MOTOR ACCIDENTS - Motor Accident Compensation Act 1999; review of medical assessment; whole person impairment; post-traumatic stress disorder and persistent depressive disorder with a persistent major depressive episode; pre-accident workplace challenges; physical injuries; symptoms consistent with post-traumatic stress disorder and major depressive disorder; psychological symptoms persisting; impaired current functioning; psychiatric impairment; rating scale pre-accident; significant difficulty with social and recreational activities; concentration, persistence; significant difficult adaptation; Held - Review Panel assessed 16% whole person impairment (WPI).

Certificate issued under Part 3.4 of the Motor Accidents Compensation Act 1999

The Review Panel revokes the certificate of Medical Assessor Gerald Chew dated 25 November 2024 and issues a new certificate that:

• the following injuries caused by the motor accident give rise to a permanent impairment of 16% and IS GREATER THAN 10%:
  • post-traumatic stress disorder and persistent depressive disorder with a persistent major depressive episode.

1. Ms Walford (the claimant) is a 56-year-old woman who was injured in a motor vehicle accident on 12 January 2012. Following the motor vehicle accident the claimant lodged an Application for Personal Injury Benefits and, after the expiration of some 10 years, sought a concession from the insurer that her injuries gave rise to a degree of whole person impairment in excess of 10%. Following a review the insurer declined to make this concession and, consequently, the claimant lodged an Application for Assessment of Whole Person Impairment (WPI) for psychiatric injury.
2. The claimant was examined by Medical Assessor Gerald Chew who, in a certificate dated

25 November 2024, determined that the psychiatric injuries caused by the motor accident gave rise to a permanent impairment of 8%. 3. The claimant sought a review of this application and, a certificate dated 21 January 2025 of President's delegate Stephanie Wigin determined that there is a reasonable cause to suspect that the medical assessment was incorrect in a material respect. 4. The matter was then referred to this Medical Review Panel. Panel convened on 1 September 2024 and noted that the directions issued to the parties had been complied with and all material which was before Medical Assessor Chew is now before the Panel. 5. Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A "new decision maker" is defined in cl 14A(1) of the Schedule 1 of the PIC Act. As the medical assessment, the subject of the review, was made on or after 1 March 2021, the new review provisions apply. 6. The new review provision provide that a review panel consists of two Medical Assessors and a Member assigned by the Motor Accidents Division of the Personal Injury Commission (the Commission). 7. Part 5 of the PIC Act enables the Commission to make rules with respect to its practice and procedure including proceedings before a panel reviewing a decision of a Medical Assessor. 8. Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the matter solely based on the written application. 9. The review of the medical assessment is by way of a new assessment of all the matters with which the medical assessment is concerned.

1. The claimant is a 56-year-old single woman who lives on her own in The Entrance, NSW. She works 10½ hours per week as a teacher and is supported by a Disability Support Pension.

1. The claimant was born in Sydney. She grew up with her parents and three siblings. There is a known history of bipolar disorder in one second degree relative, and a possible depressive disorder in one first degree relative.
2. The claimant has a close relationship with her mother who is aged 85 and lives in Sydney. Her father passed away five or six years ago. She has occasional contact with her siblings and their children.

1. The claimant describes a positive upbringing in her family. The claimant has always had close and positive relationships with her family members. She denied specific incidents of serious trauma in her childhood and adolescence with the first major loss events identified as death of her grandparents when she was in her early twenties. She did not enjoy primary school though high school was better. She had no significant social difficulties at school and did well academically.
2. After completing secondary education, the claimant worked for one year then commenced higher education at the University of Western Sydney to become a school teacher. She obtained a diploma in teaching then a degree and further studies in special education.
3. The claimant has had a career as a teacher in special education services. She worked for Juvenile Justice between 1993 and 2003 including in an executive position. She then worked in a small tutorial centre until commencing work at a suspension centre on the Central Coast in 2007. She was working full-time in this role at the time of the motor accident with the aim of becoming a principal.
4. The claimant has never been married. She was in a long-term relationship though this ended in separation in the late 1990s. She has no children. The claimant has a number of old friends that she made in her early life and through sport.

