again seen by Dr Salmon following the identification of tendonosis seen on ultrasound examination of the left elbow. At that time restricted duties were suggested.
41On 27 October 2006, Dr Troung referred the plaintiff to Dr Nabarro, a hand surgeon, at the suggestion of Dr Salmon. The history on referral was that the plaintiff had been forced to use his injured arm at work, resulting in pain in his left elbow and wrist.
42On 30 October 2006, Dr Salmon reviewed the plaintiff again after an ultrasound study of the left elbow had been carried out. He noted the presence on the MRI scan of oedematous thickening of the fibro cartilage and fluid distending into the distal ulnar joint. He suggested an orthopaedic opinion be obtained in relation to the elbow.
43On 2 November 2006, the plaintiff was first assessed by Dr Mark Nabarro, a hand and microsurgeon. The plaintiff was also seen by Dr Nabarro on a further 27 occasions to 25 November 2009. Dr Nabarro diagnosed the plaintiff as having a TFCC tear of the right wrist, complex regional pain syndrome of the right upper limb, pain in the three ulnar fingers of the right hand of unknown aetiology, and left wrist de Quervain's tenosynovitis, and a TFCC tear and ECU instability of the left wrist. He expressed a guarded prognosis.
44This was the first of 27 consultations the plaintiff had with Dr Nabarro, namely: 6/12/2006, 8/1/2007, 20/2/2007, 3/4/2007, 28/5/2007, 20/6/2007, 7/8/2007, 21/8/2007, 10/9/2007, 17/9/2007, 10/10/2007, 7/11/2007, 19/12/2007, 20/2/2008, 1/5/2008, 25/6/2008, 6/8/2008, 4/12/2008, 28/1/2009, 12/3/2009, 28/4/2009, 15/6/2009, 21/7/2009, 14/9/2009, 3/11/2009 and 25/11/2009.
45On 8 November 2006, at the request of Dr Nabarro, the plaintiff underwent an ultrasound guided injection into his left elbow.
46On 18 December 2006, at the request of Dr Nabarro, the plaintiff underwent an ultrasound examination of the right forearm, which noted typical post-surgical appearances. On the same date, the plaintiff underwent an MRI scan of the left wrist. This revealed post-operative scarring and some changes in the wrist.
47On 16 January 2007, the plaintiff was examined again by Dr Salmon. On that occasion the plaintiff reported more pain in the right wrist than in the left wrist.
48On 1 February 2007, Dr Salmon noted the plaintiff's continuing complaints of pain in both wrists, the left more than the right. It was noted that Dr Nabarro had planned some surgery for the plaintiff.
49On 21 August 2007, at the request of Dr Nabarro, the plaintiff underwent an MRI scan of his left wrist. This was reported a showing evidence of progression towards healing of the repaired peripheral tear of the articular disc of the TFCC, and some synovial thickening, and some mild infiltration-scarring to the fat plane at the margins of the dorsal branches of the ulnar nerve, without evidence of neuroma.
50On 10 September 2007, Dr Nabarro carried out surgery on the plaintiff's left wrist.
51On 11 December 2007, the plaintiff consulted Dr Tan Hiep Mai, a general practitioner. This was the first of a series of 55 consultations with that doctor ending on 23 November 2010. This doctor was of the view the plaintiff had lateral epicondylitis of the left elbow, the previously diagnosed conditions of TFCC tears, De Quervain's Syndrome in both wrists, right trapezius strain and depression. Dr Mai thought it was unlikely the plaintiff would return to his pre-injury duties.
52On 18 March 2008, the plaintiff was seen by Dr Sun for a second time. Dr Sun confirmed his view that the plaintiff's work accident was the cause of his impairments and disabilities. He stated the prognosis to be for the plaintiff to continue to suffer from bilateral upper limb symptoms affecting his daily activities, including work.
53On 3 April 2008, at the request of his solicitor, the plaintiff was examined by Thomas Clark, a consultant psychiatrist. Dr Clark considered that the plaintiff had developed a chronic reactive depression or dysthymia as a consequence of his work injury and the related chronic regional pain syndrome that subsequently developed. The salient features of that depressive condition were withdrawal, sense of loss, avoiding reminders of the incident, and being obsessed with the incident.
54On 6 May 2008, at the request of the solicitor for the defendant, the plaintiff was assessed by Dr Robin Mitchell and Mr David Brown, who are respectively, experts in rehabilitation medicine and occupational psychology. The report dated 12 May 2008, identified a range of suggested alternative employment positions, namely catering assistant, hand packer, machine operator (general plastics). This report made occupational assessments and recommendations which will be analysed in connection with the reasons for assessment of the claim for past loss of earning capacity.
