Non-economic loss
61 The judge made the following findings in relation to the plaintiff's physical capacity before the accident:
(1) She was able to play Bocce, a traditional Italian game of bowls, twice a week for three hours in the morning and three hours in the afternoon. A player has to bend down and bend his or her back and legs to lift the ball, which weighs approximately 1 kg.
(2) She was an accomplished cook of Italian cuisine.
(3) She made her own clothes, and she was accomplished in knitting, crocheting and dressmaking.
(4) She helped out at an old person's home, where she assisted the disabled and elderly.
(5) She looked after her own domestic work. The home in which she and her husband lived consisted of two stories, containing three bedrooms, lounge, dining and breakfast rooms, with spare rooms downstairs. She did all of the household chores, including the washing, ironing and cleaning.
(6) Her recreations included swimming and, occasionally, fishing from the promenade.
(7) Although the plaintiff suffered an unrelated injury to her right hand some time prior to this accident, the effects of that injury cleared up quickly, and the plaintiff was not impeded in their everyday activities by reason of this pre-accident injury.
These findings were open on the evidence, despite recorded complaints by the plaintiff of low back pain since 1995, and radiological evidence in 2000 of the onset of osteoporosis, but they depended on the judge's acceptance of the plaintiff's evidence. He was not bound to reject her evidence because of her pre-existing conditions, as her evidence was not necessarily inconsistent with their existence. On the evidence, they could have been largely symptom-free.
62 The judge made the following findings in relation to the plaintiff's physical capacity after the accident:
(1) At first, the plaintiff was unable to sit, she was sleeping poorly because of pain, and she had severe pain when travelling in a car. Her walking was limited by pain, and she was unable to use her right hand.
(2) She was unable to participate in swimming, playing sport or her usual household duties.
(3) Some eight months after the accident, the plaintiff had developed severe low back pain, which did not respond to physiotherapy. She had pain in her right thumb and wrist. The ability to do "house work, cooking etc" was significantly impaired. She was unable to play Bocce.
(4) Twenty-seven months after her accident, there had been little change to the plaintiff's condition, despite the operative procedures to her thumb.
These findings were also open on the evidence and they were supported by the plaintiff's medical evidence, but again they depended on the judge's acceptance of the plaintiff's evidence.
63 The particular issue raised by the defendant on appeal is whether the cause of these post-accident complaints of pain and disability was her pre-existing medical condition rather than the accident. An alternative issue is whether the accident exacerbated or aggravated her pre-existing medical condition.
64 The trial was conducted on the basis of medical reports without calling the doctors who wrote those reports as witnesses in the case, notwithstanding that the reports of Dr Trefely (the plaintiff's family doctor) and various orthopaedic specialists retained by the plaintiff did not deal at all with the plaintiff's pre-accident medical history which had been investigated by Dr Bliss for the defendant. It is clear that the plaintiff's orthopaedic specialists did not know of the extent of that history, so that the judge had no assistance from what their views may have been had they known of it, and Dr Trefely was not requested to attend for cross-examination in relation to the history of her pre-existing ailments recorded over the years.
65 Such an approach appears to be commonplace in the District Court these days, notwithstanding the sometimes stark contrast between the reports of each party. As such medical reports rarely deal with the views expressed in the other reports, the judge is left with the difficult task of determining which reports to accept without the very real assistance which can often be given by a medical witness when different facts as to what happened, and different views as to the consequences of what happened, are put to the doctor in cross-examination.
66 There is no suggestion in the present case that the views of Dr Bliss came as such a surprise to the plaintiff's legal representatives that they had no chance to have her doctors record their reactions to this new material or to seek to have Dr Bliss attend for cross-examination. The plaintiff bears the overall onus of proof on the issue of damages, and thus must face the consequences of her damages being assessed on the understanding that the opinions of her doctors were based on insufficient material and that the opinion of Dr Bliss was untested and unanswered. In my view, however, provided that absence of any challenge is taken into account, it does not follow that the tribunal of fact must necessarily accept the whole of the reports of Dr Bliss in favour of the defendant, without making its own assessment of the intrinsic value of his opinions based on the material before him.
