AAI Limited t/as GIO v Hlis
[2023] NSWPICMP 16
•20 January 2023
| DETERMINATION OF REVIEW PANEL | |
| CITATION: | AAI Limited t/as GIO v Hlis [2023] NSWPICMP 16 |
| CLAIMANT: | The late Linda Hlis |
INSURER: | AAI Limited t/as GIO |
| REVIEW Panel | |
| MEMBER: | Terence O’Riain |
| MEDICAL ASSESSOR: | Margaret Gibson |
| MEDICAL ASSESSOR: | Tai-Tak Wan |
| DATE OF DECISION: | 20 January 2023 |
CATCHWORDS: | MOTOR ACCIDENTS – Motor Accidents Compensation Act 1999; the claimant suffered injury in a motor accident on 17 May 2017; medical dispute under Part 3.4 about whether the motor accident caused permanent impairment greater than 10%; medical assessment done on the papers; only complaint of neck injury more than 2 years after the accident; hospital specifically excluded neck injury; no reasons provided for neck condition nexus with accident; claimant frequently saw treating doctors before and after accident with nil complaint of neck injury; accepted right shoulder injury; neck and shoulder combined more than 10%; Dogon v Redmond & Ors, Nguyen v The Motor Accidents Authority of NSW & Zurich Australian Insurance Ltd and Bugat v Fox considered; Held – Panel found no nexus with cervical injury and accident; permanent impairment 10%; previous Medical Assessment Certificate revoked. |
| DETERMINATIONS MADE: | Medical Assessment – Permanent impairment The Panel revokes the certificate dated 11 November 2021 and issues a new certificate The motor accident caused the following injuries to give rise to a permanent impairment which is 10% and IS NOT GREATER THAN 10%: · right shoulder – soft tissue injury The motor accident did not cause the following injuries, and does not give rise to a permanent impairment · Neck injury–soft tissue |
REASONS
BACKGROUND
The late Ms Linda Hlis (the claimant) suffered injury when a motor vehicle struck her when she was moving across a pedestrian crossing on 17 May 2017 in NSW.
AAI Limited t/as GIO (the insurer) insured the owner and/or driver of the other motor vehicle for liability to pay the claimant any damages to which she may be entitled under the Motor Accidents Compensation 1999 (the MAC Act).
The parties are in dispute as to whether the motor accident caused injuries with a degree of permanent impairment greater than 10%. This constitutes a medical dispute within the meaning of the MAC Act.[1]
[1] Section 63(7) of the MAC Act.
Permanent impairment is determined by assessment pursuant to Motor Accident Permanent Impairment Guidelines - Version 1, effective from 1 June 2018 (the Guidelines)[2]. The Guidelines are based upon the American Medical Association Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4). However, where there is any difference between AMA 4 and the Guidelines, the Guidelines prevail.[3]
[2] Issued pursuant to s 44(1)(c) of the MAC Act and see s 133 of the MAC Act.
[3] Clause 1.2 of the Guidelines.
The insurer applied for assessment of permanent impairment on 4 May 2020 in respect of alleged injuries to the right arm, right foot, left and right lower legs, right shoulder and lower back.
The late Ms Hlis lodged a Reply on 26 May 2020, listing additional injuries including the cervical spine.
On 1 March 2021 the Personal Injury Commission (Commission) commenced and now has jurisdiction in relation to this application.
Medical Assessor (Assessor) Neil Berry assessed the claimant’s alleged physical injuries on the papers. A certificate was issued to the parties on 12 November 2021.
Assessor Berry assessed the late Ms Hlis’s whole person impairment (WPI) at 15%, comprising of 5% WPI relating to the cervical spine and 10% WPI relating to the right shoulder.
The insurer applied for Review of Assessor Berry’s certificate pursuant to s 63 of the MAC Act, within 28 days of receiving the assessment certificate.[4]
[4] Section 63(7) of the MAC Act.
On 25 February 2022, the Presidential delegate referred the medical assessment to the Review Panel (the Panel) as she was satisfied there was reasonable cause to suspect the medical assessment was incorrect in a material respect having regard to the particulars set out in the application.[5]
[5] Section 63(2B) of the MAC Act.
