State of New South Wales (Hunter New England Local Health District)

WORKERS COMPENSATION - Workplace Injury Management and Workers Compensation Act 1998; appeal following assessment of a psychiatric injury on the grounds of demonstrable error; Medical Assessor (MA) found that an assessment of whole person impairment (WPI) could not be made finding that the appellant had not reached maximum medical improvement (MMI) in respect of a comorbid condition of dementia and could not be assessed on the basis of a single clinical assessment due to her severe memory deficits; Appeal Panel found MA erred in not identifying the primary psychiatric injury and identifying whether that primary psychiatric injury had reached MMI; Appeal Panel found that the work related injury has resolved such that there were no symptoms by the middle of 2023 and the appellant's primary psychiatric condition was in remission; Appeal Panel satisfied that the appellant's cognitive difficulties at the time of the MA's examination were caused by her comorbid neurocognitive disorder (dementia) and none of the current WPI was attributable to the work injury; Held - Medical Assessment Certificate revoked.

1. On 18 November 2025 Jennifer Quiring (the appellant) lodged an Application to Appeal Against the Decision of a Medical Assessor. The medical dispute was assessed by Dr John Lam-Po Tang, a Medical Assessor, who issued a Medical Assessment Certificate (MAC) on 20 October 2025.
2. The appellant relies on the following grounds of appeal under s 327(3) of the Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act):
   • the MAC contains a demonstrable error.
3. The delegate is satisfied that, on the face of the application, at least one ground of appeal has been made out. The Appeal Panel has conducted a review of the original medical assessment but limited to the ground(s) of appeal on which the appeal is made.
4. Rule 128 of the Personal Injury Commission Rules 2021 (the PIC Rules) and Procedural Direction PIC7 - Appeals, reviews, reconsiderations and correction of obvious errors in medical disputes set out the practice and procedure in relation to the medical appeal process under s 328 of the 1998 Act. An Appeal Panel determines its own procedures in accordance with r 128(1) of the PIC Rules.
5. The assessment of permanent impairment is conducted in accordance with the SIRA NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4th ed 1 March 2021 (the Guidelines) and the American Medical Association Guides to the Evaluation of Permanent Impairment, 5th ed (AMA 5).

1. The appellant sustained a psychological injury deemed to have occurred on 22 March 2022 in her employment as a registered nurse employed by the State of New South Wales (Hunter New England Local Health District) (the respondent).
2. The appellant lodged an Application to Resolve a Dispute (ARD) in the Personal Injury Commission (Commission) dated 16 June 2025 in which she claimed lump sum compensation in respect of the psychological injury.
3. The matter was referred to Dr John Lam-Po-Tang, Medical Assessor, for assessment of whole person impairment (WPI) of a psychiatric/psychological disorder as a result of the injury deemed to have occurred on 22 March 2022.
4. The Medical Assessor examined the appellant on 13 October 2025 and found that WPI could not be accurately assessed on the basis of a single clinical assessment, due to her severe memory deficits leading to difficulties in providing accurate answers. The Medical Assessor found that the neurological system had not reached maximum medical improvement.

1. The Appeal Panel conducted a preliminary review of the original medical assessment in the absence of the parties and in accordance with the Procedural Direction PIC7.
2. As a result of that preliminary review, the Appeal Panel determined that it was not necessary for the appellant to undergo a further medical examination because there was sufficient information on which to make a determination and because of the appellant's comorbid dementia a further re-examination would not provide any additional information to assist in making a determination.

1. The Appeal Panel has before it all the documents that were sent to the Medical Assessor for the original medical assessment and has taken them into account in making this determination.

1. The parts of the medical certificate given by the Medical Assessor that are relevant to the appeal are set out, where relevant, in the body of this decision.

1. Both parties made written submissions. They are not repeated in full but have been considered by the Appeal Panel.
2. The appellant's submissions include the following:

(a) the MAC contains a demonstrable error as the Medical Assessor declined to make an assessment of the WPI dispute referred for assessment.

(b) The Medical Assessor by explicitly declining to make any assessment of WPI ignores the function vested in him by the President, that is, to provide an assessment of WPI.

(c) The referral of the medical dispute to the Medical Assessor was on the basis that there was an accepted psychological injury capable of being assessed for WPI.

(d) The assessment of WPI is governed by s 322 of the 1998 Act.

(e) The authorities identify that for there to be a permanent impairment there needs to be an impact on an aspect of function which is not temporary but lasting or enduring.

(f) The appellant's injury has a date of injury of 22 March 2022. The applicant was diagnosed with dementia in late 2024. Dr Hong made his WPI assessment of the appellant in June 2024.