1. The claimant suffered from asthma and eczema as a child though was never hospitalised for these. She suffered a broken leg at age 14. She denied any other serious health problems.
2. The claimant has had surgery on five occasions for musculoskeletal problems arising from motor accidents in 2012 and 2014. She has persistent pain in her lower limbs and some restriction in movement secondary to these injuries.
3. In 2021 The claimant was found to have abnormal liver functions tests and multiple polyps in her gallbladder. Further investigation revealed that she had autoimmune hepatitis, and she proceeded to have a liver transplant. She described the transplant procedure going very well and recovering well. She viewed herself as being very fortunate to have received the transplant and has gratitude for that. The claimant takes daily medication to prevent rejection of the transplant.

1. The claimant recalled first meeting with a health professional about a mental health problem following a workplace incident in 2003. She had intervened to prevent a student attempting to jump from a bridge. The police were involved in helping to resolve the episode. The claimant recalls meeting with a counsellor on one occasion following this incident. She did not recall seeing any other health professional or having any other type of intervention.
2. The claimant described a previous incident in the workplace in 1999 in which she suffered a shoulder injury when intervening to protect a student who was being attacked by others. She did not have any contact with a health professional about any psychological disorder following this incident.
3. The claimant explained that she did not regard either of these incidents as being particularly psychologically traumatic but rather an expected part of the role that she had in a challenging workplace.

1. The claimant increased her use of alcohol following the motor accident which concerned her. She has not ever had an alcohol use disorder. Since her liver transplant the claimant rarely has small amounts of weak alcoholic drinks.
2. The claimant does not smoke or use illicit drugs.
3. The claimant occasionally goes to a club on her way home from work and plays "pokie" machines. She does not accrue significant debits and appears not to gamble problematically.

1. The claimant takes Mycophenolate 250mg twice daily and Tacrolimus 2mg twice daily for her liver transplant. She is prescribed the antidepressant/antianxiety medications Venlafaxine 187.5mg and Bupropion 150mg daily. The claimant is prescribed Zopiclone 7.5mg and Clonidine 50mcg for sleep and Lorazepam 1mg which is taken rarely for panic.

1. The claimant said that in the period before the motor accident her life was good. She had bought a new unit in The Entrance and would spend time developing the garden. She was pleased to have work in her chosen field in the local area. The claimant said that she was fully independent in her daily activities and had no significant health problems or impairments. She had several friends that she met with more than once per week and would do things such as visit local clubs to participate in raffles and have dinner. She enjoyed having her nieces and nephews visit and stay at her home. The claimant said that she was working full-time in a profession she had a strong vocation for and had received awards as recognition of her work.

1. The claimant said that on the day of the accident she had picked up her father and two nephews in her car and was driving to the Central Coast. She stopped at an intersection waiting to join a major road. She saw a garbage truck approaching and recalls then hearing "a crunch" as the pickup arm of the truck hit the roof of her car which was pushed towards the highway. She recalls being scared that her nephews may be seriously injured or killed either by the garbage truck or being pushed into traffic.
2. The claimant was able to exit her vehicle and speak with the other driver who said that he had failed to see her. The claimant called the police though was told that as her vehicle was driveable, they would not come to the scene. The claimant then drove to her sister's home.

History of Symptoms and Treatment Following the Accident

1. The day after the motor accident the claimant consulted with her GP. She was stiff and sore generally with particular pain in her ankle and foot. She recalls being "scared". She said that she was diagnosed as having a whiplash injury and she was referred for X-rays. Her foot and ankle problems persisted and the claimant was referred to an orthopaedic specialist. Imaging by MRI found a significant musculoskeletal problem and the claimant proceeded to surgery. She said that there had been five surgical procedures on her ankle and one on her wrist since the motor accident.
2. The claimant recalls experiencing a progressive deterioration in her mental health in the months following the motor accident characterised by social withdrawal, a lowering of her mood, and increased self-criticism such as that she was not doing her job properly. The claimant had started to drink more alcohol which concerned her. On the recommendation of a friend, she was referred to psychologist Gaye Colwell.
3. The Panel notes the report of G. Colwell dated 7 January 2015. This report, and seeking to provide a relatively contemporaneous clinical history of the claimant in the post-accident period, states:

"It became apparent that Cassandra's premorbid PTSD and anxiety had been reactivated from the car accident."

