"I confirm that the dispute is limited to causation. If causation is established, CTP Care concedes that the proposed treatment is reasonable and necessary."

1. The provisions of the Civil Liability Act 2002 (the CL Act) apply to the MAI Act in determining issues of causation. Particularly ss 5D and 5E of the CL Act.[11] In Raina v CIC Allianz Insurance Ltd[12] Campbell J stated:

"One may accept that a review panel is engaged in a process of dispute resolution by expert assessment of medical issues arising under the Act. However, the questions arise in a legal context and it is incumbent upon the panel, medical practitioners they may be, to correctly apply the law including the law of causation in the exercise of their powers. This includes the provisions of Division 3 of Part 1A of the Civil Liability Act 2002 (NSW), ss5D and 5E: see s 3B(2)(a) of that Act. Although it may be expected that questions about the appropriate scope of liability will arise but rarely."

1. Further, cls 6.5 to 6.7 of the Motor Accident Guidelines refer to causation of both injury and whether the degree of permanent impairment is caused by injury.
2. Clause 6.7 of the Guidelines provides:

"There is no simple common test of causation that is applicable in all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be the sole cause as long as it is a contributing cause, which is more than negligible."

1. The Medical Assessor summarised the medical dispute as whether a surgical consultation with Dr Damien Ryan to assess the hand injury is reasonable and necessary in the circumstances.
2. The Medical Assessor noted that the claimant alleged that he sustained a tendon injury to the left thumb while cutting some bread. He alleged that the knife held in the right hand slipped due to the limited dexterity in the right hand caused by the right wrist arthrodesis performed in 2022.
3. The Medical Assessor noted the insurer's submission that the thumb injury was caused by the claimant's failure to use the equipment provided to him, specifically that the spread board would not have slipped and the claimant's left thumb injury would not have occurred had he used the equipment.
4. The Medical Assessor noted the history of treatment since the motor accident, particularly persistent symptoms in the right wrist and thumb, which were managed by orthopaedic surgeon, Professor Graham Gumley. Due to ongoing functional limitations in pain, right arthrodesis was performed on 31 October 2022. That surgery significantly reduced mobility and dexterity in the dominant right hand, making many manual tasks challenging.
5. The Medical Assessor noted that the claimant was provided with assistive equipment and occupational therapy input including a home craft reflex slicing knife with a serrated blade, nonslip mats and a spread board. These aids were intended to improve safety during food preparation and compensate for the loss of fine motor function in the right hand.
6. The Medical Assessor recorded the following history concerning the accident:

"On 22 April 2025, he sustained a significant injury to his left hand while attempting to cut bread using his right fused hand. He reported that the knife slipped during the task due to his compromised grip and hand position. Activities of daily living review showed that during the incident, he used a non-serrated knife and did not properly utilise the assistive equipment. Specifically, he failed to use the Reflex Slicing Knife and the Dycem non-slip mat. He placed the Spread Board directly on the kitchen benchtop, which allowed it to slide while he exerted force with his right hand. This contributed to the knife slipping and injuring his left thumb."

1. The Medical Assessor noted the claimant's history that he was provided with only one knife and a pair of push style scissors which were difficult to use. The knife eventually broke and he had to continue using it for all tasks. Mr Mangano informed Icare about the broken knife and cutting board and it was subsequently replaced.
2. On examination the Medical Assessor noted severe muscle guarding and severe rigidity over the right wrist joint. There was mild muscle guarding and rigidity over the left wrist joint.
3. The Medical Assessor found that the surgical consultation with Dr Ryan was reasonable and necessary due to reduced range of motion and poor grip strength resulting in significant difficulties with personal care and activities of daily living.
4. There were no findings by the Medical Assessor as to whether the proposed treatment related to the injuries caused by the motor accident.

1. It is unnecessary to fully summarise the material given the narrow issue for consideration and the insurer's acceptance that the right wrist arthrodesis was causally related to the motor accident.
2. In a report dated 25 October 2022, Ms Leudmila Ugov recommended that the claimant be provided with various equipment for allowing easier access to his premises.[13]
3. In a report dated 18 November 2022, Ms Ugov requested that the claimant be provided with various equipment which would assist him in the performance of daily tasks associated with the preparation of food.[14] This equipment request included a reflex slicing knife with serrated blade, a Dycem nonslip mat and homecraft spread board.
4. The request noted that the claimant had undergone a right wrist arthrodesis on

