A.1 Facts established by the contemporaneous clinical notes, reports, WorkCover certificates and other records of Mr Rahman's treating doctors
- The histories stated in the medical reports in the Court Book were admitted as facts of the history being given to the doctor but not as the truth of those facts. This limitation on the use to be made of the evidence did not apply to clinical notes. The limitation was somewhat overridden when it was put to Mr Rahman in cross-examination, and he agreed, that he had told the truth to all of the doctors he had seen (T170:30).
- I find that the following facts are established by the contemporaneous clinical notes, reports, WorkCover certificates and other records of Mr Rahman's treating doctors.
- The ambulance officers who attended the scene of the accident recorded that Mr Rahman complained of pain to his left breast and lumbar spine, and that they observed a seatbelt bruise.
- When Mr Rahman saw his GP, Dr Wilton, the day after the accident he complained of ongoing chest pains and a sore back.
- Dr Wilton sent Mr Rahman for an x-ray of his chest, ribs and thoracic spine. The radiologist who performed the x-ray two days after the accident, Professor John Magnusson, noted in his report that there was a clinical history of a suspected fracture. No evidence of an acute fracture was seen.
- Two and half weeks after the accident, in a Medical Certificate dated 22 September 2017, Dr Wilton recorded that Mr Rahman's soft tissue injuries to his anterior chest wall, which he referred to as an "airbag injury", had resolved, but that Mr Rahman complained of persistent low back pain and intermittent neck pain. He also noted injuries to Mr Rahman's right wrist, right knee and right ankle.
- Three and half months after the accident, on 19 December 2017, Dr Wilton saw Mr Rahman and recorded that today's examination confirmed no serious injuries were sustained but that Mr Rahman continued to suffer from significant pain in his back extending from the thoracic region to the lumbar area; that he continued to have pain and swelling in his right wrist; and that his ankles and feet were notably swollen and produced aching with prolonged movement.
- Five months after the accident, on 9 February 2018, Dr Wilton examined Mr Rahman and recorded that he continued to suffer from lower and middle back pains occasionally extending to the upper part of his back and that his right leg in particular continued to become painful and weak. Dr Wilton noted that his aching back was benefited by regular physiotherapy.
- A little over six months after the accident, on 16 March 2018, Dr Wilton certified that Mr Rahman had suffered back and leg injuries in the accident and the factors delaying his recovery were worsening pain in his back and legs with any prolonged sitting or driving. He referred Mr Rahman to a specialist in rehabilitation medicine, Dr Seamus Dalton.
- Dr Dalton was confident that if Mr Rahman could build up his core stability and overall fitness, his symptoms would improve and he would be able to get back to work. He referred Mr Rahman to an exercise physiologist, Mr Luke Bowen.
- Mr Bowen shared Dr Dalton's optimism. Upon assessing Mr Rahman eight months after the accident, on 2 May 2018, he too was of the view that Mr Rahman would benefit from a comprehensive core, gluteal and trunk strengthening programme. He observed however that Mr Rahman "has nil active coping strategies and feels that pain means trauma or injury".
- By July 2018, now 10 months after the accident, Dr Wilton was concerned that Mr Rahman had suffered from severe back pain and sciatic pain since the accident, that he could not sit still for more than half an hour, had never had proper analgesics and that he suffered from chronic pain. He therefore referred Mr Rahman to Professor Philip Siddall, who was a Professor in Pain Medicine and the director of the Pain Management Service at the Greenwich Hospital. Professor Siddall's impression was that Mr Rahman had pain in the mid to lower back as well some pain in the right arm and leg. His impression was that there were a number of contributors to the pain. In the absence of skeletal changes on imaging, Professor Siddall said it was difficult to be clear on the underlying pathology but the presumed focus of pain was localised inflammatory changes in the spine with secondary muscle tension. He said that the tenderness in the lumbar spine and right sacroiliac joint suggested that there may have been involvement of the lower lumbar facet joints and sacroiliac joint contributing to the pain. He also noted that Mr Rahman reported some symptoms of post-traumatic stress. Professor Siddall recommended to Dr Wilton that with the ongoing disability and pain Mr Rahman was experiencing, an intensive program such as the one offered at Royal North Shore Hospital would be advisable.