67 Dr Bliss first saw the plaintiff in December 2002. He reported that the plaintiff was recovering from her fall, but had been left with limitations. He thought that her injuries and disabilities were consistent with the manner in which the accident is stated to have occurred. Having seen an x-ray, the doctor said that he did not think that the plaintiff had any pre-existing condition which may have predisposed her to the injuries she received. He did suspect the presence of osteoporosis. He thought that the plaintiff may have damaged her lumbar spine in the fall, and that she was likely to continue to suffer from some back pain. He did not think that the plaintiff suffered from any functional overlay. The doctor's prognosis was that a complete recovery from this type of injury rarely occurs in the plaintiff's age group, although he suggested that she would regain more function if she were determined to do so. He thought that the plaintiff would obviously continue to require assistance in keeping the house clean.
68 Dr Bliss next saw in the plaintiff in July 2004. At this stage, he expressed his doubt that the fall in January 2002 was the only source of the plaintiff's limitations. He assigned the reason for her continuing problems as being, in part, her resentment at the defendant's negligence rather than to the physical injury itself. The doctor accepted that the fall could have exacerbated the degenerative condition at the base of her right thumb. He said that, if the plaintiff's complaints were to be accepted, her continuing incapacity was "major". Her inability to play bowls arose from the pain in her back and her inability to hold a heavy bowl and bend low enough to project the bowl along the lawn. Dr Bliss now perceived some evidence of functional overlay, but he accepted the plaintiff's inability to bake, knit or sew at all. Later in his report, however, he expressed a different view, that he did not think that the plaintiff's wrist was really as bad as she stated so as to totally incapacitate her from activities such as knitting, sewing and baking. He thought that this was a result of ageing rather than the fall, the effects of which, he said, had been resolved by this time, partly due to a recent surgical intervention to the plaintiff's thumb. The doctor said that the plaintiff would continue to deteriorate "as much as to ageing as due to any long-term "affects" [sic] of the injuries", although he thought that she may have remained fitter if she had continued to play bowls. He dismissed the need for a live-in carer, but he thought that, if the need did arise, it could be a result of ageing and not the effects of the accident.
69 Following this second report, Dr Bliss was provided with the plaintiff's family doctor's hand-written notes and further reports by him "plus other reports including some of investigations". It is unclear from the third report from Dr Bliss, dated 13 July 2004, just who had prepared the other reports and investigations to which he referred, although they may well have been radiological investigations and reports. Dr Bliss drew attention to the fact that the plaintiff had suffered from backache and "reduced walking distance" in 1995. In 1997, she complained of right hip and sacroiliac joint pain radiating to the left thigh, with low back pain, for which she attended hydrotherapy. Also in 1997, the plaintiff was found to have osteoarthritis at the base of her right thumb. In 1999, she fell at Clovelly when she bruised her leg and had a painful left shoulder with a restricted range of movement. In 2000, the plaintiff slipped at bowls and had pain in her left shoulder. Chest x-rays also showed some osteoporosis in the lumbar spine (as did later x-rays in April 2004). Later in 2000, the plaintiff sprained her right ankle, which was painful and she was on crutches for four weeks. In March 2001, the plaintiff complained again of the low back pain. Except in relation to the incident in late 2000, Dr Bliss does not appear to have considered the periods of incapacity (if any) arising out of these incidents to be significant. The typed extracts of the family doctor's notes disclose some other such material, but the ones to which i have referred in this paragraph are those that Dr Bliss thought to be sufficiently significant to include in his third report.
70 Dr Bliss now expressed doubts as to the degree of the plaintiff's limitations in her domestic situation, but the basis for that opinion appears to be simply one that, because her physical and radiological examination did not demonstrate those limitations, the existence of those limitations should not be believed. He said at one stage of his report that the plaintiff's current limitations "do not have much to do with the accident" (my emphasis). At another stage of his report, the doctor said that the condition of the plaintiff's thumb was due solely to a pre-existing degenerative condition, although the fall could have triggered pain "for a time but not disabling up until now [July 2004]", and that she may not be trying as hard because she felt depressed.
71 The doctor also expressed doubt that the plaintiff would have been able to carry out the tasks she claimed to carry out before the accident. Notwithstanding all this, he concluded:
Overall therefore I do not think that despite the many, many visits to her family doctor in the past that this alters the opinion expressed in my two [previous] reports.
He emphasised that his previous opinion that the plaintiff would need nursing and domestic care in the future would probably be because of ageing and not the effects of the accident.