Pursuant to s 63(3) of the MAC Act and Sch 1, cl 14F(2) of the Personal Injury Commission Act 2020 (the PIC Act), the Panel consists of two Medical Assessors and a Member of the Motor Accidents Division of the Commission.
STATUTORY PROVISIONS
Section 57 of the MAC Act defines a “medical dispute” as a disagreement or issue to which Part 3.4 of the MAC Act applies.
Section 58 of the MAC Act provides a disagreement between a claimant and an insurer on three distinct matters are “medical assessment matters” and includes “whether the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident is greater than 10%”.
Section 60 of the MAC Act provides either party may refer a medical dispute to the President who is to arrange for the dispute to be referred to one or more Medical Assessors. Clauses 1.5-1.7 of the Guidelines relate to the assessment of permanent impairment and provide:
“1.5 An assessment of the degree of permanent impairment is a medical assessment matter under Section 58 (1)(d) of the (MAC) Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident. A determination as to whether the injured person’s impairment is related to the accident in question is implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA4 Guides, as well as the common law principles that would be applied by a court (or claims assessor) in considering such issues.
1.6 Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows ‘Causation means that a physical, chemical or biologic factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:
1. The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination.
2. The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.’
This involves a medical decision and a non-medical informed judgement.
1.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question ‘Would this injury (or impairment) have occurred if not for the accident?’ may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.”
The provisions of the Civil Liability Act 2002 (the CL Act) apply to the MAC Act in determining issues of causation. In Raina v CIC Allianz Insurance Ltd[6] Campbell J stated:
“One may accept that a review panel is engaged in a process of dispute resolution by expert assessment of medical issues arising under the Act. However, the questions arise in a legal context, and it is incumbent upon the panel, medical practitioners they may be, to correctly apply the law including the law of causation in the exercise of their powers. This includes the provisions of Division 3 of Part 1A of the Civil Liability Act 2002 (NSW), ss 5D and 5E: see s 3B(2)(a) of that Act. Although it may be expected that questions about the appropriate scope of liability will arise but rarely.”
[6] [2021] NSWSC 13 (Raina) at [65].
These observations were made in the context of a review panel being constituted by three medical experts as opposed to the composition of the present panel following the amendments to the MAC Act.
Note Principle Member John Harris’ contribution to the Commission’s Review Panels decisions has assisted this Panel in establishing the appropriate statutory framework[7].
[7] For example see, QBE Insurance (Australia) Limited v Stanisic [2022] NSWPICMP 361.
Part 5 of the PIC Act enables the Commission to make rules with respect to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a merit reviewer or a medical assessor.[8]
[8] Section 41(2) of the PIC Act.
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 proceedings solely based on the written application.[9]
[9] Rule 128 of the PIC Rules.
Review conduct
The Panel issued a Direction to the parties on 14 March 2022 requiring them to each file an indexed, paginated bundle of documents that they wished to rely upon in relation to the review. The insurer’s documents were filed as AD1, and the claimant’s documents were filed as R1.
The Panel members confirmed they had no previous involvement with this matter or with Ms Hlis.
On 6 April 2022 the Panel members conducted a preliminary review of the matter via telephone conference. The Panel considered the correspondence from the parties. On 6 April 2022 the Panel issued the following Preliminary Review and Review Panel Directions:
“The panel members met 6 April 2022 in a telephone conference and agreed to make the following directions:
Pursuant to rule 70 Commission Rules the parties are directed to confer and on or before 6 May 2022 to lodge a joint signed statement setting out—
the facts and issues on which the parties agree, and
the facts and issues that continue to be in dispute.
Among other issues the parties were to advise in writing – apart from the cervical spine – whether it is accepted or disputed that the panel can adopt Assessor Berry’s findings and conclusions on whether the accident caused or aggravated the late Ms Hlis’s injuries.
The panel agrees with both parties’ submissions to the Presidential Delegate that the real issue to be assessed relates to whether the neck impairment Dr Bodel assessed is attributable to the motor accident. The parties were to indicate whether a decision on causation applying the provisions of Division 3 of Part 1A of the CLA as per Raina v CIC Allianz Insurance Ltd would resolve the dispute or require an impairment reassessment as well.