- Dr Wilton took Professor Siddall's advice and referred Mr Rahman to the pain clinic at Royal North Shore Hospital. It took of number of months before Mr Rahman was assessed as suitable for entry into the program and another couple of months before he could commence.
- In the meantime, Dr Wilton sent Mr Rahman for an MRI of his lumbar spine at the request of a WorkCover orthopaedic surgeon. The MRI was carried out on 11 September 2018, a year after the accident, by Dr Tej Dugal radiologist who reported that the MRI demonstrated at L1/L2 a small left paracentral disc protrusion associated with left annular tear, and whilst this indented the left hemithecal sac, it did not cause neural compression. The day before, on 10 September 2018, Doctor Wilton had recorded in his notes that Mr Rahman was clearly very distressed and depressed and in obvious constant pain while sitting talking to him.
- On 5 October 2018, Dr Wilton certified in a report that as a consequence of the accident, Mr Rahman had been seriously disabled and remained so even one year later. He certified that Mr Rahman remained in constant severe low back pain preventing him from sitting more for more than a short period of time and as a consequence he had developed a significant depressive illness.
- In November 2018 Mr Rahman was assessed as suitable for entry into the ADAPT program at the pain clinic at Royal North Shore Hospital. The assessment was undertaken by Associate Professor Allan Molloy (a senior staff specialist), Dr Andrew Singer (a psychiatrist) and Ms Jessica Castle (a physiotherapist). The ADAPT program is designed to help people with persisting pain to return to work or normal activities; reduce the use of medication and healthcare services; restore general function; improve mood; and learn effective pain coping strategies.
- Mr Rahman completed the first phase of the ADAPT program in January 2019, attending Royal North Shore Hospital on a daily basis from Monday to Friday for three weeks. Dr Sarah Overton (a clinical psychologist) writing on behalf of the director of the program (Professor Nicholas), reported to Dr Wilton that "Mr Rahman attended the program every day and participated fully"; that "his application of the pain management strategies … was good."; and that "During the program it was noted that Mr Rahman has ongoing significant symptoms of PTSD which he says are holding him back. He should have professional treatment to address these and has been given the details of a relevant service". The service suggested was the Traumatic Stress Clinic in Westmead.
- On 15 February 2019, Mr Rahman attended Royal North Shore Hospital Emergency Department. According to the Discharge Referral Notes, he presented with lower back pain after pulling out a drawer that day.
- On 26 February 2019, Dr Wilton certified that when Mr Rahman attended the ADAPT program at Royal North Shore Hospital pain clinic they identified that he was suffering from significant post-traumatic stress as a result of the accident and that this was a major inhibiting factor in his recovery. Dr Wilton noted that Mr Rahman was having additional support from a psychiatrist to treat this problem and that "it is likely he will never be able to return any employment requiring prolonged driving". The psychiatrist was Dr Singer.
- The next day Dr Singer wrote to Dr Wilton informing him that he had seen Mr Rahman and that Mr Rahman had some residual PTSD symptoms, was "still quite focused on his pain in a hypervigilant way" and that he had been referred to the Traumatic Stress Clinic at Westmead.
- By 7 March 2019 Mr Rahman had started phase 2 of the ADAPT program and Dr Overton (clinical psychologist) wrote again to Dr Wilton about Mr Rahman's progress. Dr Overton told Dr Wilton that Mr Rahman's scores on psychometric measures were consistent with his presentation and showed a sustained improvement in his confidence to manage pain, but an increased level of catastrophising. She told Dr Wilton that Mr Rahman's scores on measures of mood suggested a mild level of depression and a severe level of anxiety.
- Between March and June 2019 Mr Rahman attended the Traumatic Stress Clinic at Westmead, as had been recommended by the Royal North Shore Hospital pain clinic. This was a 9 session program of trauma-focused cognitive behaviour therapy. According to a report from the Westmead clinic, written by Dr Dharani Keyan, Clinical Psychologist, and dated 8 February 2021, at Mr Rahman's initial assessment on 21 March 2019 his presentation and the symptoms he reported were consistent with a diagnosis of PTSD, and on further assessment Mr Rahman reported symptoms consistent with a DSM-5 Major Depressive Episode.