(g) In Hunter Quarries Pty Ltd v Alexandra Mexon as Administrator for the Estate of the Late Ryan Messenger [2018] NSWCA 17 (Hunter Quarries) Basten JA observed that s 66(1) of the Workers Compensation Act 1987 (the 1987 Act) envisaged a continuing life with a compromised ability to work and a compromised capacity for the enjoyment of life and in that instance where the applicant's injuries were so severe that his death was, in a practical sense, inevitable within a short period, the injury was fatal and did not result in an impairment. In Hunter Quarries, Justice Payne with whom Gleeson JA and Sackville AJA agreed, determined that the construction of "permanent impairment" required some continued and enduring experience of "impairment" for it to be understood as "permanent".

(h) The Medical Assessor determined not to provide an assessment on the basis that: "Ms Quiring's whole person impairment cannot be accurately assessed on the basis of a single clinical assessment, due to her severe memory deficits leaving to difficulties in providing accurate answers."

(i) The Medical Assessor's failure to engage with the task allocated to him is a demonstrable error.

(j) The Medical Assessor had available the statement of the appellant's husband, James Quiring, the medical report from independent medical examiner (IME), Dr Hong, and clinical notes of treating medical practitioners, Dr Plushchke and Kate Blenkin, along with the independent medical examining opinions of Dr Gates, neuropsychologist, and Dr John Roberts.

(k) The Medical Assessor in his analysis of the material identified the fact that Dr Hong was able to provide a considered opinion with respect to the various Psychiatric Impairment Rating Scales (PIRS) given he examined the appellant in June 2024. The Medical Assessor accepted by inference that there was an assessable WPI at that point.

(l) Dr Gates, examined in the appellant in September 2024, 12 months prior to the Medical Assessor, but only two months after Dr Hong and essentially concluded that it was a congenital condition [sic] that gave rise to the work injury, hence, no work-related impairment.

(m) The Medical Assessor noted Dr Roberts, in his IME report, reached a similar conclusion.

(n) The appellant's husband was present during the interview with the Medical Assessor and despite his statement in which he makes observations relative to the PIRS scales, and the Medical Assessor's concerns regarding the appellant's presentation, no input was sought as to the appellant's husband as to her level of functioning prior to her cognitive decline.

(o) The Medical Assessor's error in this regard is compounded when regard is had to the appellant's husband's statement where he provides his assessment of the appellant's capacity prior to her cognitive decline, in particular, at paragraph 13 of his statement.

(p) The Medical Assessor by failing to provide and turn his mind to the assessment of WPI that was attributable to a workplace injury, as referred, has derogated his obligation in providing an assessment.

(q) The fact that the appellant has developed a significant cognitive dysfunction unrelated to her workplace injury does not disentitle the applicant from an entitlement under s 66 of the 1987 Act. Much like a worker who sustained a physical injury which has not been assessed or determined relative to their entitlement under s 66 who dies from an unrelated cause, examining IMEs along with any Medical Assessor are still required to make an assessment, on a best fit or best means available basis, as to the likely WPI attributable to the injury. Here that would be with reference to the PIRS scales by drawing on the evidence that is available i.e. the IME opinion of Dr Hong, the evidence of the appellant's husband and clinical records.

(r) A re-examination of the appellant is required. Subject to the examiner's views, an interview could be conducted with the appellant's husband who would provide the best evidence relative to the applicant's various levels of functioning with reference to the PIRS scale but also with reference to contemporaneous material including the clinical notes of the general practitioner (GP) and Ms Blenkin.

1. The respondent's submissions include the following:

(a) with respect to the submission that the Medical Assessor has failed to engage with the task allocated to him, the appellant refers to the decision in Hunter Quarries wherein it was reinforced that a worker's condition must have reached maximum medical improvement as a prerequisite to an assessment of permanent impairment.

(b) The appellant's submission in this regard is misconceived. The Medical Assessor at page 7 of the MAC stated:

"Ms Quiring's cognitive function appears to have declined over the course of the past 10 [sic] based on a comparison of information documented in the report written by Dr John Roberts, consultant psychiatrist, dated 9 January 2025...Thus, she has not reached maximum medical improvement".

(c) The Medical Assessor 's finding in this regard means that he did discharge his duty to provide an assessment.

(d) To the extent that it is asserted that the Medical Assessor has made a demonstrable error in making a finding that is not supported on the evidence, the Medical Assessor has not made a demonstrable error in the MAC of 20 October 2025.

(e) To the best of his ability in the circumstances, the Medical Assessor took a comprehensive and detailed history of the appellant's history, current symptoms, and her activities of daily living. It is apparent from the observations recorded by the Medical Assessor that he had regard to the appellant's previous presentations before Dr Hong, Dr Gates and Dr Roberts and considered the appellant's subsequent progress within that context.

(f) The Medical Assessor correctly identified that there had been a significant deterioration in the appellant's cognitive function in the period since her assessment with Dr Hong.

(g) In particular, the Medical Assessor identified that the appellant's presentation at the time of his examination was:

"consistent with the description of her presentation in the reports provided by Dr Nicola Gates, clinical neuropsychologist, and Dr John Roberts, consultant psychiatrist, but was not consistent with the report of Dr Michael Hong, consultant psychiatrist".

