The plaintiff's ongoing psychiatric/psychological injuries and disabilities
94The plaintiff was referred by Dr Patel on 1 November 2010 to Dr Zareena Anantharaman, whom she first saw on 4 October 2010. This is two years and three months after the accident.
95The difficulties of analysis of claims arising from medical treatment first sought after a lengthy period of time has elapsed have been set out in The Nominal Defendant v Kostic [2007] NSWCA 14. It is, however, not uncommon for referrals for depression and anxiety problems to emerge as a result of injuries, or not to become apparent for some time after the accident, so I must be cautious not to place undue weight on a period of delay in reporting symptoms of this nature. Depression, anxiety and other problems of this nature not infrequently take some time to appear and be diagnosed.
96However, other aspects of the plaintiff's claim cast serious doubts upon her credibility, requiring me to reconcile inconsistencies between her evidence and contemporaneous medical reports, in the manner explained in Riley v The Owners of Strata Plan 73817 [2012] NSWCA 410 and McGlen-McLeod v Galloway [2012] NSWCA 388. In Riley v The Owners of Strata Plan 73817, supra, the plaintiff gave inconsistent evidence about where she had slipped on a ramp and the trial judge's findings concerning the plaintiff's lack of credit were undisturbed. In McGlen-McLeod v Galloway, supra, all of the contemporaneous medical records including X-rays referred to a minor injury to one leg but the medico-legal reports, written two years later, referred only to a significant injury to the other leg. The Court of Appeal held that findings as to credit were necessary and it was insufficient to find that the absence of contemporaneous treatment meant that the only injury the plaintiff suffered was the injury she complained about at the time and which was treated by the doctors at the time.
97It is necessary to set this material out in some detail, and to start with the plaintiff's treating doctors' reports as tendered to the court (Exhibit A). Dr Anantharaman has provided a report dated 29 April 2011 concerning the 26 individual sessions she had held with the plaintiff over six months. A provisional diagnosis of adjustment disorder with anxiety and depressed mood was made. The prognosis is described as "[n]ot good, due to the chronicity of the physical problems since the dog attack on 30.08.2008".
98Dr Anantharaman sets out her conclusions and recommendations in point form. Owing to the serious issues raised by the defendants in relation to this report, it is necessary to set these out in full:
"Conclusions:
- Antonia is battling with the crippling pain in her body especially in her legs, knees and feet since the dog attack on 30th August 2008.
- Antonia sustained injury to her head for the first time during the fall when she was attacked by the neighbour's dog.
- Antonia developed dizziness and fainting for the first time only after the head injury she sustained during the dog attack.
- Antonia, prior to the dog attack / head injury, she was more independent and went out by herself everywhere.
- Antonia was a confident person, enjoyed going out socializing with family and friends prior to the dog attack.
- Antonia became house bound due to the fear of falling down again when alone only after the dog attack / injury to her head.
- Antonia never experienced dizziness / fainting and falling down before the dog attack.
- Antonia's problems with the head injury / blood clot was diagnosed following the dog attack / the injury she sustained to her head during the dog attack.
- Antonia is very anxious about the constant aches and pains in her legs knees as well as the dizziness.
- Antonia is unable to bear the pain in her feet any longer.
- Antonia is keen to get the surgery done ASAP.
- Antonia is desperate to have some relief form [sic] the constant pain.
- Antonia has no capacity to return to her pre accident level of functioning physically or emotionally due to the prolonged delay in the interventions in her total recovery from the dog attack / fall.
Impact on the family:
- Antonia's son became concerned of his mother's physical / emotional well-being.
- Antonia's son had to resign his job to become Antonia's full time carer after the dog attack.
- Antonia's son has also developed depression due to the family situation.
- Antonia's son is irritable / angry with his mother since 10 months.
- Antonia is trying her best to remain calm at home.
- Antonia is not happy about her son not working because of her injury / disability after the dog attack.
- Antonia's son has lost the confidence in himself.
- Antonia's son has stopped going out / socializing due to the fear of leaving Antonia home alone.
- Antonia's son isolates / communicates minimally with Antonia.
- Antonia's son gets very impatient with his mother.
- Antonia's son becomes verbally abusive of her some times.
- Antonia is upset with her son's rude behaviour towards her.
- Antonia is concerned about her sons' [sic] future.
- Antonia's son is anxious about her health / but finds it harder to express his emotions freely.
- Antonia is keen for her son to go back to work ASAP.
- Antonia's family is not coping well since the accident / dog attack due to the chronic nature of her physical / emotional problems in Antonia.
