The Tribunal's reasons
35 Having regard to the nature of the review grounds it is necessary to consider the whole of the Tribunal's reasons and expose both the manner in which the Tribunal identified the issue for determination and the manner in which the Tribunal reached the conclusion that the decisions by the reviewers should be affirmed.
36 The Tribunal began by explaining the fact that the appeal concerned the two internal review decisions. It then considered what had been approved by the two plans. As to the first plan (para 9), amongst other things, the Tribunal noted that an assessment and recommendation from suitably qualified professionals plus appropriate quotations for construction was required for approval of modifications of the bathroom, kitchen and outdoor areas. As to the second plan (para 15), amongst other things, the Tribunal noted that it provided funding for assessments to be undertaken by qualified professionals for the provision of home modifications to bathroom/kitchen/inside of house/outside of house.
37 It may be observed that as described by the Tribunal neither plan includes supports which involve alterations to the family home. They only approve assessments. Presumably, once the assessments have been obtained there will be a need to consider whether the six criteria are met in respect of each aspect of any work at the home that may be recommended. It does appear that at some stage state funding was received for work on the bathroom of the family home (para 87). It is unclear whether an assessment of the kind contemplated by the plans was undertaken because the reasons refer to partially completed work on the bathroom at the home and also to a period of six years since that work was interrupted by a dispute with the builder.
38 The Tribunal began its reasoning as to reasonable and necessary supports by quoting s 34(1) of the Act. It referred to the Rules. It referred to an operational guideline that had been published by the CEO concerning the provision of home modifications and assistance animals. It then stated its view of the issue for determination as being 'whether for the purposes of s 34 of the NDIA Act the requested supports not approved by the delegate are "reasonable and necessary"' (para 29).
39 There are potential difficulties with the above formulation because it fails to place the issue in the context of an explicit statement of the nature of the concept of reasonable and necessary support (as explained above). It risks failing to bring a proper understanding of the nature of the supports that the legislation contemplates when forming the required state of satisfaction. Whether that has occurred in the present case will depend upon the reasoning pathway of the Tribunal in not accepting any of the proposed further supports as being reasonable and necessary.
40 The Tribunal then outlined matters that were in issue. It described that the requested supports as (a) 'home modification and repairs'; (b) 'Seizure Response Dog funding'; and (c) 'a new motor vehicle and modifications'.
41 Next, the Tribunal summarised the position of the Agency. The summary began by describing the submission for the Agency as being whether the Tribunal could be satisfied that the supports that are sought are reasonable and necessary in accordance with s 34 of the Act (para 39). This again failed to articulate what is encompassed by that concept in the Act and focussed upon the terms of s 34.
42 The Tribunal then said (para 41):
The respondent submitted that, having regard to the evidence, the Tribunal could not, at this time, be satisfied that the supports claimed by the applicant were reasonable and necessary. There was a need for independent, objective and current evidence which was absent in this matter.
43 The Tribunal then referred to a submission by the Agency that there was 'an absence of probative evidence directed to each of the criteria' (being, it would seem, the criteria in s 34(1) of the Act) (para 42).
44 Therefore, the position of the Agency as recorded by the Tribunal was that evidence that was required in order to form a state of satisfaction as to each of the six criteria was not before the Tribunal.
45 As to the home modifications, the Tribunal referred to a submission by the Agency that it was difficult to distinguish between those modification expenses that were part of wear and tear as opposed to those that were needed to support the applicant (para 43) and that it was the Agency's position that the claimed supports needed to be something more than mere wear and tear (para 44). The difficulties with that position are addressed below in the course of dealing with ground (2).
46 Reference was made by the Tribunal to offers by the Agency to fund functional assessments and a home assessment report and a submission by the Agency that without those assessments the Agency was not in a position to identify as 'reasonable and necessary' any of the supports claimed (para 44). There was further reference to the lack of 'independent assessment'.