55On 17 July 2008, at the request of the solicitor for the defendant, the plaintiff was examined by Dr Selwyn Smith, a consultant psychiatrist. Dr Smith considered that the plaintiff had displayed evidence of a mild but chronic adjustment disorder with depressed and anxious mood, which he related to the subject accident, with the associated complications that have been documented. Dr Smith considered that from a psychiatric perspective, the plaintiff was able to engage in his pre-injury employment, but he noted there were physical restrictions outside of his expertise. He also noted that the prognosis of the plaintiff's psychiatric issues was linked to the plaintiff's underlying physical condition. He deferred expressing an opinion on the plaintiff's capacity to engage in employment, pending a vocational evaluation.
56On 3 September 2008, at the request of his solicitor, the plaintiff was seen by Dr Sun for a third time. Dr Sun reviewed the plaintiff's history of treatment, and noted that the plaintiff had ceased working on 23 November 2007. Dr Sun confirmed his earlier opinions he had expressed in his report dated 31 March 2008.
57On 5 January 2009, the plaintiff was again reviewed by Dr Salmon at the Pain Clinic. At that time the plaintiff complained that his pain in the left forearm and wrist was greater in the left than in the right.
58On 16 January 2009, at the request of the worker's compensation insurer, the plaintiff was examined by Dr Allan Meares, a consultant hand, plastic and reconstructive surgeon. Dr Meares saw the plaintiff again in 2010 and 2012. In this his initial report he stated his diagnosis that the plaintiff had suffered a tear of the triangular fibrocartilaginous complex of his right wrist, and was not fit for his pre-injury work. He postulated fitness for light work and office work.
59On 3 March 2009, the plaintiff underwent surgery on his right wrist carried out by Dr Nabarro. He thought that the post-operative prognosis of the right wrist problem was only fair. At that time the prognosis for the right shoulder was poor. He thought the plaintiff would find it difficult to return to any type of work.
60On 19 July 2009, the plaintiff last attended upon Dr Tan Hiep Mai, a general practitioner in Bankstown. This was the last of 31 recorded consultations since 11 December 2007.
61On 29 July 2009, at the request of his solicitor, the plaintiff was seen by Dr Sun, for a fourth time. Dr Sun reviewed the plaintiff's recent arthroscopic surgery to his right wrist on 3 March 2009. Dr Sun re-iterated his earlier expressed opinions.
62On 19 November 2009, at the request of his solicitor, the plaintiff was examined by Dr Jeni Saunders, a sport and exercise physician. She considered that the plaintiff needed a specific physiotherapy programme, and was awaiting approval form the worker's compensation insurer.
63On 25 March 2010, the plaintiff was seen by Dr Nabarro for the twenty seventh and last time. At that time earlier expressed prognosis had not changed, and remained guarded.
64On 27 April 2010, at the request of the solicitor for the defendant, the plaintiff was examined by Dr James Vote, a consultant orthopaedic surgeon. He thought that the plaintiff would have difficulty in returning to the workforce in any capacity. He nevertheless suggested the roles of gatekeeper or some other kind of attendant. Significantly, Dr Vote thought that the plaintiff was well motivated and not in his view, overplaying or exaggerating his symptoms.
65On 20 May 2010, at the request of the solicitor for the defendant, the plaintiff was examined by Dr Meares for a second time. Dr Meares was then of the view that whilst the plaintiff may have needed domestic assistance soon after his original injury, He did not need it from the viewpoint of his hands and wrists. He was of the view that all the treatment the plaintiff had up until that time had been reasonable and necessary, and related to the subject accident.
66On 10 October 2010, at the request of his solicitors, the plaintiff was examined by Dr Clark for a second time. Dr Clark was of the opinion that the plaintiff had a severe depression. He noted a history of suicidal thoughts, poor sleep, and feelings of a great sense of loss, including to his self-esteem and pride, following his injury. He considered that the plaintiff could not come to terms with his disability.
67On 27 November 2010, the plaintiff was again examined by Dr Jeni Saunders, a sport and exercise physician. She considered that the plaintiff needed a specific physiotherapy programme, and was awaiting approval form the worker's compensation insurer.