- Antonia's physical deterioration is impacting her only son living with her.
- Antonia is a loving, caring / genuine person who is affected greatly due to the dog attack / fall.
Recommendations:
- To continue to see Dr. Niranjana Patel for medical reviews.
- To continue to attend all the specialists appointments when required.
- To continue to attend Individual Counselling sessions: to further address issues that are concerning her mental health such as the injury / Stress, anxiety, and depression.
- To improve her coping and problem solving strategies.
- To improve her communication skills.
- To manage the anxiety / stress better.
- To be more active at home as well as outside the house.
- To socialize more with friends outside of home.
- To be able to communicate to the appropriate staff / people about the problems she is facing in her life
- Antonia needs all the support form [sic] the insurance company to enable her to get the necessary medical / surgical interventions.
- Antonia's case needs to be looked holistically and more sympathetically due to her age and fragility as well.
- This family needs every possible support in stabilizing them physically / emotionally as well s [sic] financially."
99The precise status of this report is unclear. Was it a report to the general practitioner, or to the court? Counsel for the defendants points out that it is addressed and headed "To Whom It May Concern", and not to the plaintiff's treating doctor, Dr Patel. This would mean that it is a medicolegal report, albeit from a treating doctor, according to the submission of the plaintiff. If that is the case, the Code of Conduct should have been referred to, but this has not occurred. In fact, the contents of this report are a good example of the reasons for the Code of Conduct forming an essential part of medical reports provided for court purposes, as the following additional material will demonstrate.
100What has not been disclosed by Dr Anantharaman, although it must have been known to her at the time, was the list of main concerns provided to her both by Dr Patel and, more importantly, by the plaintiff, when the plaintiff commenced her treatment. These are set out in Dr Anantharaman's own notes of 4 November 2010, which have been tendered by the defendants.
101Counsel for the defendants informed me that these notes were not obtained from Dr Anantharaman but from another source, under subpoena. The failure of the plaintiff's general practitioner and Dr Anantharaman to answer a subpoena in relation to this issue has been demonstrated by the tender of the subpoenae.
102The "patient's main concerns" are identified by Dr Anantharamn, for the purposes of her treatment of the plaintiff, as being entirely different to those set out in her report "to whom it may concern". It is necessary to set out this document in full:
"Patient's Main Concerns are:
- Daughter with drug addiction.
- Son in law too with drug addition.
- Conflicts with daughter.
- Daughter is not allowing her to see her kids.
- Conflicts with sister/nephew.
- Nephew with antisocial and drug related problems."
103The "patient's main goals" were stated as follows:
"Patient's Main Goals are:
- To stabilize the mood.
- To be able to improve relationships with daughter.
- To be able to see her grand kids.
- To feel safe / secure in her home.
- To feel normal and confident like before."
104Her current mediation is listed as "Efexor 75 mg / daily" and her presenting problems were as follows:
"Presenting problems:
- Depression: Unable to sleep due to preoccupied [sic] with conflicts with sister [? , before that] grand children.
- Anxiety: On 10.10.10 incident happened on her sister's B'day party. Nephew got [? violent] and threatened to kill / destroy her things. Very insecure.
- Stress: [There does not seem to be an entry for this]
- Relationship Problems: Conflicts with daughter due to daughters drug addiction / neglect of her kids. DOCS are involved. Conflicts with her sister and her son threatening to hurt her or destroy her property.
- Work Related Problems: [There does not seem to be an entry for this]
- Health Related Problems:
Chronic back pain
NDDM
Gout
Hypotension
Reflux and gastro-oesophageal
Multiple injuries due to a fall when dog attacked 2008
[?] Blood clot / mild stroke"
105The sole reference to the dog attack is in the second-last line of this document.
106Many of the statements in this doctor's report to the court, when compared to the list she made when treating the plaintiff, must be untruthful to the knowledge of the doctor preparing the report. For example, there is no evidence that a bloody clot was diagnosed following the dog attack, or that the pain in her knees and feet or a stroke are connected. In addition, the very serious family and social problems set out in the notes of Dr Anantharaman of 4 November 2010 have not found their way into her report, which I am satisfied was prepared with the knowledge that it could be used in court proceedings.
107The plaintiff made a number of concessions in her cross-examination about the ongoing extent of these problems. Her daughter is now deceased and she has no contact with her grandchildren, mainly because of her damaged relationship with her son in law. She says that she has reconciled with her sister, and now enjoys a good relationship with her, although she gave no date as to when this reconciliation took place. She agreed that the Department of Community Services had been involved in relation to neglect issues for the children, but said that it was her son in law who was the drug user, rather than her daughter.