47 The Tribunal concluded its summary of the Agency's position by referring to a submission that there was no link between a functional capacity assessment or home assessment and the builder's report 'from which the Tribunal can be satisfied that any claimed support was reasonable and necessary' (para 45).
48 It appears from this part of the reasons that the position of the Agency as understood by the Tribunal was that there was nothing before the Tribunal from which it could reach any conclusion as to the functional capacity of Ms Isherwood and that without some form of independent assessment of the kind identified, the Tribunal could not make a decision as to what was a reasonable and necessary support.
49 The Tribunal then set out matters from a written opening prepared by Ms Isherwood's mother. Amongst other things, the Tribunal referred to a submission that Ms Isherwood is scared of strangers and will not survive being in an independent living environment and '[w]hat underpinned her application was a desire to ensure that [she] can continue to live in her current home' (para 47).
50 The Tribunal then set out the evidence of Ms Isherwood's sister (paras 52-92). The evidence included descriptions of the extent to which Ms Isherwood has mobility difficulties, that she is not comfortable around new people and would not talk to the Tribunal, her day to day interactions, her past accomplishments and struggles including incidents at school when she was said to have suffered tonic-clonic seizures, the condition of the bathroom and laundry and toilet in the family home, the fact that the family were using a camping toilet and Ms Isherwood had been showering in the laundry for a number of years, the state of disrepair in the kitchen which makes it unsafe for the applicant to cook and difficulties with ambulance officers accessing the house. The evidence explained how Ms Isherwood's dog alerts family members of a pending seizure. It also explained difficulties with the current family vehicle.
51 The Tribunal then set out the evidence of Mr Gardiner who was said to have provided a 'renovation report' in relation to the home after inspecting the property. Reference was made to various matters the subject of Mr Gardiner's evidence. They included a description of incomplete building work in the main bathroom (which was not able to be used), the state of disrepair in the kitchen, the state of disrepair of the laundry, problems with the back steps, issues with drainpipes and gutters, the need for wiring to an outside shed and issues with the front door and entrance. Reference was also made to evidence from Mr Gardiner that Ms Isherwood's mother wanted a swimming pool which could be achieved subject to planning approval.
52 The Tribunal then said (para 98):
Mr Gardiner said that a lot of the work was general wear and tear inherent in an old property. The kitchen was in bad condition as was the laundry. There had been repairs to the guttering, but the guttering was still not working properly. A lot of the items were old, worn out and in need of replacing.
53 As to the basis for Mr Gardiner's report the Tribunal's reasons record (para 104):
He said that he was asked to provide an opinion of what could and should be done to the property to make it as user friendly as possible, so he gave his opinion on everything he was asked to look at.
54 Earlier in the reasons, there was reference to the report referring to an estimated total repair cost of $293,982 (para 37(ii)). Mr Gardiner gave evidence that the costs would have increased by approximately 20% since preparation of the report (para 102).
55 The Tribunal then set out a summary of the evidence of Mr Allen. It was said to describe a series of recommended home modifications 'based on a set of goals and wishes provided to him … as representing what would be good for [Ms Isherwood] in terms of her goals and safety' (para 106).
56 The reasons referred to Mr Allen's report as describing Ms Isherwood's medical background, by referring to a medical summary which 'was not before the Tribunal' (para 109). As will emerge, the medical summary was from one of the additional medical reports obtained by the Tribunal after the hearing. Although the Tribunal referred to the relevant report in its reasons (see below), it did not consider whether the matters in the report - which by then were before the Tribunal - did provide a basis for Mr Allen's report. Instead, as to the evidence of Mr Allen, the Tribunal reasoned (at para 110) that in the absence of a functional assessment of Ms Isherwood and in the absence of any medical report informing Mr Allen of her functioning, his report could only be accepted as an expression of the opinion of Ms Isherwood's mother as to those matters and 'to some degree, an expression of [her] wishes'. It was then said that: 'Accordingly, only limited weight can be given to this report' because it was 'underpinned' by the opinions and observations of family members. The Tribunal then concluded:
Mr Allen's report does not assist the Tribunal in deciding whether the home modifications listed are reasonable and necessary in accordance with s 34 of the Act.