By way of joint signed statement lodged 6 May 2022, the parties agreed on the following points:
“1. Facts and issues on which the parties agree:
(a)The following injuries were caused by the motor vehicle accident:
(i)Right shoulder.
(ii)Lumbar spine.
(iii)Left arm.
(iv)Left leg.
(v)Left foot.
(vi)Right leg.
(vii)Skin – scarring (right leg, shoulder, arm and foot).
(b)The following injuries were not caused by the motor vehicle accident:
(i)Liver – hepatic disease with failure and ascites.
2. The facts and issues that continue to be in dispute:
(a)That the motor vehicle accident caused an injury to the late Ms Hlis’s cervical spine.
3. It is accepted by the parties that apart from the cervical spine the Panel can adopt Assessor Neil Berry’s findings and conclusions on whether the accident caused or aggravated the claimant’s following injuries:
(i)Lumbar spine: disc rupture and disc prolapse at L4/5 and compression of the nerve root at L5, soft tissue injury, disc injury with radiculopathy.
(ii)Leg-left leg and knee: radiculopathy and sciatica.
(iii)Foot-left foot: tingling to all five toes and soft tissue.
(iv)Right arm: joint effusion and synovitis, subdeltoid bursitis, soft tissue injury, bruising.
(v)Right shoulder: soft tissue injury, joint effusion and synovitis, subdeltoid bursitis, deformity.
(vi)Lumbar spine: soft tissue injury, orthopaedic and neurological injury.
(vii)Left arm: impairment to the left upper extremity due to overuse of that left upper extremity as a consequence of the need to alleviate use of the injury (dominant) right upper extremity.
(viii)Left leg: bruising.
(ix)Left foot: bruising.
(x)Right leg: bruising.
(xi)Abdomen: exacerbation of liver disease, ascites, cirrhosis, hepatic failure.
(xii)Skin-scarring (right leg, shoulder, arm and foot): cuts and lacerations.
4. The parties agree that a decision on causation applying the provisions of Division 3 of Part 1A of the Civil Liability Act 2002 (NSW) ss.5D and 5E as per Raina v CIC Allianz Insurance Ltd will resolve the dispute.
5. The parties do not require an impairment assessment of the cervical spine.”
Assessment under review
Ms Hlis died in April 2020 before Assessor Berry could assess the injuries, so the assessment was on the papers only. Assessor Berry certified on 11 November 2021 that the motor accident caused the following injuries and certified the degree of permanent impairment as 15%.
Note that references to range of movement, which infers a personal examination, are only references to what other specialists and treaters have recorded, when Ms Hlis was alive.
Cervical Spine
Assessor Berry decided the cervical spine should be assessed under the DRE methods on page 103 to assess Ms Hlis as DRE Category II which is rated at 5% WPI.
Right Shoulder
Assessor Berry applied the range of movement model. He noted in Dr Bodel's report that Ms Hlis had a very restricted range of shoulder movement and there was generalised wasting in the shoulder and based on that he assessed her as a 10% WPI.
Lumbar Spine
Ms Hlis had reported tenderness in the lower back to other doctors. The range of movement was reduced to half the normal range and was symmetrical. Assessor Berry assessed the lumbar spine condition as DRE Category I which is a 0% WPI.
Assessor Berry assessed other injuries as resolved and not attracting a permanent impairment. He did not attribute Ms Hlis’s liver condition to the motor accident.
Disputes and issues identified
The dispute is about the nexus between the subject motor vehicle accident and the neck injury.
The insurer submits the certificate contains a lack of proper conclusions and/or reasoning in relation to causation relating to the cervical spine and further there is a lack of objective evidence to support such conclusions.
The respondent claimant opposed the application on the grounds there was no reasonable cause to suspect the medical assessment was incorrect in a material respect, pursuant to s 63(2) of the MAC Act. This was based on Assessor Berry saying he had considered all the material provided with the application and reply, and there was support for a nexus between the neck condition and the accident.