(h) In this regard, the Medical Assessor identified that at the time of his report, Dr Hong provided a conditional diagnosis of Major Depressive Disorder with panic attacks, with the caveat of "Assuming that Ms Quiring does not suffer from a neurological or dementing disorder, then her presentation is consistent with pseudodementia". The Medical Assessor further noted that Dr Hong made no adjustments for the effects of a pre-existing psychiatric condition though it was evident at that time that her memory and other cognitive symptoms had been identified and were under investigation.

(i) The Medical Assessor's findings in respect of the opinion and assessment of Dr Hong are adequately supported by the evidence. This means that Dr Hong's opinion with respect to the various PIRS scales cannot be reliably depended upon.

(j) This issue is not cured by the statement of the appellant's husband who has provided a lay assessment of the appellant's cognitive capacity.

(k) On page 6 of the report of Dr Nicola Gates dated 3 September 2024 [page 6 of the Reply], wherein the doctor attempted to elicit a history of the appellant's memory issues. At that time, the doctor recorded the following:

"Interview with James indicated that he was aware of memory issues, 'a lot of anxiety still, night terrors and having conversations of being in methadone clinic, lots of stirring with very disturbed sleep'. He reported that she had been a very hard working and driven person and this was no longer the case. He confirmed that she had cognitively deteriorated in the past two years and was aware of Dr Mobbs's diagnosis and stated, 'I am probably not surprised' and indicated this was because her cognitive status had deteriorated in the past two years".

(l) Based upon the history recorded by Dr Gates, it is evident that the appellant's cognitive deterioration onset well prior to the examination by Dr Hong. This deterioration would have had the effect of impacting on all of the PIRS scales that were the subject of Dr Hong's assessment. As canvassed by Dr Gates in her report [page 9 of the Reply]:

"The neuropathology of neurocognitive disorders commences decades prior to symptoms becoming evident. Brain and cognitive reserve artificially support ongoing capacity until a critical level of pathological change and then impairment becomes obvious".

(m) The basis for appeal amounts to a subjective dissatisfaction with the assessment of the Medical Assessor. Accordingly, the appeal must fail as it is, in effect, a complaint that there is a difference of opinion. It is a matter of law that a difference of opinion is not a ground of appeal (see Ferguson v State of NSW & Ors [2017] NSWSC887 among others).

(n) There has been no demonstrable error. The Medical Assessor did provide an assessment with respect to the appellant's condition, and he separately identified inconsistencies with respect to the assessment of Dr Hong.

(o) The MAC should be confirmed.

1. The procedures on appeal are contained in s 328 of the 1998 Act. The appeal is to be by way of review of the original medical assessment but the review is limited to the grounds of appeal on which the appeal is made.
2. In Campbelltown City Council v Vegan [2006] NSWCA 284 the Court of Appeal held that the Appeal Panel is obliged to give reasons. Where there are disputes of fact it may be necessary to refer to evidence or other material on which findings are based, but the extent to which this is necessary will vary from case to case. Where more than one conclusion is open, it will be necessary to explain why one conclusion is preferred. On the other hand, the reasons need not be extensive or provide a detailed explanation of the criteria applied by the medical professionals in reaching a professional judgement.
3. The Appeal Panel reviewed the MAC and the evidence in the matter.

Ground 1 - failure to make an assessment of WPI

1. The appellant submits that the MAC contains a demonstrable error in that the Medical Assessor declined to make an assessment of the WPI dispute referred for assessment
2. Section 322 of the 1998 Act provides:

"1) The assessment of the degree of permanent impairment of an injured worker for the purposes of the Workers Compensation Acts is to be made in accordance with Workers Compensation Guidelines (as in force at the time the assessment is made) issued for that purpose.

1. Impairments that result from the same injury are to be assessed together to assess the degree of permanent impairment of the injured worker.
2. Impairments that result from more than one injury arising out of the same incident are to be assessed together to assess the degree of permanent impairment of the injured worker.

Note. Section 65A of the 1987 Act provides for impairment arising from psychological/psychiatric injuries to be assessed separately from impairment arising from physical injury.

1. An approved medical specialist may decline to make an assessment of the degree of permanent impairment of an injured worker until the approved medical specialist is satisfied that the impairment is permanent and that the degree of permanent impairment is fully ascertainable. Proceedings before a court or the Commission may be adjourned until the assessment is made."
2. Undre "Findings on Mental Stated Examination" on page 5 of the MAC, the Medical Assessor noted: "Subjectively, Ms Quiring expressed anxiety. Objectively, Ms Quiring did not present as depressed, elevated or irritable in mood".
3. Under "Summary" on page 7 of the MAC, the Medical Assessor wrote:

Ms Quiring's presentation and findings on examination are consistent with DSM-5 Major Neurocognitive Disorder (dementia).

