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AL [2017] WASAT 91

Jurisdiction:	STATE ADMINISTRATIVE TRIBUNAL	Citation No:	[2017] WASAT 91
Act:	GUARDIANSHIP AND ADMINISTRATION ACT 1990 (WA)
Case No:	GAA:939/2017	Heard:	5 APRIL 2017
Coram:	MS H LESLIE (MEMBER)	Delivered:	28/06/17
No of pages:	18	Judgment Part:	1 of 1
Result:	Advance health directive was found not to prevent AL's guardians from consenting to the medical treatment currently needed as the Advance health directive correctly construed did not refuse that treatment
Category:	B
PDF Version

Parties:	AL
Catchwords:	Advance health directive
Legislation:	Guardianship and Administration Act 1990 (WA), s 110Q, s 110Q(1), s 110Q(1)(a), s 110S, s 110T, s 110Y, s 110Z(1), Pt 9B Guardianship and Administration Regulations 2005 (WA), reg 7, Sch 2
Case References:	Nil
Summary	The application to the Tribunal was for directions regarding the construction of the terms of an advance health directive. The Tribunal determined that to be valid, an advance health directive needed to be completed in the prescribed form of alternating recitals of particular sets of circumstances, followed by the treatment which is either consented to or refused in those particular sets of circumstances. For treatment decisions expressed in an advance health directive to be valid and binding, this format needs to be followed so that each treatment decision is given a clear context. The Tribunal found that the AHD completed by the author in this case contained only one validly expressed refusal of treatment, and that other insertions in the printed form which did not follow this format of alternating recitals of circumstances, followed by the decision or decisions either consented to or refused in those particular circumstances, were not validly expressed treatment decisions. The Tribunal found that guardians validly appointed under an Enduring Power of Guardianship could make health treatment decisions for the author of the advance health directive but not a decision which contradicted this one validly expressed refusal of treatment contained in the advance health directive.

JURISDICTION : STATE ADMINISTRATIVE TRIBUNAL ACT : GUARDIANSHIP AND ADMINISTRATION ACT 1990 (WA) CITATION : AL [2017] WASAT 91 MEMBER : MS H LESLIE (MEMBER) HEARD : 5 APRIL 2017 DELIVERED : 28 JUNE 2017 FILE NO/S : GAA 939 of 2017

GAA 946 of 2017

MATTER : AL

Represented Person

Catchwords:

Advance health directive

Legislation:

Guardianship and Administration Act 1990 (WA), s 110Q, s 110Q(1), s 110Q(1)(a), s 110S, s 110T, s 110Y, s 110Z(1), Pt 9B

Guardianship and Administration Regulations 2005 (WA), reg 7, Sch 2

Result:

Advance health directive was found not to prevent AL's guardians from consenting to the medical treatment currently needed as the Advance health directive correctly construed did not refuse that treatment

Summary of Tribunal's decision:

The application to the Tribunal was for directions regarding the construction of the terms of an advance health directive. The Tribunal determined that to be valid, an advance health directive needed to be completed in the prescribed form of alternating recitals of particular sets of circumstances, followed by the treatment which is either consented to or refused in those particular sets of circumstances. For treatment decisions expressed in an advance health directive to be valid and binding, this format needs to be followed so that each treatment decision is given a clear context. The Tribunal found that the AHD completed by the author in this case contained only one validly expressed refusal of treatment, and that other insertions in the printed form which did not follow this format of alternating recitals of circumstances, followed by the decision or decisions either consented to or refused in those particular circumstances, were not validly expressed treatment decisions. The Tribunal found that guardians validly appointed under an Enduring Power of Guardianship could make health treatment decisions for the author of the advance health directive but not a decision which contradicted this one validly expressed refusal of treatment contained in the advance health directive.

Category: B

Representation:

Counsel:

Represented Person : N/A

Solicitors:

Represented Person : N/A

Case(s) referred to in decision(s):

Nil

REASONS FOR DECISION OF THE TRIBUNAL:

Application

1 The application before the Tribunal was an application under s 110Z(1) of the Guardianship and Administration Act 1990 (WA) (GA Act) for a declaration that a treatment decision in an advance health directive (AHD) made by AL had been revoked. The application had been accepted by the Tribunal as also having been made under s 110Y of the GA Act, for directions as to matters connected with the construction of the terms of the AHD.