Causation
Assessor Berry's findings on causation were: “This patient suffered an impact injury which resulted in a soft tissue injury to the cervical spine and to the right shoulder.”
There was no discussion in his certificate regarding why he accepted a nexus of the cervical spine condition with the accident.
SUMMARY OF RELEVANT DOCUMENTATION
Motor accident personal injury claim form
The late Ms Hlis's signed this form on 15 June 2017. The injuries listed are to the right arm, foot and shoulder, and back. The diagram in the claim form injury details marks the lower back as injured.
Shellharbour Hospital
Document marked A6, identified as a transfer of care document from the hospital includes the following clinical synopsis:
“presenting with mva
was standing on the curb at a crossing – was about to cross teh[sic] road when she got clipped on the right arm – spun around and fell to teh[sic] ground and hit the right forearm…
c-collar, applied by ambulance, though patient claims that she didn't hit the head or neck
Nil neck pain
nil loc…c spine cleared on canadian rule[10]
xray-nil #”
[10] Regarding Canadian C-spine rule, refer to:
Shellharbour City General Practice
An undated letter, which refers to the recent motor accident claim and addressed to the insurer does not contain any reference to neck pain, and states a good recovery was anticipated.
NSW ambulance
The electronic medical record case description states "… Alert and orientated denies any neck or back pain…" The note refers to spinal immobilisation with a short cervical collar.
Medico-legal reports
Orthopaedic surgeon, Dr Raymond Wallace produced a report for the insurer dated 23 April 2019 based on when he examined the claimant. That report refers to the Shellharbour Hospital X-raying the claimant's cervical spine. That is the only mention in Dr Wallace's report to that body part and is not supported in the hospital notes.
Orthopaedic surgeon, Dr James Bodel produced a report for the late Ms Hlis's solicitors dated 29 October 2019.
Dr Bodel refers to the claimant having ongoing disabilities in the neck as pain and stiffness.
He also mentions the claimant will have continuing disability in the neck. He recommended physiotherapy of the neck and that the ongoing disabilities in the neck have arisen as a consequence of the motor vehicle accident. These are the only references to a neck condition in his report, and he does not take any history regarding any neck injury, neck problems or his reasons as to why the accident caused this disability.
He assessed a DRE Cervicothoracic Category II level of assessable impairment in accordance with the description Table 73 on page 3/110 of AMA 4. He found asymmetry of movement and guarding but no clinical sign of radiculopathy, which he assessed as 5% WPI.
A scan of the late Ms Hlis's long medical history does not reveal any complaints regarding the cervical spine, which could be related to the accident.
Assessor Berry’s Medical Assessment Certificate 11 November 2021
The injuries referred for assessment to Assessor Berry were set out above. On page 4 of Assessor Berry's certificate headed clinical examination the Assessor records:
“The last physical examination is provided by Dr James Bodel dated 29 October 2019… Her clinical examination also provided a reduction in neck… Movements consistent with her accident.
12. Cervical spine (cervicothoracic)
The patient had restriction on all movements of the neck, particularly right rotation."
On page 5, headed Summary of relevant documentation the assessor noted:
The Ambulance report for confirming the clinical findings.
I am provided with the Shellharbour Medical Practice notes; and
The reports of Dr Raymond Wallace dated 23 April 2019 Dr James Bodel dated 29 October…”
SUBMISSIONS
Insurer’s submissions
The insurer provided submissions dated 30 November 2021, and 23 March 2022 with this review.
The insurer's initial causation submission regarding the cervical spine is that the certificate lacked proper conclusions or reasoning relating to how a cervical spine condition was linked to the accident. Further, there was a lack of objective evidence to support such conclusions. That lack of evidence is addressed above in the relevant document summary.
Assessor Berry did not evaluate the hospital discharge summary, the ambulance report, the claim form or the claimant's treating general practitioners clinical file.
In Moran v Motor Accidents Authority of NSW [2013] NSWSC 1135, the Supreme Court confirmed an assessor must show genuine consideration was given to material before the assessor and the relevance, if any, to be placed on the material. Failing to do so, could lead to an inference that an Assessor did not consider the material, resulting in a determination being quashed.
