1. On 8 August 2025 Jan Tooth lodged an Application to Appeal Against the Decision of a Medical Assessor. The medical dispute was assessed by Dr Surabhi Verma, a Medical Assessor, who issued a Medical Assessment Certificate (MAC) on 29 July 2025.
2. The appellant relies on the following ground 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 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 has determined that the Medical Assessor has erred in determining that the appellant has reached maximum medical improvement (MMI) and as a consequence, has erred in her whole person impairment (WPI) assessment of the various categories of the psychiatric impairment rating scale (PIRS).
3. The Panel has determined that the appellant should undergo a further medical examination however, that is not possible to arrange at this time due to the appellant's current circumstances.
4. Accordingly, the Panel has determined that no re-examination should take place unless and until the appellant's treating doctors confirm that MMI has been reached.

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. Both parties made written submissions. They are not repeated in full, but have been considered by the Appeal Panel.
2. In summary, the appellant submits that the Medical Assessor erred in concluding that the appellant had reached (MMI) and as a consequence, erred in her assessments of five of the categories of the PIRS.
3. In reply, the respondent submits that no errors were made.

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 appellant was referred to the Medical Assessor for assessment of WPI in respect of a primary psychological injury on 7 June 2022.
4. The Medical Assessor obtained a history of the circumstances of the injury which we do not intend to repeat here.
5. The Medical Assessor continued:

"Previously energetic and efficient, she gradually became lethargic and unmotivated at both home and work. She withdrew socially and even from her family. When her mental health worsened in 2023, she overdosed on about eight or nine Clonidine tablets, and her husband took her to hospital. She was treated in ED and discharged. In December 2024, she overdosed again, this time with a 'handful of clonidine tablets,' feeling her anxiety had worsened and she didn't know how to help herself. She described feeling 'sad, angry and frustrated all the time,' and was subsequently transferred to Maitland Hospital.

Ms Tooth reported that since she stopped working, she has been admitted to Maitland Private Hospital three times - in January 2025, May 2025, and most recently on 21 July 2025. The first stay lasted about five weeks, the second three weeks. She said her mental health deteriorated further, and she has felt quite unhappy, disengaged from others, and has experienced intense suicidal thoughts."

"Ms Tooth is currently in the inpatient unit at Maitland Private Hospital. She has been seeing her psychologist, Sam Wolfe, since January 2025. Previously, she saw Sarah Adams until 2024. She meets with Sam twice a week when inpatient and fortnightly when in the community. She consults Dr Young, a psychiatrist, during inpatient stays and Dr Tarun Yadav, also a psychiatrist, in the community. Her medications include Clonidine 100 mg, Sertraline 200 mg, Magnesium 1000 mg, Prazosin 5 mg, Vitamin D 1000 IU, Periciazine 5 mg, Lorazepam 6 mg, and Temazepam 10 to 20 mg."

"Ms Tooth reported that the medications and the treatment have not been quite effective, and she continues to experience the same symptoms as before. She feels a pervasive sense of being overwhelmed and despair most days. She also experiences anxiety and ruminates about past incidents at work, feeling anxious about her future. Memories and reminders of her previous job trigger her, including her inability to drive through places where her office was. She feels scared and anxious in social situations and around people.

Her sleep remains disrupted, and she wakes up between 1:00 and 2:00 pm due to intrusive memories and thoughts. She often struggles to get a restful night's sleep, leading to poor attention and concentration, which makes it difficult to remember simple things. She stays hypervigilant and worries about running into Yvette, so she has avoided going out. She experiences anger outbursts and feels irritable and snappy over minor issues. She has lost interest in activities she once enjoyed and even finds visiting her grandchildren exhausting. She has been experiencing chronic suicidal thoughts regularly.

She has overdosed twice, and this time she was also thinking about harming herself, which led to her admission. She also avoids any events related to her employment, including NDIS, and actively ignores emails. She said she gained about 16 kg from January to May 2025 due to mirtazapine, which she attributes to the medication. She currently weighs 80 kg and has lost weight since being prescribed Mounjaro for weight loss. She continues to feel pessimistic and struggles to plan for her future. Overwhelmed by feelings of helplessness, hopelessness, and worthlessness, her thoughts are often dark.

On typical days at home, she would stay in bed until late morning, crochet, and make blankets. She learned to crochet blankets during her first hospital admission and has made around five blankets in January 2025 to keep her mind active. She used to enjoy riding her ride-on mower, but no longer does. Her daughter, a midwife, often takes her to shops and drives her around, which she finds quite overwhelming. She reported that until her issues with EML are resolved and her case is open, she will continue to experience these symptoms, as they have been a constant stressor.