Ms Quiring's cognitive function appears to have declined over the course of the past 10 [sic] based on a comparison of information documented in the report written by Dr John Roberts, consultant psychiatrist, dated 9 January 2025. When assessed by him on 16 December 2024, Ms Quiring appears to have been able to provide more information about her history than during the present evaluation. For example, she was able to accurately recall having had five Caesarean section operations and arm fractures, and was able to recall being prescribed candesartan. Thus, she has not reached maximum medical improvement.

It was not possible, due to Ms Quiring's severe memory impairment, to determine whether she had previously experienced another psychiatric diagnosis.

Ms Quiring's presentation was internally consistent, characterised by marked difficulties recall present and historical information.

Ms Quiring's presentation was consistent with the description of her presentation in the reports provided by Dr Nicola Gates, clinical neuropsychologist, and Dr John Roberts, consultant psychiatrist, but was not consistent with the report of Dr Michael Hong, consultant psychiatrist."

1. Under "Evaluation of Permanent Impairment" on pages 7-8 of the MAC, the Medical Assessor wrote:

"a. Is the worker claiming for any body part/system outside your field of expertise? If so, please indicate the body part/system: No.

1. Have all body parts/systems stabilized/reached maximum medical improvement? No.
2. If not, please list those injuries not yet stable/at maximum medical improvement: Neurological.
3. If stabilisation/maximum medical improvement, of any or all injuries has not been reached, when, in your opinion, will this occur? The usual course of Alzheimer's dementia is ongoing progression of symptoms."

1. Under "Reasons for Assessment" on page 8 of the MAC, the Medical Assessor wrote:

"a. My opinion and assessment of whole person impairment

Ms Quiring's whole person impairment cannot be accurately assessed on the basis of a single clinical assessment, due to her severe memory deficits leading to difficulties in providing accurate answers.

In making that assessment I have taken account of the following matters:-

- A specialist understanding of the nature of the diagnosed condition

1. An explanation of my calculations (if applicable) Not applicable: it was not possible to calculate Ms Quiring's whole person impairment."

"Consider comorbid features (eg bi-polar disorder, personality disorder, substance abuse) and determine whether they are directly linked to the work-related injury, or whether they were pre-existing or unrelated conditions".

1. As noted above, the appellant submits that the MAC contains a demonstrable error in that the Medical Assessor declined to make an assessment of the WPI dispute referred for assessment.
2. The Appeal Panel accepts that the referral of the medical dispute to the Medical Assessor was on the basis that there was an accepted psychological injury to be referred for assessment of WPI.
3. The Appeal Panel notes that the Medical Assessor at page 7 of the MAC found that the appellant's presentation and findings on examination were consistent with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) Major Neurocognitive Disorder (dementia). He noted that her cognitive function appeared to have declined in the last 10 months and then wrote: "Thus, she has not reached maximum medical improvement." The Appeal Panel notes that the Medical Assessor found that the appellant's unrelated pre-existing neurocognitive disorder (dementia) was progressing; the Medical Assessor did not find that the work-related psychiatric injury referred for assessment was not at maximum medical improvement.
4. This is confirmed at page 8 of the MAC where the Medical Assessor at Part 8b found that "the injuries not yet stable/at maximum medical improvement: Neurological". The Appeal Panel notes that the Medical Assessor found that the unrelated condition of dementia (Alzheimer's) was not stable. He did not address whether the psychiatric condition arising from the work injury referred to him for assessment was stable.
5. The failure to assess whether the work injury, rather that the unrelated neurocognitive disorder, was stable and at maximum medical improvement is a demonstrable error.
6. This error then effects the Medical Assessor's later reasoning on page 8 of the MAC:

"Ms Quiring's whole person impairment cannot be accurately assessed on the basis of a single clinical assessment, due to her severe memory deficits leaving to difficulties in providing accurate answers."

1. If the condition arising from the work injury had not reached maximum medical improvement then there would be no requirement to assess whole person impairment at that time.
2. The Medical Assessor has not identified the primary psychiatric injury, and thus not identified whether this injury had reached maximum medical improvement and, if so, assessed the impairment arising from this injury (even given the complexity of the case).
3. In the PIRS table, and in his summary of injuries and diagnoses the Medical Assessor states the "psychiatric diagnosis" is "Major neurocognitive disorder (dementia)". This is not primary injury referred but a progressive neuropsychiatric disorder unrelated to the injury.
4. The Appeal Panel accepts that the Medical Assessor made a demonstrable error in not making an assessment of WPI and failing to engage with the task allocated to him.
5. The Appeal Panel, having found error, will identify the primary injury and assess the WPI arising from that injury. In making an assessment, the Appeal Panel has to take into account the appellant's comorbid unrelated condition of dementia.
6. The appellant submits that a re-examination of the appellant is required and an interview could be conducted with the appellant's husband who would provide the best evidence relative to the appellant's various levels of functioning with reference to the PIRS scale but also with reference to contemporaneous material including the clinical notes of the GP and Ms Blenkin.
7. The Guidelines at 11.6 provide:

"It is expected that the psychiatrist will provide a rationale for the rating based on the injured worker's psychiatric symptoms. The diagnosis is among the factors to be considered in assessing the severity and possible duration of the impairment, but is not the sole criterion to be used. Clinical assessment of the person may include information from the injured worker's own description of his or her functioning and limitations, and from family members and others who may have knowledge of the person. Medical reports, feedback from treating professionals and the results of standardised tests - including appropriate psychometric testing performed by a qualified clinical psychologist and work evaluations - may provide useful information to assist with the assessment. Evaluation of impairment will need to take into account variations in the level of functioning over time. Percentage impairment refers to whole person impairment (WPI)."

1. The Medical Assessor conducted a Mini Mental State Examination and found that the appellant's presentation and findings on examination were consistent with DSM 5 Major Neurocognitive Disorder (dementia).
2. The Appeal Panel does not consider that a further re-examination of the appellant, whose comorbid dementia is progressive, would not provide any further information that would assist in making an assessment of WPI.
3. The Appeal Panel has read the statement of the appellant's husband dated 12 June 2025 and notes that Mr Quiring does not identify when the changes in functioning in the various PIRS categories occurred. This is important, particularly, in view of the diagnosis of dementia in late 2024. The Appeal Panel notes that such a diagnosis is only made after lengthy investigations and many months, usually a few years of cognitive decline and impairment. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM5-TR) criteria for diagnosis require evidence of an insidious onset over "months or years", associated with functional impairment over this period, and significant deficits in memory and at least one other cognitive domain. The date of the diagnosis is thus not the date of the onset of the dementia or its associate impairments.
4. The appellant's submission that an interview with Mr Quiring in order to obtain information about her levels of functioning is most unlikely to provide any further information that would assist in the assessment process, given the extensive contemporaneous clinical documentation. The Appeal Panel notes that parts of Mr Quiring's statement appear to be inconsistent with the notes of the treating psychologist, Ms Blenkin, particularly, the notes dated 15 June 2023. Further, Dr Gates, in her report of 3 September 2024 noted that Mr Quiring confirmed that the appellant had cognitively deteriorated in the past two years.
5. The Appeal Panel considers that the contemporaneous material, particularly, the clinical notes of the GP and Ms Blenkin, provides the best and most accurate basis for an assessment of WPI before the impairment arising from her Alzheimer's became so severe that it precluded assessment of the work injury related WPI based upon the appellant's current function.
6. Mr Quiring in his statement dated 12 June 2025 noted that the appellant sustained a psychological injury during the course of her employment on 22 March 2022 He stated that she was diagnosed with Major Depressive Disorder. Mr Quiring wrote:

"7. Prior to the workplace injury Jennifer was a highly capable manager, having expertise in Drug and Alcohol treatment and Aged Care, including multiple University achievements.

1. She was very social and highly regarded across several communities, having a caring nature, freely giving of support and advice, a playful nature and possessing a high degree of wit and sense of humour.
2. She enjoyed engagement in outdoor activities such as bike riding and running, having travelled by bike through Cambodia and Vietnam in previous years, and participated an several running events across the state.
3. She was a very caring and involved Grandmother, regularly asked to look after grandchildren during their parents' absence. As a marriage partner, she was the dominant partner in organising our social and business affairs, and main provider of maintaining the household including shopping, cooking and cleaning.
4. She was extremely capable and engaged across all aspects of her life, and generally extremely happy in doing so.
5. As a result of the psychological injury at work, Jennifer suffers from the following impairments with respect to her day-to-day life:

(a) Self-care and personal hygiene

• Stopped preparing meals.
• Needs reminding to shower each day.
• Needs reminding to wash her hair.
• Needs reminding to change to new clothes.

(b) Social and recreational activities

• Withdrew from social activities.
• Stopped regular exercise.
• Lost interest in participating in sporting activities and would only go at behest of myself.
• If participating would want to leave early and be disengaged.
• Would only go out to events if accompanied by a friend or family member.

(c) Travel

• Will only travel locally alone.
• Local area is without much public transport but if it was available I am confident that she could have used it

(d) Social functioning

• Able to maintain some existing friendships.
• Is unable to maintain any work-based friendships.
• Becomes argumentative with me at times.
• Was previously very social but no longer able to build new friendships.

(e) Concentration persistence and pace

• Has lost interest in reading, was previously an avid reader and now cannot concentrate on reading for any length of time.
• Found it difficult to undertake modules of work provided by work assessment team.
• Found it difficult to undertake learning modules to maintain registration.
• Lost interest in playing word games and doing jigsaw puzzles.