31 October 2022 and there was no movement in the right wrist joint. The claimant was right hand dominant, and the equipment would assist in buttering and cutting bread to accommodate for the reduced wrist movement. 5. In a report dated 27 July 2023, Ms Ugov noted that the claimant had been provided with various equipment including a homecraft reflex slicing knife with serrated blade, Dycem non slip mats and homecraft spread board.[15] The report noted that the claimant was provided with an education session on 23 November 2022 to ensure that he was able to use the aids safely. A second education session was offered, however the claimant reported that this was not necessary. 6. A report dated 29 April 2024 authored by Elisha Tabone after the claimant was transitioned to CTP care recommended a case management to identify and coordinate the treatment and care needs.[16] The report noted that the claimant wore a splint on his right hand and had limited right hand function to lift/carry or grip objects. The following was noted:

"Mr Mangano reported he has experienced severe depression since the MVA and described symptoms of post traumatic stress disorder (PTSD). Mr Mangano stated he has difficulty accepting his functional limitations and the significant impact the MVA and the subsequent surgeries have had on his functional abilities. Mr Mangano also described a sense of loss for his professional identity and became emotional when discussing his inability to return to the profession he loved and his inability to continue the business he had spent time establishing.

Mr Mangano stated he is engaged in fortnightly sessions with his psychologist who is using EMDR therapy (Eye Movement Desensitisation and Reprocessing, a therapy often used to treat PTSD) and has sessions with his psychiatrist every 6 weeks. Mr Mangano stated he has fluctuating moods and at the time of the assessment indicated he was feeling positive and had not given up hope that his situation would improve."

1. Ongoing functional incapacity included restriction in meal preparation due to limited function in the right hand and reduced mobility in the left-hand.
2. Imaging report of the left thumb dated 22 April 2025 reported a probable complete tear of the proximal segment flexor pollicis longus.[17]
3. Dr Kordjian provided a report dated 24 April 2025, requesting funding for an MRI scan and hand surgeon review after the claimant sustained a recent knife injury to the left base of the thumb. The doctor noted that the injury occurred whilst the claimant was using his right hand which had been surgically fused and had left the claimant with limited range of motion and weakness.
4. The doctor noted that the claimant was trying to cut items to eat with the aid of the kitchen cutting board when the right dominant hand loss grip and he stabbed his left hand/thumb.
5. Ms Tabone provided a further report dated 21 May 2025.[18] The author noted that the claimant had provided a video demonstration of how the injury occurred. Ms Tabone stated:[19]

"Mr Mangano was using a Homecraft Spread Board, which was provided to him following a previous ADL Assessment completed by Benchmark Rehab on 25-10-2022. The Equipment Request dated 18-11-2022 indicates a right-angled knife and bread board was recommended for Mr Mangano to improve his independence with buttering and cutting bread to make toast for a snack. The Equipment request also indicates a Dycem mat was recommended as this would reduce any movement of the board on which the item was being cut.

The Homecraft Spread Board is a moulded board that has a raised L-shape in the corner, designed to hold sliced bread in place for one-handed spreading. The board also has a set of 6 stainless steel spikes which can be used to hold produce such as bread or fruit/vegetables in place while being sliced or chopped. The board is designed for one-handed, basic meal preparation. The board does not have a non-slip base and is only designed for cutting/chopping of items which can be chopped using a downward rocking motion. This style of board is commonly used for cutting sandwiches, and chopping items that can be secured with the spike board, such as cucumbers, tomatoes or potatoes using a rocking knife, downward force motion.

In the video supplied by Mr Mangano, he demonstrated using the Spread Board to place a French-style bread stick onto the spikes of the board. Mr Mangano then used his right (dominant) hand to cut the breadstick using a large, non-serrated knife. Mr Mangano demonstrated using his left hand to stabilise the chopping board as it was sliding back and forth on the kitchen benchtop with the forceful sawing motion required to cut the breadstick. In the video, Mr Mangano was using the Spread Board directly on the kitchen benchtop. During the ADL review, Mr Mangano was unable to recall if he was using the non-slip mat provided by Benchmark Rehab, at the time of the injury. When assessed by the OT, the Spread Board was found to slide easily over the kitchen bench as the small rubber feet did not grip the benchtop. However, when placed on the non-slip mat previously provided, the Spread Board remained in place."