Ms Tooth mentioned that her sleep schedule varies since she lacks a fixed routine. She experiences nightmares related to incidents at her workplace and often wakes feeling quite exhausted. She also suffers panic attacks and episodes of overwhelming anxiety, especially when driving through Kurri Kurri, and has been actively avoiding driving in that area. She avoids locations where she might encounter staff from Kurri Kurri as well. She feels easily triggered and even avoids reading newspapers, worried she might come across updates about her ongoing case. She also refrains from going to the local shopping centre alone, preferring to go with her family members."

1. When asked to provide "Details of any previous or subsequent accidents, injuries or condition", the Medical Assessor said:

"Ms Tooth reported that she had stressors at her previous job as well but was 'never diagnosed with any mental health.' She then said that she saw a psychologist about 8 to 10 years ago in relation to workplace stressors and had 'one session with the EAP.' She initially said she was not on any antidepressants and then said she 'could have been on antidepressant,' which was probably due to 'normal life stressors.' She noted that she did not remember the reason if she was on any antidepressant at all. I have also noted an extensive history of psychological symptoms from 2005, including a letter by Dr Timothy McDonald dated 31 January 2005, who diagnosed her with protracted major depressive disorder with prominent anxiety as a result of unsupportive and undermining management.

I have also reviewed documents by Dr Greg Steele dated 14 September 2004. She was on antidepressant Paroxetine 20 mg and Temazepam at that time. She had seen someone for marital problems around the age of 18 to 20 and then consulted a psychologist regarding grief after the death of her mother, possibly in 1996. She also experienced panic attacks following her father's death in 2000, which required treatment from her GP. There was a workplace incident while she was employed with New South Wales Home Care in 2001, when she developed psychiatric symptoms around 2004. She was diagnosed with major depression with comorbid panic disorder.

The document also notes that her mother likely had depression and there was some genetic vulnerability, and it attributes her symptoms to conflict between Ms Tooth and her supervisor over a two-year period, with links to some gossiping behaviour. There are also reports of psychological injury when she was employed in age disability and home care in July 2004, for which no compensation was paid. Additionally, there was a psychological injury dated 10 February 2017 while employed by Mai-Wei Group, with no compensation paid. Another psychological injury occurred while she was employed by Awabakal Ltd, with Certificates of Capacity provided and Worker's Compensation Payments made."

1. The Medical Assessor then set out details of the impact of her injury on her social activities and activities of daily living (ADL's) as follows:

"Self-care and Personal Hygiene: Ms Tooth reported that she showers regularly, usually every afternoon, but only dresses when she is going somewhere. She can do household chores, but not to the standard she used to, as she feels quite overwhelmed. She is 'able to cook some days and some days she is unable to remember.' She initially gained weight, which she attributed to mirtazapine, but was able to lose weight while taking Mounjaro.

Social and Recreational Activities: Ms Tooth used to enjoy knitting, socialising, watching movies, and her son's football matches. She still knits and now prefers crocheting, as it is 'more challenging.' However, she has not engaged in craft work and has not even taken out her craft machine. She had close friends who 'lived all over the place and down the road,' but they did not understand what she was going through, and even Ms Tooth did not want to deal with other people. She sees her son's children on Sundays and her daughter's children when her daughter visits, but she doesn't like spending time with them alone. She also used to enjoy motorbike riding and has been able to do it infrequently with her husband, only on short trips now. She has a friend of 30 years and continues to stay in touch, but she no longer interacts with her friends as often as before.

Travel: She can leave the house on her own to buy groceries and drive there. She can also drive to the nearest shopping centre, Greenway, about a 15-minute drive, but experiences anxiety when travelling to unfamiliar places. She tends to avoid driving to Kurri Kurri, as it feels quite triggering. She denied having any interstate or overseas travel.

Social Functioning: She reported that her family members have been very supportive, and if not for them, she would not be here. Her husband "continues to contribute a lot and tries to keep things as normal as possible." She said she continues to have a positive relationship with her children and grandchildren, who visit and spend time with them. However, she has lost a few friendships as she is no longer in touch with those friends.