The report goes on to note symptoms including hyper arousal, reduced confidence, sadness, nightmares, flashbacks, confusion, insomnia and anxiety. It states that the claimant experienced these symptoms associated with the car accident she experienced and this had intensified her symptoms.

1. When assessed by Ms Colwell the claimant was found to have a range of psychological symptoms consistent with post-traumatic stress disorder and major depressive disorder. The claimant has had regular psychological treatment since 2013.
2. In 2019 the claimant was referred to psychiatrist Dr Martin Cohen. She had previously been reluctant to use psychotropic medication though, due to the persistence and severity of her symptoms, changed her view on this. She has been under regular psychiatric review with Dr Cohen since 2019 and is prescribed psychotropic medication for her mental condition.

Injuries or Conditions since the Motor Accident

1. The claimant was involved in a subsequent motor accident in 2014 when she was hit from the back by another vehicle when she stationary. This incident caused exacerbation of the claimant's ankle injury. She described a minor and temporary exacerbation of her continuing psychological symptoms following this motor accident.

1. The claimant describes persistent psychological symptoms and said that "I put on a façade of coping". Her mood is persistently low, and she gets little enjoyment from any activities. She has occasionally had suicidal thoughts and feels guilty about these due to having been given a transplanted donor liver four years ago which she feels very grateful for. The claimant identified the relationship that she has with her niece as a positive factor in her life, though little else.
2. The claimant has persistent low energy and motivation. On days that she is not at work she spends much of her time in bed watching television or short YouTube videos.
3. The claimant has persistently poor sleep despite medication and has occasional nightmares relating to the motor accident. She has intrusive recollection of the accident and said, "It's like my brain still wants to think about the accident".
4. The claimant is avoidant of busy traffic, and hypervigilant for the threat of an accident when driving. If she sees a garbage truck she experiences unpleasant physiological symptoms of anxiety.
5. The claimant has unresolved feelings about the accident and the support she received from the insurance company. She said, "the accident changed my life".
6. The claimant described her home as being cluttered with boxes and items which she has bought but does not need. She is ashamed of this.
7. The claimant has poor concentration and no longer reads for pleasure. At work she has a teacher's aid in her classroom of 3 or 4 children as she struggles to deliver the programme.

1. The claimant meets with her psychiatrist, Dr Cohen, monthly. He prescribes the antidepressant/antianxiety medications venlafaxine 187.5mg and bupropion 150mg daily. The claimant is prescribed zopiclone 7.5mg and clonidine 50mcg for sleep and lorazepam 1mg which is taken rarely for panic.
2. The claimant meets with her psychologist, Ms Colwell, monthly for psychotherapy.

1. The claimant joined the video link from her psychologist's office in Newcastle. She showed reasonable self-care. The claimant was frequently tearful during the interview and became more upset when reflecting on her current life situation. Her speech was normal. Her effect conveyed a high level of emotional distress. Her mood was objectively and subjectively low with high anxiety. Her thought form was normal. Her thought content showed prominent negative and self-critical cognitions in keeping with a depressive syndrome. There were no abnormal beliefs in the form of delusions or over-valued ideas, and no abnormal perceptions. The claimant was fully alert and orientated. She was able to attend adequately for the purpose of the interview. There were necessary pauses at times in the interview to allow her to recompose herself due to emotional upset.