57 In context, the expression of that conclusion reflected reasoning which treated evidence of family members based upon their own observations of Ms Isherwood as evidence that could not be used to reach the conclusion as to the issue as formulated by the Tribunal. It was not formulated in the terms of the legislation because it focussed upon s 34 as the legislative expression of what may constitute reasonable and necessary support, rather than upon an understanding informed by the use of that expression in the Act as a whole, particularly the manner in which it is articulated in the principles set out in s 4 of the Act. It also treated the evidence of Mr Allen as being unsupported by the contents of the medical report referred to by him, even though the Tribunal obtained that report and referred to its contents in its reasons.
58 The Tribunal then stated its conclusion that the evidence of Dr Jenkins was wholly unsatisfactory (para 111). Later, the Tribunal expressed reasons for that conclusion. None of the grounds seek to impugn that conclusion on the basis of alleged error of law.
59 The Tribunal then dealt with the circumstances in which it obtained the additional reports that give rise to the complaint the subject of ground (1). It stated: 'Following the hearing, and given the absence of reliable medical evidence before the Tribunal, the Tribunal requested the parties produce [three identified] medical reports' (para 112). This is indeed what the Tribunal had done and the basis upon which it did so. It sought the reports on the basis of its view that they were relevant.
60 In its reasons, the Tribunal then proceeded to deal with the additional reports that it had received (paras 113-123). It quoted from the report by Dr Myers and Prof Scheffer which it found was the report to which Mr Allen had referred (paras 115-119). The Tribunal referred to the report as describing 'prolonged events, including leg extension and general stiffening, as the most frequent type of event for [Ms Isherwood]' and as recommending a plan for further investigation.
61 The reasons also included the following concerning a report of a Dr Norton, a neurologist (para 121):
After prolonged monitoring over several days, it was felt that the episodes which were causing concern were in fact functional and behavioural and were not true epileptic seizures in the accepted sense.
62 The above aspect of Dr Norton's report was given significance later in the Tribunal's reasons. It will be necessary to consider that aspect. At this point it is sufficient to observe that Ms Isherwood's primary disabilities were not confined to epilepsy. They also included Dravet syndrome, intellectual disabilities and autism spectrum disorder (para 32). However, it does appear from the Tribunal's reasons that in certain respects it was the risk of epileptic seizure that was relied upon as the basis for a number of the supports which were sought to be included in the participant plan for Ms Isherwood.
63 The Tribunal then set out its findings as to the evidence of Dr Jenkins. They included the following (para 141):
In answer to a question from the respondent's counsel, Dr Jenkins told the Tribunal that the applicant's sister prepared the majority of the report dated 19 October 2020. When asked what part of the report she did prepare, Dr Jenkins answered: 'I asked for advice from the family because I don't live with them, and I certainly checked everything'. When asked whether, apart from turning her eye over it and applying her stamp, she had prepared the report, Dr Jenkins answered 'No'.
(original emphasis)
64 As has been noted the Tribunal found that the evidence of Dr Jenkins was not reliable (paras 149, 179-188).
65 The Tribunal's reasons then continued under the heading 'Consideration'. They began in the following way (para 144):
The fundamental issues in this hearing were the nature and extent of the applicant's functional capacity as a consequence of her agreed medical conditions, and whether the claimed supports were reasonable and necessary supports to be funded by the Scheme.
66 Reference was made to the position of the Agency in its opening submissions that 'there was an absence of independent objective and current evidence upon which the Tribunal could be satisfied that the claimed supports were reasonable and necessary as required by s 34(1)(a)-(f) of the Act' (para 147). Reference was also made to the Agency's position that it was necessary to distinguish between home modifications that were 'reasonable and necessary supports' (on the one hand) or 'general wear and tear expenses that were reasonably expected to be paid, for example, by the family' (on the other hand) (para 147).