- On 27 June 2019, Dr Wilton prepared a report which set out the following summary of Mr Rahman's injuries, treatment and progress up to that point:
In summary, there were no serious physical injuries sustained by this gentleman at the time of the accident. However he immediately developed severe low back pain which persisted. This has finally improved following his attending a prolonged course at the specialised pain clinic at Royal North Shore Hospital. He continues to have ongoing back pain but is now able to tolerated (sic) it much better. He is unable to tolerate any significant lifting or any activity that might put strain to his back and has difficulty with prolonged sitting. He will never be able to return to any occupation requiring significant physical activity or prolonged sitting. He is unable to do any home activities requiring lifting more than 1 or 2 kg and is unable to lift his children or play with them in any more than minor physical activity. He is unable to assist his wife with any daily activities such as shopping or cleaning that may require more than minor physical exertion. In 2018 as part of his management by the pain clinic, he was diagnosed as having a significant post-traumatic stress disorder. This explains his long history since the injury in his having ongoing panic attacks and a degree of agoraphobia and has developed a significant depression as a result. He has flashbacks and will never be able to return to any occupation in which he would be the driver of a motor vehicle for any length of time. He is having ongoing treatment from psychologists. However the prognosis remains unclear.
- According to Dr Wilton, by 9 September 2019 Mr Rahman's back pain had significantly increased recently despite Mr Rahman doing all the treatments advised from the pain clinic. His mood was holding up, however, because he was seeing a psychiatrist regularly, and he was on a new antidepressant.
- On 31 October 2019, now a little over two years after the accident, Dr Singer (psychiatrist) wrote to Dr Wilton after reviewing Mr Rahman at the clinic that day. Dr Singer reported to Dr Wilton that Mr Rahman continued to experience low back pain and low mood associated with light headedness and other somatic symptoms, and that he had some symptoms of PTSD largely related to driving and being on the road. Dr Singer reported that Mr Rahman was compliant with medication and the Westmead stress clinic program "seem(ed) to have helped at the time". Dr Singer said, "In summary, his improvement seems to have plateaued.".
- On 2 December 2019, after seeing Mr Rahman, Dr Wilton recorded that Mr Rahman's back pains were worsening with often significant stabbing pains now occurring.
- On seeing Mr Rahman a month later Dr Wilton recorded that Mr Rahman had spontaneously developed worsening pain in his lower back, now sometimes radiating into his right buttocks and into his right lateral thigh.
- At the end of January 2020 Dr Wilton referred Mr Rahman for a CT of his lumbar spine and an x-ray of his right hip. This was undertaken on 6 February 2020 and the radiologist, Dr Nalayini Balendran, reported that "At L5-S1, there is a small, broad-based disc protrusion seen, indenting on the exiting L5 nerve roots bilaterally.".
- Dr Wilton saw Mr Rahman on 11 March 2020 and recorded in his clinical notes that Mr Rahman had rapidly worsening low back pain radiating to his right buttocks and around to his right groin and that the recent CT scan of his lumbar spine suggested possible nerve impingement at the L5 level bilaterally from a disc protrusion. Dr Wilton came to the view that Mr Rahman was obviously in pain and recorded graphically in his notes that "This gentleman was unable to sit in the chair opposite me for more than 3 or 4 minutes before needing to get up and paste the floor due to the pain in his back".
- Dr Wilton saw Mr Rahman another nine times from March to July 2020. By 31 July 2020 Mr Rahman had had further investigations carried out including an ultrasound and bone scan. Dr Wilton recorded in his clinical notes of 31 July 2020 that the bone scan indicated inflammatory changes were present on the right side at the level of L3/4 in the facet joint. Dr Wilton recorded that he "confirmed with the patient that this was consistent with his chronic significant pain".
- By 12 October 2020 Mr Rahman had recently had facet joint steroid injections to his lumbar spine which had resulted in improvement to his back pain, although Dr Wilton said it was still "early days".
- In the meantime, Mr Rahman continued to see Dr Singer.
- On 10 March 2021 Dr Wilton recorded that Mr Rahman had been recently reviewed by the pain clinic who recommended assessment for possible nerve ablation.
- Mr Rahman continued to see Dr Wilton and Dr Singer regularly throughout the rest of 2021 and 2022, and into 2023.
- Dr Singer provided a detailed report on 1 September 2022 about his treatment of Mr Rahman, the progression of his disabilities and his prognosis which I refer to below. He also provided a further short report on 14 September 2023.
- Dr Wilton provided further WorkCover certificates in February, June and August 2023.