The first reference to the claimant suffering a cervical spine injury is contained in Dr Bodel's report, which is two years and five months after this accident.
The Assessor's failure was to not discuss the lack of contemporaneous evidence. It looks like the Assessor did not properly consider the causation question.
The insurer referred to a number of cases including Dogon[11], in which Hulme J concluded the Assessor's reasons on causation were insufficient and did not comply with the obligations to explain the nexus between the accident and the alleged injury. The Assessor in that case summarised the medical evidence and only stated "I have accepted that the left shoulder and left wrist was sustained in the MVA."
[11] Dogon v Redmond & Ors [2010] NSWSC 1329 at [12].
The later submissions replicate the earlier submissions.
Claimant’s submissions
The claimant’s lawyers submit there is no reason to suspect Assessor Berry did not consider all the material provided to him, including the ambulance records, the Shellharbour Hospital records and the report of Dr Wallace. Assessor Berry records (p 3) “I have considered the documents provided in the application and reply.” He refers to the ambulance material and the Shellharbour Hospital material on p 3 and he refers to Dr Wallace on p 4. He makes further references to the documents on p 5.
On p 4 he refers to Dr Bodel’s examination as revealing a reduction in “neck…movements consistent with her accident.”
He would have used his clinical expertise to form the opinion the claimant’s neck condition was a result of her motor accident as recorded on p 6, where he refers to taking into account the history and clinical examinations.
In a situation where the claimant was deceased at the time of Assessor Berry’s assessment, the assessment could only be taken upon a consideration of documents made available to Dr Berry. He simply could not have made an assessment without having considered that material because there was no other material upon which he could act.
The claimant submits the Court of Appeal has often warned about placing too much emphasis on recordings or lack of recordings in ambulance reports; clinical notes and hospital records.
Dr Wallace simply failed to address any issue relating to impairment of the neck, despite the fact the ambulance officers immobilised Ms Hlis’s neck in a cervical collar. He says (p 6) her neck was X-rayed before she was discharged from hospital but the only X-ray in the hospital records relates to her right arm.
Dr Bodel clinically examined the claimant’s neck and found there to be tenderness in the trapezius muscles at the base of the neck on the right side and guarding in that area as well as asymmetric neck movements justifying an impairment rating of 5%.
Dr Bodel considered the claimant had disabilities in her neck (p 5) which had “arisen as a consequence of her motor vehicle accident” (p 6). He assessed her neck impairment as 5%.
The real issue relating to the claimant’s neck is whether Dr Bodel’s findings arise from the motor accident. Dr Bodel’s clinical findings relevantly refer to the base of the neck on the right side, in close proximity to the accepted right shoulder injury.
There is no material suggesting that the neck impairment is attributable to any event other than the motor accident. Nguyen’s[12] case is authority for the proposition that if an impairment arises in the neck as a consequence of an injury to the shoulder it is compensable. There is no objective evidence of any degenerative condition in the neck to which her clinically assessed neck disability could be attributed.
[12] Nguyen v The Motor Accidents Authority of NSW & Zurich Australian Insurance Ltd [2011] NSWSC 351.
Dr Bodel is the only doctor who has clinically examined the claimant’s neck with a view to determining her impairment resulting from her accident. Dr Berry agreed with that assessment and there is no reason to suspect the impairment results from anything other than the motor accident.
PANEL’S DETERMINATION
The Guidelines at 1.5 to 1.7 address injury causation, noting the assessment must determine the injured person’s permanent impairment resulting from injuries, which the accident caused.
Various Supreme Court and Court of Appeal cases discuss the applicable principles to determine causation in motor accident cases. Those cases warn against treating the absence of a contemporaneous complaint or report of injury as solely determining causation as it can lead to error.