67 The Tribunal addressed the issue of a functional assessment. It referred to reasons that had been given for not undertaking a further assessment. They included reliance upon the report of Mr Allen. As to Mr Allen, the Tribunal reasoned (para 150):
However, the occupational therapy report was obtained at the request of the [Agency] for the purpose of a functional capacity assessment. The applicant's representatives chose Mr Wayne Allen. The applicant would not cooperate with the occupational therapist who was unable to observe any aspect of the applicant's functional capacity. Hence, the report including the applicant's functional capacity was based on information provided by [Ms Isherwood's mother] and her family and was not founded on any medical evidence about the applicant nor any independent observation of the applicant or independent corroborative evidence about the applicant and her functional capacity.
68 This 'foundation' was found to 'go to the probative value of its content' (para 151). Again, this reasoning failed to have regard to the fact that the Tribunal obtained the report that contained the medical summary referred to in Mr Allen's report. It treated the report of Mr Allen as if its only foundation as to the functional capacity of Ms Isherwood was the information from the family.
69 The Tribunal referred to a refusal by Ms Isherwood's mother to accept a proposal by the Agency, after the evidence had been received, for an assessment to be obtained (paras 152-153).
70 There are a number of references in the reasons to the proposed building work being 'renovations' or 'repairs' or work that was required as part of 'general wear and tear'. It was reasoned that there was 'no evidence' that the building work requested was any more than a renovation (paras 155-156).
71 The Tribunal acknowledged the possibility that 'there may be aspects of the renovations that need to be considered specific to [Ms Isherwood's] needs that are reasonable and necessary'. It gave examples. However, it immediately observed that there was no 'independent evidence before the Tribunal about those renovations relevant to [Ms Isherwood's] specific needs that are reasonable and necessary supports in consequence of her particular disability' (para 158).
72 The Tribunal went through the matters identified by Mr Gardiner in his report and repeatedly made the observation that there was an absence of independent evidence linking the disabilities and functional capacity of Ms Isherwood to what was described as renovations. In the course of this part of its reasons, the Tribunal referred to the absence of independent evidence about the nature and extent of Ms Isherwood's use of and need for a wheelchair, particularly in and around the home (para 165). This is an example of the Tribunal's concern as to the conclusions it could reach without independent evidence of functional capacity.
73 The Tribunal then dealt with the request to fund the purchase of a new motor vehicle as to which the Tribunal also found that there was an absence of independent evidence addressing the applicant's functional capacity (para 171). The same was said in respect of the funding sought for an assistance dog (para 172).
74 Then, the Tribunal returned to the evidence of Dr Norton. It quoted again the conclusion that the episodes that were causing concern were 'functional and behavioural' and were not true epileptic seizures. Further parts of the report of Dr Norton were quoted to the effect that the episodes of which the family complain 'are not epilepsy'. The Tribunal then quoted a passage from the report to the effect that Ms Isherwood's mother 'is somewhat confused about the concept of stress-related events in the diagnosis of epilepsy and still uses that term in her discussion' (para 173).
75 This evidence was used, together with other reasoning, to reach a conclusion that there was insufficient evidence for providing funding for an assistance dog as a reasonable and necessary support (paras 174-178).
76 Finally, under the heading 'Conclusion', the Tribunal began by stating that to the extent that the Tribunal had received evidence about the functional capacity of Ms Isherwood, that came from the family (in the form of evidence from Ms Isherwood's sister or in what was communicated to Mr Allen, Mr Gardiner and Dr Jenkins). Then it said: 'That asserted functional capacity has not been the subject of independent and current assessment by an appropriately qualified practitioner' (para 189). The focus upon both independence and currency may be noted (in that regard, see also paras 147, 149, 172, 198-199). It is also significant that the requirement for independence and currency was being applied to an assessment by an appropriately qualified medical practitioner.