Concentration, Persistence, and Pace: Ms Tooth reported that her memory is poor and she gets distracted during conversations, often needing to repeat herself. She mentioned that she sometimes cannot 'remember what she was doing three minutes before.' She found it difficult to watch TV shows because she often gets distracted. However, she said she can listen to audiobooks and podcasts, and she can remember the characters and storylines, as she has never been a reader. She also learned crocheting during her first inpatient admission and now does crocheting because it is more challenging than knitting. Since her first hospital admission, she has crocheted at least five blankets. Objectively, she was able to focus during the assessment and was not distracted."

1. The Medical Assessor made no reference to the category of employability but in the table accompanying the MAC, she rated a Class 5 in this category.
2. Findings on examination were reported as follows:

"I reviewed Ms Tooth via video. She was present at the Maitland Private Mental Health Unit, and her husband was also in attendance. She engaged well during the assessment and was cooperative. She appeared as a middle-aged woman who looked her stated age. She was dressed in a jumper and track pants and was wearing rings and jewellery. There was no evidence of psychomotor agitation or retardation. No abnormal motor movements such as tics or mannerisms were noted. She provided a clear account of her symptoms and difficulties. She reported her mood as low, and her affect was congruent with the mood described. Her speech was spontaneous, normal in volume and tone.

Her thoughts were logical and goal-oriented. She currently reports ongoing thoughts of self­ harm, suicidal ideas, low mood, lack of interest in activities, and avoidant symptoms. There is no evidence of manic, psychotic, or perceptual abnormalities. She has insight into her symptoms and is keen to engage in treatment. She continues to experience persistent thoughts of self-harm and suicidal ideas but did not mention any specific suicidal plan. She was able to focus and pay attention during the assessment and was not distracted."

1. The Medical Assessor then summarised the injuries and diagnoses as follows:

"Ms Tooth is a 50-year-old married woman who previously worked as a team leader at Kurri Kurri Community Services. She has a history of significant mental health issues associated with workplace stressors at her previous employers, including a past Workers' Compensation claim for similar issues.

With her former employers, she reported being bullied and later exposed fraudulent activities, which worsened the bullying. She experienced an incident at work when she collapsed and was later diagnosed with stress-related cardiomyopathy. She returned to work but was unable to continue due to ongoing bullying and harassment.

Since stopping work, Ms Tooth has overdosed twice and has been experiencing overwhelming feelings of anxiety, low mood, lack of interest in activities, sleep difficulties, and fluctuating appetite. She was also involved in court cases related to the fraud investigation. She experienced moral injury and, at one point, wished to seek justice but was unable to withdraw from the investigations or legal proceedings. Her mental health deteriorated further, requiring hospital admissions on two previous occasions, and she is currently admitted to a mental health unit. Her current presentation aligns with a diagnosis of Post-traumatic Stress Disorder and Major Depressive Disorder with Anxious Distress, consistent with DSM 5 criteria.

Since ceasing work, she has undergone regular psychological therapy, psychiatric input from her psychiatrist, and participated in a 12-week outpatient stress and anxiety reduction programme. While she has received evidence-based treatment for her ongoing symptoms, her response has been limited. I believe her improvement is unlikely to exceed 3%, with or without further treatment. Additionally, I consider that her ongoing claim continues to perpetuate her symptoms, and unless the claim is finalised, she is likely to remain impacted by it."

"Ms Tooth's presentation was mostly consistent with the history provided during the clinical interview documentation received and the mental status examination. However, Ms Tooth was guarded about her past history and was not forthcoming with details. I also noted that Ms Tooth reported struggling significantly with her attention and concentration and that she forgets what she has said even during conversations. Nevertheless, during the one-hour assessment, Ms Tooth was able to focus, pay attention, and was not distracted even once; I did not have to repeat myself."

1. The Medical Assessor assessed 8% WPI from which she deducted one-tenth in respect of the pre-existing condition, leaving a total of 7% WPI.
2. She then set out a summary of the material she had before her which again, for reasons we will discuss below, we do not consider necessary to repeat here.

1. We have summarised the appellant's submissions above.
2. As indicated, we agree that the appellant has not reached MMI contrary to the terms of the Guidelines.
3. She has had several hospital admissions this year and was an inpatient at the time of the assessment - having been admitted, acutely unwell, only one day previously.
4. She has "intense suicidal thoughts."
5. As a matter of procedural fairness it is appropriate that she be re-examined when MMI is achieved.
6. For these reasons, the Appeal Panel has determined that the MAC issued on 29 July 2025 should be revoked.
7. It is not appropriate to issue a new Medical Assessment Certificate at this time.
8. The appellant may re-list the matter in the Commission when the medical material as to MMI is received.