(f) Employability

• Says she could not go back to working in the same role and environment.
• Was interested in finding a new role but did not feel capable of going back to work at the time.
• Hoped to find a less stressful role to work in."

1. Mr Quiring stated that the appellant was diagnosed in late 2024 with dementia following cognitive decline. He wrote: "The impacts described above however were present from March 2022 and well before her decline and diagnosis."
2. In the clinical notes and records of Dr Stephan Pluscheke, GP, the following entries were made:

(a) on 25 March 2022 Dr Pluscheke noted the appellant had been subjected to workplace stresses over a long time and on "Tuesday night all came to a head, and broke down". He noted that she was "teary, not sleeping well, ruminating, getting up in the morning is a struggle, appetite reduced, focus and concentration poor".

(b) On 22 April 2022, Dr Pluschke noted there were no major changes and the appellant continues to struggle with mood. He reported that her main issues were "low mood, anxiety, unable to focus/concentrate, poor memory when gets into state and poor sleep."

(c) On 12 May 2022, Dr Pluschke noted that she appeared brighter but stated she was still struggling with depressive symptoms.

(d) On 14 June 2022 Dr Fatima Sadia noted that the appellant had developed anxiety and depression in the context of daily exposure to aggressive patients.

(e) On 5 August 2022 Dr Sadia noted that Lovan had been increased to 60mg which the appellant thought was helping. The appellant reported she was anxious all the time and her sleep was terribly disturbed.

(f) On 4 November 2022, Dr Sadia noted that the appellant had reduced fluoxetine to 40mg from 60mg and was sleeping better. She wrote: "There has been talk of RTW and this is making her anxious. Main concern is memory changes noted by self and investigated by SP in Feb with nil clinical findings. Is concerned if this will impact her ability to work".

(g) On 2 December 2022, Dr Sadia noted: "has had a set back mentally 1.5 weeks ago more anxious and tearful and hopeless."

(h) On 19 January 2023, Dr Pluschke noted that he had not seen the appellant since earlier last year and that there had been "definite improvement overall". He reported that the appellant still struggled with low mood and anxiety.

(i) On 5 March 2023, Dr Pluschke noted that there had been no change in symptoms "still up and down".

(j) On 18 April 2023, Dr Pluschke noted that "not much has changed". He wrote:

"...with memory, not terrific at times, queries further investigation... overall Jenny feels she has been a bit better. James states that emotionally Jenny is in a much better place however she will be repetitively asking the same question, getting lost driving, not finding car..."

(k) On 16 June 2023, Dr Pluschke noted "no changes".

(l) On 8 July 2023 Dr Pluschke noted: "...in view of ongoing difficulties accessing Psychiatrists and significant anxiety relating to possible Neurodeg condition suggest referral to Neurologist ".

(m) On 14 July 2023 Dr Pluschke noted: "review MRI scan - somewhat concerned by mild-mod atrophic changes noted." He wrote: "biggest concern for Jenny is concern re possible organic brain disease /dementia".

(n) On 3 October 2023 Dr Pluschke noted: "Work Cover review no major changes."

(o) On 3 November 2023, Dr Pluschke noted "ups and down persist not really progressing although certainly a lot better than 6 months ago".

(p) On 1 December 2023, Dr Pluschke noted:

"...no change...generally Jenny has been a more positive...continues to struggle with complex tasks, memory, will forget where she is going in car...smiling reactive, but repeated a couple of sentences during consult - I had not noticed this previously."

1. In the report of MRI and MRA scan of the brain dated 3 July 2023, Dr Niranjan Ganeshan, radiologist, concluded that there was mild cortical cerebral atrophy and hippocampal atrophy which can be neurodegenerative in aetiology.
2. In her clinical notes and records, Ms Blenkin made the following entries:

Jenny meets criteria for adjustment disorder with anxiety and depression. She has a very fixed and unhelpful thinking style and engages in a range of cognitive errors including catastrophizing, all or nothing thinking, black and white thinking, perfectionism. She has traditionally been a very successful woman within her career and as a family member as a daughter, sibling, wife and mother of three grown men.

Today we revisited the nature of anxiety and the impact of her thinking on physiology including executive functioning. Suggested the book - rewire your anxious mind and to increase exercise to included getting her HR above 120 for 15 - 20 minutes.

We also discussed work options that fall within a related field - eg Allied Health Assistance - which would involve using transferable skills but not involving any real responsibility or management."

(b) In an entry dated 7 February 2023 Ms Blenkin noted "Significant anxiety and depression. Unable to return to work. Late today as took wrong turn and ended up in Forster. Then berated herself...."

(c) In an entry dated 7 March 2023, Ms Blenkin noted that the appellant was much more settled "as has come to the realization that she needs to let go of the anxiety." Under History/Discussion, Ms Blenkin wrote:

"Family history of dementia and Jenny has had some checks with GP that indicated that there is. a cognitive decline. We discussed how anxiety also has an impact on executive functioning and that it was best to be as calm in all situations to function as well as we possibly can...