77 Then the Tribunal reasoned (para 190):
Further, to the extent that [Ms Isherwood's mother and sister] continue to refer to the [Ms Isherwood] suffering seizures including tonic-clonic seizures, the medical evidence before the Tribunal indicated that is not the case and, arguably, there are functional and behavioural issues which impact upon the applicant's behaviour.
The above passage appears to be a further reference to the statement in the report by Dr Norton.
78 Then the Tribunal reasoned that it needed evidence 'other than from family members to be reasonably satisfied about the applicant's functional capacity and reasonable and necessary supports' (para 191). It may be noted that this statement was directed to the issue of functional capacity.
79 The Tribunal then referred to the refusal to accept the invitation for a home assessment to occur and dealt with the explanation that had been given for that refusal (paras 192-193).
80 Then, after observing that the fact that Ms Isherwood has not had the benefit of a functioning bathroom for six years 'is a serious concern', the Tribunal again referred to the absence of any independent reliable evidence about the applicant's functional capacity and the requested supports in dispute' (para 196). Again the statement about independent reliable evidence is directed towards material concerning the functional capacity of Ms Isherwood. It is not expressed in terms of the need for independent evidence as to all matters that must be considered in forming the states of satisfaction required by s 34(1).
81 The Tribunal found that the 'list of home renovations' was 'generally in the nature of wear and tear home repairs or replacements' (para 197).
82 Then (at para 198), the Tribunal again gave significance to the evidence of Dr Norton in the following manner (after again describing the evidence as to Ms Isherwood's functional capacity coming from the family):
[The assessment by Ms Isherwood's mother of Ms Isherwood's] various conditions and their impact upon her, albeit genuinely held, do not necessarily accord with the available medical opinion as indicated by Dr Norton who has reported that there are functional and behavioural aspects to the applicant's presentation.
83 This was followed immediately by the following (para 199):
Hence, the Tribunal agrees with the respondent's submission that there is a lack of independent, objective and current evidence upon which the Tribunal could be satisfied that the claimed supports were reasonable and necessary as required by s34(1)(a) - (f) of the Act.
84 As has been observed, the passages from the report of Dr Norton that were quoted by the Tribunal in its reasons concerned only the diagnosis of epilepsy. They did not address whether the other diagnoses of Ms Isherwood may account for those 'functional and behavioural aspects'.
85 The requests for an assistance dog and a motor vehicle were again addressed on the basis of a lack of evidence (paras 200-206). There was a repetition of earlier reasons that the opinions of Ms Isherwood's mother and sister were genuinely held but the Tribunal 'is not satisfied that this is reliable evidence about [Ms Isherwood's] medical condition, giving rise to her presentation and what are reasonable and necessary supports' (para 211).
86 The final two paras are as follows (paras 213-214):
After the hearing, we asked for copies of those other medical reports to which we have referred. Unfortunately, they did not assist the Tribunal other than to give a general overview of her condition and in part a diagnosis different to the view of the applicant's family about her medical condition over the last few years.
The evidence before the Tribunal was unsatisfactory. We agree with the respondent's submission that there was a lack of independent, objective and current evidence from which the Tribunal could be satisfied, at this time, that the claimed supports were reasonable and necessary.
87 In the passage quoted above, the statement that the additional reports 'did not assist the Tribunal' is qualified by what follows and appropriately so. As has been explained, the report of Dr Norton was relied upon by the Tribunal.
88 It may be seen that there were two consistent themes in the reasoning. First, the absence of independent, objective and current material concerning the functional capacity of Ms Isherwood. Second, the characterisation of the home alterations as renovations or repairs for fair wear and tear.
89 Beyond identifying that the internal review for the second plan 'confirmed that self-management of funding had been approved' for the supports that were approved by the reviewer (para 16), the Tribunal's reasons did not address the issue of self-management. This was a consequence of the formulation of the issue as being whether for the purposes of s 34 of the Act the requested supports that were not approved were reasonable and necessary.