1. Ms Tabone noted that various items required replacement including the homecraft reflex slicing knife with serrated blade.
2. In an email dated 21 April 2025, the claimant advised the insurer that on Good Friday whilst he was attempting to cut through bread, his right hand slipped because of the weakness from the right wrist arthrodesis and the knife stabbed him in the left thumb.[20]
3. Dr Damien Ryan, orthopaedic surgeon, provided a report dated 19 May 2025.[21] The doctor noted that the claimant had recently injured his left thumb whilst using a knife in difficult circumstances due to the stiffness in the right hand. Dr Ryan stated:

"He relates this injury to the awkward position of using knife with his fused right wrist and what he describes as some inadequate assistive equipment that he was using whilst cutting with the knife."

1. By notice and then internal review, the insurer denied liability for the initial consultation with an expert and the provision of an MRI scan.

1. The claimant provided a statement in response to the panel's request for respective bundles of documents.
2. The claimant stated that the knife had broken, and the board was too small for basic tasks and was frequently unstable. Items arrived without instructional demonstration leading him to navigate complex tasks with limited dexterity and no guidance.
3. The claimant stated:

"On the day of the injury, I was using a board that had been supplied to me by QBE's occupational therapist as part of my assistive equipment. I was attempting to cut a loaf of bread - a routine task - when the incident occurred. Due to the fusion in my right wrist, I had to stabilize the board with my left hand while sawing with a large knife. The board slipped on the benchtop, and the knife severed the tendon in my left thumb. This was not misuse - it was a direct consequence of inadequate equipment and the physical limitations caused by the MVA."

1. The claimant noted that ongoing pain, depression and medication side-effects had left him cognitively foggy and unable to constantly advocate for himself.
2. The claimant stated that the injury to the left thumb was not an isolated event but the inevitable result of cascading impairments, inadequate equipment, oversight and delayed support. The consequences of this have been profound, he is no longer able to work and his independence has been significantly compromised.

Authority submissions dated 8 July 2025[22]

1. The authority opposed the claimant's request for an MRI scan of the left hand and an initial consultation with Dr Ryan. It submitted that:
   • the claimant's left thumb injury was caused by his failure to use equipment provided by the insurer to address the injury sustained in the motor accident;
   • the failure to use the equipment provided by the insurer "broke the causal chain between the [motor accident] and the subsequent injury to the claimant's left thumb", and
   • accordingly, the motor accident did not cause the need for the requested treatment.
2. The authority accepted that the right wrist arthrodesis was caused by the motor accident.
3. The authority referred to the closure report provided by Leudmila Ugov dated 27 June 2023 which confirmed that the claimant was provided with the following equipment:
   • a home craft reflex slicing knife with serrated blade;
   • Dycem nonslip mats, and
   • home craft spread board.
4. The authority submitted that the feature of reflex knives included easy to grip contour handles for people with a weak grip and limited arm power which was set at an angle from the hand to minimise wrist movement. It "understood" that the serrated blade made slicing items like bread easier.
5. The authority referred to the Dycem nonslip mat which is placed under objects and produced the most effective way to keep items in place and improve gripping.
6. The authority referred to the Home Craft spread board which is a durable one-piece board allowing bread to be spread using one hand. It noted the spikes present at the bottom of the spread board which are designed to allow the user to secure items such as vegetables or fruit whilst they are chopped or sliced.
7. The authority referred to the report of Ms Ugov which confirmed that the claimant had been provided with equipment and education to address the limited dexterity in his right hand and minimise the risk of the kind of injury the claimant sustained.
8. The authority referred to the description of the mechanism of injury provided by Elisha Tabone dated 21 May 2025. This description is contained in the summary of evidence.
9. The authority submitted that the claimant used the spread board provided to him, failed to use the reflex slicing knife with serrated blade and failed to use the Dycem nonslip mat.
10. The authority submitted that the claimant's left thumb injury would not have occurred had he used the equipment provided to him. The reflex slicing knife with serrated blade would have made it easy to slice the bread and would have reduced the force of the soaring motion which caused the spread board to slide back and forth. It also submitted that even if the claimant had used a knife other than the reflex slicing knife with serrated blade, the spread board would not have slid back and forth if the claimant placed the Dycem nonslip mat under the spread board.
11. The authority submitted that the left thumb injury was caused by the claimant's failure to use the reflex slicing knife with serrated blade and the Dycem nonslip mat and the left thumb injury would not have been injured had he used the above equipment. It submitted that the failure to use the said equipment constituted an intervening act which broke the causal chain between the injury sustained in the motor accident and the left thumb injury.