108The circumstances in which the report of Dr Anantharaman contains misleading and untruthful information do not reflect well on the plaintiff's credit. I have taken into account that the plaintiff, who cannot read or write English, would have played little part in the preparation of this report. It must materially undermine the claim that the plaintiff's emotional and psychological problems arise from the circumstances of the accident the subject of this claim.
109However, the plaintiff repeated these claims when she saw Mr Gerard Glancey for medicolegal purposes on 23 May 2011, and I must assume that the plaintiff played a greater role in the giving of information to this psychologist than may have been the case with Dr Anantharaman. Mr Glancey's reports of 23 May 2011, 6 July 2012 and 7 August 2013, contained in Exhibit A, contain similar findings, although Dr Anantharaman's report is referred to by him only in the third of these reports (7 August 2013). I shall discuss each in turn.
110The contents of the first and second reports tell a story not dissimilar to that which is contained in the report of Dr Anantharaman, namely a history of the plaintiff having had friends and a happy lifestyle, including relative independence from pain or ill health, prior to the injury. Following the injury the plaintiff told Mr Glancey she suffered black outs, a stroke, a right ankle injury requiring surgery, an injury to her left ankle and a loss of independence. The family problems were briefly identified as a "family dispute" which meant she had no contact with her daughter or grandchildren as a result (p 3, report of 23 May 2011).
111The description of the events set out in Dr Anantharaman's notes of 4 November 2010 as a "family dispute" is also similar to the plaintiff's complaints to Mr Glancey. When the plaintiff "laments the loss of her previous life" (p 5 of the report), Mr Glancey accepts at face value the assertions that her life prior to the accident was a happy one where she enjoyed good health. There is no reference to the 2001 injury, to the long period of time on which she had been on disability pension, or to the family issues which caused such serious concerns to her in the years leading up to November 2010, only six months beforehand. Not only has the plaintiff provided a slanted and selective history, but Mr Glancey has not sought to inquire.
112Mr Glancey's second report, dated 6 July 2012, again emphasises that the plaintiff blames her blackouts on the blow to her head sustained in the dog attack (p 2). This included suffering a stroke on 22 April 2012. She described the previous conflict with her daughter as "now resolved" and said she was having "frequent contact with her daughter and her three grandchildren" (p 2). She described her foot injuries as being a significant issue and complained of flashbacks in relation to the dog attack as well as nightmares which caused her to awake screaming about once every three weeks, persisting depression and irritability. Whereas prior to the accident she used to sing and dance, she is now depressed and feels her life has no meaning. Mr Glancey diagnosed major depressive disorder. He described the depression as "a consequence of the major stressors of her life". These stressors are the chronic pain and physical restrictions, her physical condition involving black outs and stroke and post traumatic stress disorder (p 6). She was concerned about the condition of her feet and the prospect of reliance on a wheelchair, as well as the possibility of further stroke and death.
113Mr Glancey concludes:
"Her reports support the view that black outs which she claimed occurred following 29/6/2008 [sic] and subsequent stroke generated significant stress in her life which generated specific anxieties and compounded her depressive disturbance.
If pressed to apportion, mental disturbance to injuries sustained in the dog attack of 29/6/08 [sic] and her history of blackouts and stroke, I would suggest that fifty percent of her anxiety is related to her experiences of blackout and stroke.
In apportioning her depressive disturbance to the alternate stressors of her life, I would express the view that her depression is primarily related to the dog attack of 29/6/08 [sic] and would be evident in her mental functioning had she not experienced the blackouts and subsequent strokes. One must remember that depression is a neuro-chemical disorder. In my view her experience of dog attack and the injuries sustained in the attack established the neuro-chemical imbalance manifest [sic] by depression.
The stress of her general health problems has served to reinforce depression and therefore could be considered responsible for thirty percent of her depressive disorder."
114Mr Glancey went on to comment that the plaintiff would benefit from continued psychological counselling.
115Mr Glancey's third report of 7 August 2013 is along similar lines. I note that he describes the plaintiff's son as being now self-employed and that he "spoke of juggling work demands and the demands of caring for his mother" (p 2). In fact, as is set out below, the plaintiff's son was put before me as her carer. In response to an enquiry about family relationship, the plaintiff told Dr Glancey that her daughter had died in 2012 and that she was having no contact with the children because of opposition from the daughter's husband. He commented that "little has changed", although this is inconsistent with the information in his previous report. He saw no basis upon which to speculate optimistically regarding her prognosis in respect of mental disturbance.