68On 20 December 2010, at the request of his solicitor, the plaintiff was examined by Dr James Bodel, a consultant orthopaedic surgeon. Dr Bodel summarised the plaintiff's history of presenting physical complaints as being ongoing pain and stiffness in the right shoulder, right arm and wrist, aggravated buy repeated pushing, pulling and use of the right arm, ongoing left shoulder, elbow and wrist pain, and an intermittent sensation of pins and needles throughout the left arm. He also noted the complaints of headaches, neck pain, sleep disturbance and intermittent back pain aggravated by prolonged sitting. Dr Bodel stated that (in addition to the laceration to the right arm) the plaintiff had received soft tissue injuries to the neck, both shoulders and both wrists and hands as a consequence of his work accident, resulting in incapacity for his pre-injury work and causing a need for domestic assistance and future treatment.
69On 7 March 2011, the plaintiff consulted Dr Allyson Browne, a clinical psychologist. He attended a series of 9 appointments with Dr Browne that concluded on 12 December 2011. A major depressive disorder of moderate severity was diagnosed, along with chronic pain disorder. Accompanying symptoms were persistent low back problems, radiation of pain to the right thigh and to both wrists, right forearm and shoulder, and the right side of the neck, sleep disturbance associated with pain, reduced physical functioning, and reduced interest in pleasurable activities due to pain. Dr Browne's notes recorded the impression that the plaintiff had post-traumatic stress disorder with secondary major depression and chronic pain disorder.
70On 4 July 2011, the plaintiff underwent x-ray and ultrasound examinations of his right shoulder. The report of those examinations concluded that he had subacromial/subdeltoid bursitis, with some arthritic swelling of the acromioclavicular joint.
71On 5 July 2011, the plaintiff underwent x-ray and ultrasound examinations of his left shoulder. The report of those examinations concluded that he had mild osteoarthritis of the left acromioclavicular joint.
72On 29 March 2012, at the request of the solicitor for the defendant, the plaintiff was examined by Dr Meares for a third time. Dr Meares noted the plaintiff had not worked since December 2007. He also noted that the plaintiff stated he had pain in both upper extremities. Dr Meares observed the plaintiff to have used his hands normally when dealing with his belongings. Dr Meares did not include in his mention of that detail, any explanation from the plaintiff on those circumstances. Dr Meares thought there were no signs of chronic regional pain syndrome in the plaintiff's right hand. He did not explain that comment with supporting reasons. He nevertheless expressed the opinion that the plaintiff was unfit to engage in his pre-injury employment. Dr Meares thought the plaintiff was fit for some (kind) of employment, but needed to be retrained, and was fit for some light office duties, with lifting restrictions applicable to both arms. Dr Meares suggested a vocational assessment by a rehabilitation provider to assess the plaintiff for suitable future employment. Dr Meares' opinion did not take into account any psychological factors that were influencing the plaintiff's situation.
73Dr Meares seems to have based his opinion on the plaintiff's fitness for some kind of light work on his own observation that the plaintiff appeared to use both hands and arms in a normal fashion when handling his belongings. I consider that Dr Meares' opinion in this regard should be discounted and given diminished weight because there is no evidence that the plaintiff had been afforded procedural fairness by being given an opportunity to explain any adverse inferences that he may have drawn from his observations, as these may have been capable of consistent explanation.
74On 21 May 2012, at the request of his solicitor, the plaintiff was examined by Dr Bodel for a second time. Dr Bodel reviewed the plaintiff's presenting complaints, and noted they were the same as when he saw the plaintiff two years earlier. Dr Bodel stated that the plaintiff was certified as being unfit for work, with a poor prognosis for a return to work, and with only a theoretical ability to be trained for alternative employment.
75On 2 October 2012, the plaintiff attended Mr Tu Hoan Tran for physiotherapy treatment to his neck, shoulders and wrists. Mr Tran recorded his belief that the plaintiff had reached a plateau in his condition, but that his condition was aggravated by maintaining prolonged postures and activities involving the neck and shoulders.
76On 25 October 2011, at the request of his solicitor, the plaintiff was examined by Dr Sun, for a fifth time. Dr Sun again re-iterated his earlier expressed opinions.
77On 17 April 2012, at the request of his solicitor, the plaintiff was seen by Dr Clark for a second time. Dr Clark considered his earlier diagnosis of Regional Pain Syndrome with an associated Major Depressive Disorder superimposed upon the plaintiff's perfectionist personality, which prevented him from coming to terms with his disability. Dr Clark stated that the re-examination of the plaintiff did not cause him to change his earlier expressed findings. He stated that the plaintiff continued to suffer from a Major Depressive Disorder, his impairments were permanent, and he was presently unemployable, with a poor prognosis.
78The plaintiff gave evidence that he had been seeing a psychiatrist, Dr Nguyen. No reports from Dr Nguyen were tendered in the proceedings.