Authority's submissions dated 8 September 2025[23]

1. These submissions were filed seeking leave to review the medical assessment.
2. The authority noted that the original submissions dealt solely with the question of whether the motor accident caused the need for the treatment. It noted that they did not make submissions regarding whether the proposed treatment was reasonable and necessary.
3. The authority submitted that the Medical Assessor proceeded to deal with a dispute as if the only controversy was whether the treatment was reasonable and necessary and at no point did he address causation.

1. The Panel determined that it did not need to re-examine Mr Mangano for the following reasons.
2. The nature of the claimant's right hand/wrist condition requiring equipment is not in dispute. The nature of the incident when Mr Mangano cut his left hand is also not in dispute save as to one factual matter. Our subsequent reasons have determined that fact adversely to the claimant.[24]
3. Any medical examination would not assist in the resolution of the issue of causation.
4. Any further questioning of the claimant would not assist in the issue of causation as we are satisfied that we have sufficient information.
5. Finally, we note the modest amount at issue in this dispute. Our decision is not binding on any other potential dispute. We otherwise find that the claimant's case on causation is clear and that the actions he took on the day did not break the chain of causation.

1. The Panel conducts a new assessment of all the matters with which the medical assessment is concerned.[25]
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 t/as NRMA Insurance v Keen[26] and Insurance Australia Ltd v Marsh.[27]
3. We accept that the original Medical Assessor did not make findings on causation.

1. The Medical Assessor set out how the incident occurred.[28] A fuller and precise summary is also contained in the report of Ms Tabone.[29] We adopt those histories as to how the claimant injured his left thumb.
2. We find that the claimant did not use the Dycem nonslip mat for the reason explained by

"When assessed by the OT, the Spread Board was found to slide easily over the kitchen bench as the small rubber feet did not grip the benchtop. However, when placed on the non-slip mat previously provided, the Spread Board remained in place."

1. We find that the claimant did not use the serrated knife because it was broken at the time of this incident. The claimant stated the serrated knife was broken and Ms Tabone stated in her report dated 21 May 2025 that the serrated knife required replacement. Whilst the history to Ms Tabone post-dates the incident, the report is consistent with the claimant's account.

"(2) No statutory benefits are payable for the cost of treatment and care to the extent that the treatment and care concerned was not reasonable and necessary in the circumstances or did not relate to the injury resulting from the motor accident concerned."

1. The motor accident need only be a material contribution between the motor accident and the need for treatment: AAI Limited t/as AAMI v Phillips.[30]
2. There is a clear causal connection between the motor accident, the claimant's right wrist injury, subsequent fusion surgery and the injury to the left thumb. The right wrist was and is weak and made simple tasks such as cutting bread challenging. The medical evidence shows, and we accept, that Mr Mangano has a weakened right-hand grip which is due to the motor accident. He is right hand dominant.
3. We accept the opinion of the Medical Assessor, consistent with the medical experience on the Panel, that surgery significantly reduced mobility and dexterity in the dominant right hand making many manual tasks challenging. That conclusion is otherwise consistent with the opinion of Dr Kordjian in April 2025 that the claimant had limited right wrist range of motion and weakness and the claimant's email on 21 April 2025 referring to right hand weakness.
4. The provision of the food preparation equipment was necessary to avoid the type of accident that occurred.
5. For these reasons there is a very strong causal connection between the motor accident causing the significant right wrist injury and the subsequent left thumb injury.

1. Without reference to any legal decision, the authority submitted that the failure to use the equipment constituted an intervening act which broke the chain of causation. It submitted that the incident would not have occurred if Mr Mangano had used the Dycem nonslip mat and serrated knife.
2. For the reasons set out earlier,[31] there is no fault by Mr Mangano in not using a serrated knife that was broken. Accordingly, that aspect of Mr Mangano's "fault" is ignored for the purposes of determining whether Mr Magano's actions were sufficient to break the chain of causation.
3. Mahony v J Kruschich (Demolitions) Pty Ltd[32] is a unanimous decision of five Justices of the High Court. The worker then sued his employer (J Kruschich (Demolitions) Pty Ltd) claiming damages for a personal injury. The employer cross-claimed against Dr Mahony alleging that the doctor had been negligent in treating the worker. That cross-claim was struck out by the trial judge as disclosing no cause of action. The cross-claim was restored by the Court of Appeal. Dr Mahony appealed to the High Court.
4. The Court stated that a negligent tortfeasor does not always avoid liability for the consequences of a subsequent injury and it depends on whether or not the consequences "are themselves properly to be regarded as foreseeable consequences of the first tortfeasor's negligence".[33] The Court noted that reasonable minds may differ as to whether a subsequent injury "was foreseeable or whether it was too remote to be regarded as a consequence for which an earlier tortfeasor may be held liable".[34]
5. The Court held that original injury does not carry the risk of medical treatment that was "inexcusably bad" or "completely outside the bounds of what any reputable medical practitioner might prescribe" and did not extend to "grossly negligent medical treatment".[35]
6. In March v Stramare (E. and M.H.) Pty Ltd[36] Mason CJ (with whom Toohey and Gaudron JJ agreed) after referring to the decision in Mahony stated:

"Just as Chapman v Hearse rejected reasonable foresight as a test of causation, so McKew and Mahony rejected it as an exclusive criterion of responsibility."

1. In Secretary, Department of Education v Johnson[37] Emmett AJA (with whom Macfarlan JA and Simpson AJA agreed) stated that questions of foreseeability do not arise in determining issues of causation under the workers compensation scheme. His Honour stated:[38]

"In common law contexts, an injury or incapacity may be attributable, in the legal sense, to more than one cause operating concurrently. There is no difference between the legal view of causation in tort and causation in the field of workers compensation, subject to the qualification that, in a claim for workers compensation, it is unnecessary to prove that the incapacity was the natural and probable consequence of the injury. That is to say, the question of foreseeability does not arise. It is sufficient that the incapacity results from the injury by a chain of legal causation unbroken by a novus actus interveniens." (footnotes omitted)

1. In our view questions of foreseeability are not determinative in the resolution of causation for the motor accident statutory compensation scheme. The wording of s 3.24 of the MAI Act is similar to the causation test for the entitlement of medical expenses under the workers compensation legislation.[39] We accept that the observations in Johnson are apposite to the interpretation of causation in s 3.24 of the MAI Act.
2. Finally, we refer to the observations of Gleeson and Kirk JA in State of New South Wales v Cullen[40] concerning the type of actions sufficient to amount to a novus actus and break the chain of causation. Their Honours stated:[41]

"Arguments that the chain of causation is broken by what has traditionally been called a novus actus interveniens invoke a well-established type of limitation on legal causation. Whether or not the chain of causation is broken is "very much a matter of circumstance and degree": Chapman v Hearse [1961] HCA 46; (1961) 106 CLR 112 at 122; [1961] HCA 46; Mahony v J Kruschich (Demolitions) Pty Ltd [1985] HCA 37; (1985) 156 CLR 522 at 524; [1985] HCA 37. This aspect of causation is distinct from whether or not the type of injury that occurred is reasonably foreseeable: ibid."

1. We are required to determine the issue, adopting the words of Mason CJ in March "applying commonsense to the facts of each case".[42] There is a strong causal connection between the motor accident, the injuries suffered and what occurred on the day when the claimant injured his left thumb. This was an expected outcome from a serious right wrist injury. The claimant's conduct may have been careless in not using the nonslip mat, but his conduct does not come close to breaking the chain of causation between the injuries caused by the motor accident and the injury to the left thumb. This was not a criminal act, it was unintentional and even if the contact amounted to negligence, it was an extremely minor and a brief casual act in not using the nonslip mat for cutting the bread. Our descriptive of the claimant's conduct is that it was probably careless or a minor and casual act of negligence which does not come close to conduct that could be described as breaking the chain of causation.
2. We are satisfied that the claimant has established that the need for treatment of the left thumb injury is causatively related to the motor accident within the meaning of s 3.24 of the MAI Act.

1. The medical assessment certificate for the medical dispute of reasonable and necessary is confirmed. A certificate is issued at the commencement of these Reasons for the issue of causation.

[1] See for example Sarwary v Allianz Australia Insurance Limited [2023] NSWPICMP 125.

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

[12] [2021] NSWSC 13; 95 MVR 73 (Raina), at [65].

[26] [2021] NSWCA 287; 399 ALR 765; 98 MVR 164, at [40], [41] and [45].

[27] [2022] NSWCA 31; 99 MVR 1, at [11], [21] and [64].

[30] [2018] NSWSC 1710 (Phillips) at [29].

[32] [1985] HCA 37; (1985) 156 CLR 522 (Mahony).

[36] [1991] HCA 12; (1991) 171 CLR 506 at 510 (March).

[37] [2019] NSWCA 321 (Johnson).

[39] See s 60 of the Workers Compensation Act 1987.

[40] [2024] NSWCA 310 (Cullen).