72 The judge held that cause of the plaintiff's continuing complaints and disabilities was her fall in the accident, and he rejected the defendant's argument that they were the natural consequence of her previous ailments. He did so on the basis that he accepted the evidence given by the plaintiff, whom he described as a "truthful and reliable witness", and that he was persuaded that "the injury which she suffered in the fall in January 2002 is the cause of her current disability." He accepted the plaintiff's evidence that she had been an active woman prior to the accident, and that, had the accident not occurred, she would have been able to continue her participation in these activities for many years to come. He did not accept the opinion of Dr Bliss that the ageing process would by now have restricted the plaintiff's activities to the degree to which they are now restricted.
73 In relying solely on the plaintiff's evidence that she had suffered her pain and disabilities only after the fall in determining that the fall was the sole cause of that pain and disability, the judge gave no express consideration to the uncontradicted evidence that she had the pre-existing ailments already referred to, even though it was open to him to accept her evidence that they were largely pain-free. Of particular importance was the pre-existing degenerative condition of the plaintiff's right thumb, which was one of the principal causes of her inability to play bowls after her fall. The other principal cause of that inability was the pain in the plaintiff's back, which was also a principal cause of her inability to do her housework.
74 The absence of any express consideration of those matters by the judge leads strongly to the conclusion that either he did not consider them to the relevant or he gave them insufficient weight. In my opinion, in either case error has been demonstrated, and it therefore becomes necessary for this court to consider for itself whether the plaintiff's pre-existing medical condition was the cause of her complaints of pain and disability rather than the fall, or alternatively whether the fall exacerbated or aggravated her pre-existing medical condition to produce her pain and disability.
75 I accept that, as argued by the plaintiff on appeal, no error has been demonstrated in the judge's finding that her pre-existing ailments did not prevent her from carrying out her activities on a regular basis before the fall. Nevertheless, I also accept that the evidence of the plaintiff's doctors must be significantly qualified because of the absence of any consideration by them also of her pre-existing ailments. However, I do not accept that plaintiff's next argument, that the evidence shows that her back had "fully recovered" by the time of her fall. The fact that the plaintiff suffered pain intermittently for some years prior to her fall demonstrates that there must have been some underlying condition, one which sometimes produced pain and sometimes did not. Nor do I accept the plaintiff's argument that, because not every one of the matters raised by the defendant on appeal in relation to her pre-existing ailments had been put to her in cross-examination, the defendant should not be permitted to rely on the reports of Dr Bliss insofar as they are based on the matters which had not been put to her. All those matters were in evidence, in the records of the plaintiff's family doctor. They arose to a very substantial extent during the course of her evidence, and sufficiently to entitle the defendant to rely on the reports of Dr Bliss without procedural unfairness. As to her pre-existing back pain, this was adequately dealt with in her evidence at the following pages of the Black Appeal Books: 19, 82, 85, 86, 88, 89 and 90. As to her pre-existing problem with her thumb (and hand generally), this was adequately dealt with at the following pages: 61, 83, 84, 85, 86 and 87. There was no breach of the rule in Browne v Dunn (1894) 6 R 67.
76 Considering all of the material in evidence for myself, I do not accept the defendant's argument that the reports of Dr Bliss support its claim that the plaintiff's present condition would have been the same without the fall on the promenade in January 2002. The defendant's argument overlooks the important statement made by Dr Bliss in his third and last report that, despite everything disclosed in the material produced immediately before that report was written, he remained of the opinions expressed in his two previous reports. The opinions expressed in his two previous reports were that, on the basis of an x-ray he had seen, he did not think that the plaintiff had any pre-existing condition which may have predisposed her to the injuries she received, that she may have damaged her lumbar spine in the fall, and that the fall could have exacerbated the degenerative condition at the base of her right thumb. In his second report, Dr Bliss said that, in his opinion, the plaintiff had become disabled "for a number of reasons", and that the fall was not necessarily "the only source of her limitations". In his third report, he conceded that the plaintiff's current limitations did have something (although not much) to do with her accident, and that the fall could have triggered some pain in the plaintiff's thumb.