She completed a 10 km run last weekend and although 'finished last' knows that there were many people lying on lounges that did not start at all. She noticed while she was doing the run that she was in the moment and not thinking about it finishing.

(d) In an entry dated 12 April 2023, Ms Blenkin wrote:

"Jenny very positive today - 'Clearer, Brighter Better'. Has realized that ~he does not want to return to nursing and that she will finish in terms of W/C in the near future.

Is still concerned about her cognitive functioning and will request a brain scan when she sees her GP next week. Jenny appreciates that her decline may be a consequence of anxiety but just wants to be sure it is nothing organic.

Overall doing very well. We will make her final W/C session for 2 months' time".

(e) In an entry dated 15 June 2023, Ms Blenkin wrote:

DASS administered - all scales within the normal range.

Jenny is pleased with how she is going, although notes some cognitive decline which she is investigating.

Otherwise, dos [sic] does not feel there is any further role for psychological session so we will close this episode of care Management:

1. Dr Michael Hong, consultant psychiatrist, in a report dated 28 June 2024 noted that the appellant said that her biggest struggle was her cognitive difficulties. Dr Hong noted that in the mental state examination, the appellant smiled and laughed and engaged with the assessment process but was disorganised and needed frequent prompting from her husband. Dr Hong made a diagnosis of major depressive disorder.
2. Dr Hong wrote: "Ms Quiring has consulted at least 2 neurologists, and my understanding is that they do not believe that she has a neurological disorder or dementia." Dr Hong assessed 22% WPI. However, Dr Hong qualified his opinion and assessment on the basis that he assumed the appellant does not suffer from a neurological or dementing disorder. If that were the case her presentation was consistent with pseudo-dementia.
3. In a report dated 3 December 2024, Dr Nicola Gates, clinical neuropsychologist, noted that the appellant presented as a friendly woman with intact social pragmatic skills and a warm nature, but was visibly confused and looked to her husband for support even to answer simple questions. Dr Gates noted that Dr Mobbs, neurologist, had made a diagnosis of early Alzheimer's Disease.
4. Dr Gates reported that the results of the cognitive assessment indicated that the appellant had experienced severe cognitive deterioration, but her profile was not consistent with major depressive disorder.
5. Dr Gates wrote:

"The results are consistent with her self-reported memory impairment and deterioration, the brain CT scan of atrophy especially in the hippocampi, and the diagnosis of Dr Mobbs.

Assessment confirms DSM 5 diagnosis of Neurocognitive Disorder, probably Alzheimer's type, however medical examinations appear to be ongoing. Based on the reported impact of her impaired cognition on her daily function, corroborated by her husband, Mrs Quiring is considered to have moderate to severe neurocognitive disorder.

The neuropathology of neurocognitive disorders commences decades prior to symptoms becoming evident. Brain and cognitive reserve artificially support ongoing capacity until a critical level of pathological change and then impairment becomes obvious".

1. Dr John Albert Roberts, consultant psychiatrist, in a report dated 9 January 2025 considered that the appellant presented with a pleasant manner and displayed evidence of profound cognitive impairment. Dr Roberts referred to the report of Dr Gates dated 3 September 2024 and stated that he agreed with Dr Gates' assessment that the appellant had neuropathology long before the work stress issues. Dr Roberts concluded that the appellant was suffering from a pre-existing non work-related condition of dementia and the prognosis was for a progressive deterioration in symptomatology over time.
2. Based on the examination findings of the Medical Assessor and the evidence in this matter, the Appeal Panel was satisfied that the appellant has an unrelated condition, namely, dementia (Alzheimer's) that had not been diagnosed at the time of the work injury. Dementia (Alzheimer's) is progressive. This can be regarded as a comorbid condition.
3. Using the evidence the Appeal Panel made the following assessment of the appellant's current WPI under the PIRS:

The appellant reports showering on a daily basis, attending to dental hygiene. Mr Quiring advised the Medical Assessor that the appellant required prompting to attend to activities of daily living, does not do so independently or wholly make meals but assists him at times and eats three meals a day. The Appeal Panel considers that this is a moderate impairment, Class 3, and that the appellant would be unable to live independently without regular support and would not be safe for any extended time by herself.

Dr Hong reported that the appellant attends occasional social recreational activities with her family and friends but overall, had been doing it less since her injury. Dr Hong reported that she had a catch up with her husband and friends two times per week recently. Dr Gates referred to the appellant going for walks and noted that the appellant indicated that she rose at 8am and would read, listen to music, potter, watch Netflix and attend to some housework. The Medical Assessor noted that the appellant reported being able to enjoy spending time with her children. Mr Quiring stated that the appellant only goes out if accompanied by a family member of friend.

The Appeal Panel considers that this is a moderate impairment, Class 3, as she continues to do some family activities but only accompanied by her husband, family or other support person.