1. The claimant lives alone in a unit that she owns at The Entrance. She can live independently though described lack of motivation for self-cares. She will shower on the evening before going to work on three days per week. She shops for herself locally and at times orders delivery of groceries. The claimant buys items she does not need, such as some clothes, and her home is untidy and overcrowded with these items. She cooks simple meals from the freezer or orders takeaway to be delivered.
2. The claimant rarely goes to social and recreational events and mostly when prompted by friends or family. One of her friends encourages her to meet for a meal at a local pub each month.
3. The claimant will participate in some family events such as a family gathering at a park which occurred one month ago and visiting her mother in Sydney to celebrate her birthday two months ago.
4. The claimant can drive independently in familiar areas. She rarely travels outside of her local area and when she does, she will carefully plan her route to decrease the risk of meeting heavy traffic. She last travelled out of the state when she visited a nephew in Western Australia two years ago.
5. The claimant has less contact with family and friends compared to before the accident. She has been able to sustain positive relationships with her family and meets with them occasionally. She has a positive relationship with her mother, and they speak frequently on the phone. The claimant has some old friends that she has sustained relationships with and meets with occasionally.
6. The claimant no longer reads for pleasure due to poor concentration. She will watch documentaries on YouTube for up to 20 minutes though does not attempt longer videos as she cannot sustain her concentration longer than that. In her workplace she relies on a teacher's aide to carry out the formal programme due to difficulties in sustaining mental focus.
7. The claimant has continued to work as a teacher in a special education service though with less responsibility and 10½ hours per week. She delegates tasks that she is unable to perform to a teacher's aide who is present at all times with her in the classroom.

1. The claimant's presentation to the Medical Assessors and as reflected in treating clinicians' records is consistent. Her account at interview was internally consistent.

1. The claimant is a 56-year-old single woman who lives alone and works part-time as a teacher in a special education service. Following a motor accident on 12 January 2012, the claimant developed lower limb problems requiring surgery and psychological symptoms which impacted on her usual level of functioning. Despite long-term treatment for these injuries in the intervening period, the claimant has persistent physical and psychological symptoms and associated reduction in function.

1. Following the DSM-5TR system, the claimant is currently suffering from post-traumatic stress disorder (PTSD) and persistent depressive disorder with a persistent major depressive episode.
2. Copied below are the diagnostic criteria for these disorders with comment on criteria met by the claimant.
   • Diagnostic Criteria - Post-traumatic Stress Disorder in Individuals Older Than Six Years
3. Criteria A: Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

The motor accident of 12 January 2012 was severe as there was the possibility of death or serious injury to the claimant, her father and her young nephews.

2. Witnessing, in person, the event(s) as it occurred to others.

3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

1. Criteria B: Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

The claimant describes frequent, recurrent, intrusive recollections of the accident which are distressing. She commented, "It's like my brain still wants to think about the accident".

2. Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).

Note: in children, there may be frightening dreams without recognizable content.

The claimant has trauma related nightmares, which have improved to an extent with pharmacological treatment.

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)

Note: In children, trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

The claimant experiences marked physiological reactions when she sees a garbage truck.

1. Criteria C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

The claimant avoids heavy traffic if possible and plans her routes for that purpose.

1. Criteria D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," "The world is completely dangerous," "My whole nervous system is permanently ruined").

The claimant has persistent negative and self-critical thoughts such as that the motor accident has changed her life and she is no longer able to perform her work role.

3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.

4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

The claimant has persistent low mood, anxiety and shame.

5. Markedly diminished interest or participation in significant activities.

The claimant has a persistent loss of interest and participation in a range of activities.

6. Feelings of detachment or estrangement from others.

7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

The claimant is unable to experience joy or pleasure as she would before the accident.

1. Criteria E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behaviour and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.

The claimant has hypervigilance for threat when driving.

6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

Sleep is poor despite medication and interrupted by occasional trauma related nightmares.

1. Criteria F: Duration of the disturbance (Criteria B, C, D, and E) is more than one month.

1. Criteria G: The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

1. Criteria H: The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

There is no evidence to support these factors causing the psychological disturbance.

1. Diagnostic Criteria - Persistent Depressive Disorder

This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder.

1. Criteria A: Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least two years.

The claimant describes persistent low mood for at least two years.

1. Criteria B: Presence, while depressed, of two (or more) of the following:

There is a disturbed eating pattern with neglect of nutritional value.

The claimant has fatigue, low energy and low motivation.

The claimant has low self-esteem, is self-critical and expresses inappropriate shame with respect to her situation.

5. Poor concentration or difficulty making decisions.

1. Criteria C: During the two year period (one year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than two months at a time.