77 It was, as I have already stated, open to the judge to accept the plaintiff's evidence as to both her ability to carry out her normal activities before the incident and her pain and disabilities immediately after the accident and continuing. Dr Bliss does not address the precise coincidence of the sudden onset of the plaintiff's continuous pain and disabilities with the fall in her accident - except for the implicit suggestions that the plaintiff could not have been able to carry out her pre-accident activities and that her present limitations have been exaggerated. In the light of the judge's findings that the plaintiff did carry out those activities, and (based in part of the reports of the plaintiff's doctors) that she does suffer from those limitations, the fundamental thesis put forward by the defendant collapses.
78 In my opinion, in the light of the judge's findings of fact (other than as to the cause of the plaintiff's post-accident condition), the medical evidence should be treated as accepting that the fall caused some new problems for the plaintiff, that it exacerbated the plaintiff's pre-existing and largely pain-free conditions, and that she suffers continuing effects of the fall. The somewhat grudging nature of the concession made by Dr Bliss that she did continue to suffer at least some effects is dependent on his disbelief of much of the plaintiff's claim of such continuing effects. As the judge has accepted her evidence that she does continue to suffer from those effects, I reject the limitation which Dr Bliss has imposed on that concession.
79 The new problems for the plaintiff produced by the fall were the immediate effects of the fracture of part of her coccyx, and the abrasions and bruising to her right buttock. I am not satisfied on the evidence that those particular effects still continue. In my opinion, the fall exacerbated the effects of the pre-existing degenerative condition of her right thumb and the condition of her back which before the fall had produced intermittent pain. What had previously been intermittent pain became virtually continuous, and disabling, pain. I see no reason to disturb the judge's findings as to the plaintiff's continuing pain and disabilities, set out in par [62] supra, except that I would classify them as the effects of the exacerbation of the plaintiff's previous ailments rather than the result only of her fall. The major exacerbation was to make virtually continuously painful and almost completely disabling what had previously been only intermittently painful and disabling to a minor degree.
80 The next issue which arises is the length of time during which the exacerbation will continue and whether and when the continuous pain and disabilities would have developed in any event as a result of the normal course of the ageing process on the plaintiff's pre-existing ailments, without the fall. (I have already rejected the defendant's argument, based on a misunderstanding of the evidence of Dr Bliss, that they would have developed at the time of the fall even without that fall: par [75] supra.) This present issue is by no means easy to determine without the assistance of any evidence from the plaintiff's doctors. Indeed, one course would be to send the issue of damages back to the District Court for reassessment, when the judge will have the assistance of balanced medical evidence. However, as I stated earlier (at par [66]), the plaintiff (as the overall bearer of the onus of proof on the issue of damages) must face the consequences of the inadequacies of the procedure adopted in relation to the medical evidence in the District Court.
81 The plaintiff was seventy-two years of age at the time she fell. She is now seventy-six years of age. Her life expectancy as at the date of the trial (September 2004) was 13.6 years. No current figure for life expectancy was given on appeal. It is reasonable to make the assumption, based on the history of the plaintiff's pre-existing ailments, that even without the fall she would in time have suffered some restriction of movement and some back pain which would interfere with her pre-accident activities, but I am not prepared to find, as the defendant asserts, that without the fall she would ever have reached the state of pain and disability from which she now suffers. I am satisfied that the effects of the exacerbation of the plaintiff's pre-existing ailments will be permanent, although an allowance must be made in assessing her non-economic loss for the fact that the ageing process would eventually have produced some pain and disability even without the fall.
82 The judge found that the severity of the plaintiff's non-economic loss was 30% of a most extreme case. The defendant has submitted that this should be reduced to 20%. That submission was based on the defendant's view of the medical issues which I have almost wholly rejected. In my opinion, a much more modest adjustment is required following the views I have expressed in the last four paragraphs of this judgment. I would reduce the percentage of a most extreme case from 30% to 27%. As this is a rehearing on the issue, the law to be applied is that which applies as at the date of the rehearing: Video Excellence Pty Ltd v Cincotta (1998) 44 NSWLR 742 at 745. That decision was applied by this Court in relation to s 16 of the Civil Liability Act in Coleman v Barrat [2004] NSWCA 27 at [70]. The maximum amount of damages for non-economic loss in a most extreme case had been increased at the time of the hearing of the appeal to $400,000. The calculation presented by the s 16 schedule is 10% of that figure, or $40,000. I would therefore include in the plaintiff's damages an amount of $40,000 for non-economic loss.