The question to be answered is whether the motor accident materially contributed to the injury to the body part in question. For instance, at [31] in Bugat v Fox(2014) 67 MVR 150; [2014] NSWSC 888 the Court stated:
“One of the pivotal questions for the panel was whether the injuries of which the plaintiff complained had been caused (or materially contributed to) by the motor accident she alleged. To that question the presence or absence of contemporaneous evidence of injury was relevant but not determinative in circumstances where there was other evidence, in particular the plaintiff’s claim form made but 15 days later, the remarks of Dr Hor in his report of 13 July 2011, and the plaintiff’s statements which the certificate discloses were made to the panel to the effect that at the time of the accident she suffered ‘pain in her neck going out to both shoulders.”
The Courts have also considered causation issues in the situation where an injury sustained in a motor accident has subsequently materially contributed to an injury to another body part. In AAI Ltd Trading as GIO as agent for Nominal Defendant v McGiffen[13] the Court of Appeal held at [64]:
“The question that the review panel was required to address was not simply whether there was any contemporaneous evidence of complaint about an injury to the lumbar thoracic spine. It included whether Mr McGiffen’s lumbar thoracic spinal injury was causally related to the ‘gait derangement’, itself caused by the accident. That is, was the accident a contributing cause of a lumbar thoracic spinal injury by reason of the gait derangement caused by the accident.”
[13] [2016] NSWCA 229.
Cervical spine
The evidence is the ambulance paramedics put the claimant in a cervical collar. However, the hospital examined her and made an evaluation of the potential for any cervical spinal injury. There was no finding confirming a cervical spine injury. She was discharged to the care of her general practitioner, who she frequently saw.
The ambulance and hospital treating staff evaluated Ms Hlis’s cervical spine before discharge. Ms Hlis expressly excluded neck involvement when the hospital staff questioned her.
Up until when Ms Hlis died, her general practitioner did not make any reference to his patient having any neck issues as a result of the accident.
Dr Bodel’s examination was the first mention of Ms Hlis having a neck condition. He evaluated her neck movement and attributed it to the accident without an explanation as to how it could be linked. Dr Bodel did not record any history about how the neck injury happened, what issues it was causing after the initial evaluation at the Shellharbour Hospital or whether there had been any treatment.
Assessor Berry noted Dr Bodel’s conclusions and did not address the nexus with the accident either.
Ms Hlis was a woman who required frequent medical attention, and as her claim was accepted there were frequent opportunities to inform her health care providers and obtain treatment if she had an accident related neck condition.
The claimant suggests the accepted right shoulder condition could be related to a cervical condition, applying the Nguyen principle, but there is no evidence or reasoning supporting a secondary link between the claimant’s right shoulder and her neck.
The claimant’s argument is that since there was no other incident that could have caused neck pain, and Dr Bodel’s finding follows the accident, the accident must have caused it.[14]
[14] This is the posthoc ergo propter hoc fallacy referred to at [63] as per Coventry v Insurance Australia Ltd T/as NRMA Insurance [2019] NSWSC 1096.
The Panel declines to adopt that approach.
Applying the principles set out in the Guidelines, the Panel cannot be satisfied Ms Hlis sustained a cervical spine injury in the motor accident.
The Panel finds the motor accident did not cause any injury to the cervical spine, and hence there is no cervical spine permanent impairment to assess.
Permanent impairment
The Panel’s findings in relation to the degree of permanent impairment of the injuries the motor accident caused are different to the findings stated in Assessor Berry’s Permanent Impairment Certificate.
Relevantly to the disputed issue Assessor Berry decided the motor accident caused the cervical spine – soft tissue injury.
Assessor Berry relied on Dr Bodel’s assessment in his report dated 19 October 2019 as the basis for his assessment for the cervical spine.
The Panel found that there was insufficient evidence to find a link between the condition and the accident as there were no complaints or findings on that point until the one occasion more than two years after the accident.
Accordingly, the Panel has determined this certificate is to be revoked and the Panel will issue a new Permanent Impairment Certificate.
The motor accident caused the right shoulder – soft tissue injury to give rise to a permanent impairment which is 10%. The accident did not cause the cervical injury, and no impairment will be assessed.
Member O’Riain, Medical Assessor Gibson and Medical Assessor Tai–Tak Wan have viewed this certificate and confirmed they are in agreement.
is a protocol to decide whether to take a cervical spine x-ray
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