1. Criteria D: Criteria for a major depressive disorder may be continuously present for 2 years.

1. Criteria E: There has never been a manic episode or a hypomanic episode.

1. Criteria F: The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

There is no evidence that the claimant has any of these disorders.

1. Criteria G: The symptoms are not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).

There is no substance misuse. The symptoms are not attributable to prescribed medication or due to another medical condition.

1. Criteria H: The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

There is significant distress and impairment of function.

1. The claimant worked in a challenging environment and was exposed to disturbed behaviour and violence between students. However, she describes accepting this as an expected part of the work which she had a strong vocation for and does not regard it as traumatising. She continues to work in this field.
2. The claimant did not have significant contact with health professionals for a mental condition before the subject accident. There is no convincing evidence that the claimant suffered from a significant mental disorder before the motor accident of 12 January 2012.
3. In the period following the motor accident the claimant developed psychological symptoms which affected her work and social function. This led her to seek referral to a psychologist where she had assessment and treatment was commenced.
4. The claimant developed potentially fatal autoimmune liver disease approximately five years ago which led to having a liver transplant in 2021. The process of surgery went well and there has been a good recovery. This episode of serious physical health problems is not causally related to the claimant's current mental condition.

1. The claimant has had a significant psychological condition for over 10 years. She has had reasonable treatment for this. It is unlikely that her degree of impairment will improve further and it is permanent.

Psychiatric Impairment Rating Scale Prior to the Motor Accident

No deficit. The claimant had several friends that she met with more than once per week and would do things such as visit local clubs to participate in raffles and have dinner.

The claimant had good relationships with her family of origin and the younger members would often visit and stay at her home. She had several friends that she would meet with weekly.

The claimant was able to concentrate on complex tasks without difficulty.

The claimant was working full-time as a teacher in a special education environment. She was successful in this and had a strong vocation for her work.

List Classes in Ascending Order Median Class Value

2. Persistent depressive disorder with persistent major depressive episode

Venlafaxine 187.5mg and Bupropion 150mg daily; Zopiclone 7.5mg and Clonidine 50mcg for sleep and Lorazepam 1mg occasionally

The claimant meets with her psychologist every month for psychotherapy

The claimant described lack of motivation for self-cares. She will shower on the evening before going to work on three days per week. She can live independently and shops for herself. She cooks simple meals from the freezer or orders takeaway to be delivered.

The claimant rarely goes to social and recreational events and mostly when prompted by friends or family. One of her friends encourages her to meet for a meal at a local pub each month. The claimant will participate in some family events such as a family gathering at a park which occurred one month ago, and visiting her mother in Sydney to celebrate her birthday two months ago.

The claimant can drive independently in familiar areas. She rarely travels outside of her local area and when she does, she will carefully plan her route to decrease the risk of meeting heavy traffic. She last travelled out of the state when she visited a nephew in Western Australia two years ago.

The claimant has less contact with family and friends compared to before the accident. She has been able to sustain positive relationships with her family and meets with them occasionally. She has a positive relationship with her mother, and they speak frequently on the phone. The claimant has some old friends that she has sustained relationships with and meets with occasionally.

The claimant no longer reads for pleasure due to poor concentration. She will watch documentaries on YouTube for up to 20 minutes though does not attempt longer videos as she cannot sustain her concentration longer than that. In her workplace she relies on a teacher's aide to carry out the formal programme due to difficulties in sustaining mental focus.

The claimant has continued to work as a teacher in a special education service though with less responsibility and 10½ hours per week. She delegates tasks that she is unable to perform to a teacher's aide who is present at all times with her in the classroom.

List Classes in Ascending Order Median Class Value

Pre-existing Impairment (If yes, determine % as above) Median Class Value

Apportionment - pre-existing/subsequent impairment

1. There is no apportionment for a pre-existing condition.
2. Though there was some temporary exacerbation of psychological symptoms following the 2014 motor accident, there was no significant effect on the level of impairment. There is no apportionment for this.

1. There has been a mild improvement due to the effect of treatment warranting an adjustment of 1%.

Degree of permanent impairment caused by the motor accident

1. The claimant has a permanent impairment of 16% caused by the motor accident.