The Appeal Panel notes that the Medical Assessor was told by Mr Quiring that the appellant cannot drive. The Appeal Panel is satisfied that the appellant would be unable to travel away from her residence due to her cognitive impairment, and the level of impairment described would preclude safe use of public transport unaccompanied. The appellant was accompanied by Mr Quiring to the examination. The Appeal Panel considers that this is a moderate impairment, Class 3.

The appellant reported to the Medical Assessor that she enjoyed spending time with her children. The appellant appears to be well supported by her husband and family. a mild impairment. Dr Hong assessed Class 2 for social functioning. The Appeal Panel considers that this is a mild impairment, Class 2.

The appellant was unable to provide an accurate history in the examination by the Medical Assessor. Mr Quiring clarified that she does not manage or access her bank accounts. The appellant's MMSE score was 10/30. This is substantially below the 23/30 threshold for probable dementia and indicates poor cognitive function in several domains. The Medical Assessor noted that the appellant's cognitive function appeared to have declined over the last 10 months based on the findings made by Dr John Roberts and noted in the report of 9 January 2025. Dr Gates' report documents a range of standardised cognitive tests, which indicated global and clinically significant cognitive impairment on Ms Quiring's part, including extremely poor word-finding difficulties, visual memory task impairment, a below average short-term memory, and extremely low information processing speed. Ms Quiring was documented to perform extremely poorly in tests of new learning, immediate recall and retention, the core memory features of Alzheimer's disease, scoring below more than 99% of her peers.

Dr Hong in his report of 28 June 2024 noted that there was a history of significant cognitive difficulties and assessed Class 4 for concentration, persistence and pace. The Appeal Panel considers that this is a severe impairment, Class 4.

The Medical Assessor noted that the appellant was unable to give any information of her work history and could not even recall when she ceased work. Appeal Panel notes that Dr Hong assessed Class 5 for employability. The Appeal Panel considers that the appellant is totally impaired, cannot work at all, Class 5.

1. The Appeal Panel must consider whether this WPI is attributable wholly or in part to the work related injury.
2. The appellant sustained a primary psychiatric injury at work deemed to have occurred on 22 March 2022. The Appeal Panel is satisfied from the contemporaneous clinical evidence that this primary psychiatric injury, major depressive disorder with panic attacks, had resolved by the time the appellant finished treatment with Ms Blenkin on 15 June 2023, and the cognitive difficulties referred to by Ms Blenkin in her clinical notes were caused by the progressive dementia and not by the work injury. The Appeal Panel noted that the appellant completed a 10km run just before her consultation with Ms Blenkin on 7 March 2023. The appellant required no further treatment from Ms Blenkin after 15 June 2023 as she was well, and all of the Depression, Anxiety, and Stress Scales (DASS scales) (measuring symptoms of depression, anxiety and stress), were in the normal range indicating no clinically significant symptoms of the depression or anxiety remained at the stage.
3. It is significant that the appellant did not present as depressed in the medical examinations with the Medical Assessor (page 5 of the MAC).
4. As such the evidence before the Appeal Panel is that the work-related injury had resolved such that there were no symptoms of this injury in the middle of 2023. The Appeal Panel is satisfied that the appellant's work-related injury was in remission and that her cognitive difficulties at the time of the Medical Assessor's examination were caused by her comorbid neurocognitive disorder.
5. Given the injury had resolved in mid 2023 none of the current WPI is attributable to this injury, the work-related injury's impairment is 0% and all the current WPI is caused by the comorbid and progressive condition, Alzheimer's Disease.
6. In summary, the Appeal Panel makes an assessment of 26% WPI and finds that none current WPI is attributable to the work injury deemed to have occurred on 22 March 2022.
7. Therefore, the assessment of total WPI by the Appeal Panel is 0% WPI in respect of the injury deemed to have occurred on 22 March 2022.
8. For these reasons, the Appeal Panel has determined that the MAC issued on

20 October 2025 should be revoked, and a new MAC should be issued. The new certificate is attached to this statement of reasons.

State of New South Wales (Hunter New England Local Health District)

This Certificate is issued pursuant to s 328(5) of the Workplace Injury Management and Workers Compensation Act 1998.

The Appeal Panel revokes the Medical Assessment Certificate of Medical Assessor John Lam-Po-Tang and issues this new Medical Assessment Certificate as to the matters set out in the table below:

Chapter, page and paragraph number in NSW workers compensation guidelines

Chapter, page, paragraph, figure and table numbers in AMA 5 Guides

Proportion of permanent impairment due to pre-existing injury, abnormality or condition

Sub-total/s % WPI (after any deductions in column 6)

Total % WPI (the Combined Table values of all sub-totals)

The above assessment is made in accordance with the SIRA NSW Guidelines for the Evaluation of Permanent Impairment for injuries received after 1 January 2002.