Background

2 On 20 March 2014, AL signed an enduring power of guardianship (EPG) appointing his wife VL, and his daughter JH, the applicants in the proceeding jointly, as enduring guardians. On the same day he signed an enduring power of attorney (EPA) appointing VL and JH as joint and several attorneys. The EPA is not subject to any restrictions or conditions. Both powers are completed on standard printed form documentation issued by the Office of the Public Advocate (Public Advocate).

3 Relevantly, the EPG authorised the joint enduring guardians to perform all of the functions of an enduring guardian including making all decisions about AL's healthcare and lifestyle. The EPG was not subject to any restrictions other than a direction by AL, expressing a preference 'to continue seeing my current GP, [Dr L], for my general medical needs as he has been my GP for a long time'.

4 On 15 April 2014, AL signed an AHD on the standard printed form documentation issued by the Public Advocate in compliance with the Guardianship and Administration ActRegulations 2005 (WA) (GA Regulations). The AHD is validly signed and witnessed. The relevant portion provides as follows (words inserted into the printed form in handwriting appear in italics):

This advance health directive contains treatment decisions in respect of my future treatment.

A treatment decision in this advance health directive operates in respect of the treatment to which it applies at any time I am unable to make reasonable judgements in respect of that treatment.

…

5 [Following some explanatory notes the following provisions appear]

1. Treatment decision

In the following circumstances:

No body to ring for ambulance should I be involved in an accident

I refuse consent to the following treatment:

to be treated in any hospital

2. Treatment decision

In the following circumstances:

nobody to instruct doctors to administer any treatment

I refuse consent to the following treatment:

to be put on any life support machines

[.]

6 The AHD on its final page, contains an optional statement to the effect that AL had discussed the making of the AHD both as to its legal and medical implications with Dr L. It appears that a lawyer was not consulted. The AHD on its final page also contains an optional indication that AL had also made an EPG.

7 The evidence is that on 23 March 2017, at his request, AL's family took him to Fiona Stanley Hospital Emergency Department (ED) for treatment of a gangrenous toe. It appears that the family had been endeavouring to persuade AL to obtain treatment for the fifth toe on his right foot for some time. He suffers from diabetes and has peripheral vascular disease. The evidence from JH is that his toe had gone black and was causing him much pain and distress. A suppurating wound had developed and it was hurting AL to walk even on his heel. He then accidentally bumped his toe causing 'absolute agony when it happened'. It appears that AL had been enduring significant pain for some time before asking to be taken to hospital. He was admitted into hospital on Thursday, 23 March 2017 from the ED.

8 JH's evidence is that, following admission, notwithstanding his apparent agreement with and wish for the surgery and his communication of that to the treating team, AL was assessed by the treating hospital team as lacking capacity to consent to the treatment of his toe and, in particular, to the recommended amputation surgery and the associated angiography and angioplasty which was recommended to improve healing by improving blood flow (the surgical treatment). JH's evidence is that she has been advised that delay puts AL at risk of a more significant amputation being required, for example, multiple toes or possibly his foot. JH acknowledges that AL suffers from 'advanced dementia'. Accordingly, in consultation with VL and JH, and with their consent as guardians under the EPG, arrangements were made for preliminary treatment with intravenous antibiotics and for the surgical treatment to take place on Friday, 31 March 2017.

9 It appears that the hospital staff became aware at some point of the existence of the AHD because of a past reference to it in their clinical records. It appears that they did not have a copy. The family provided a copy upon request and, upon a consideration of the content of the AHD, in accordance with legal advice received, the hospital authorities indicated that they were not prepared to accept the consent of the guardians to the preliminary treatment or the surgical treatment on the basis that that consent conflicted with the terms of the AHD. The surgery arrangements were therefore cancelled and the intravenous antibiotics withdrawn. The applicant made an urgent application to the Tribunal for a consideration of the meaning of the AHD.

Concerns raised by the hospital

10 In communication with the Tribunal prior to the hearing, the hospital raised the following points:

1

) The definitions contained in the AHD executed by AL are very broad in effect he has said that he does not want to go to hospital and does not want any treatment of any kind

2) The AHD (and EPG) were executed at a time not long after AL suffered an acquired brain injury (believed to be around February 2016 and July 2016) when he was deemed to lack capacity by a geriatrician. The AHD has been witnessed by a general practitioner (GP) in the period between those dates.

3) The appointed persons under the EPG (AL's wife and daughter) are advocating for treatment and have consented to AL receiving intravenous antibiotics (which have been discontinued) and admission to hospital.

The hearing

11 The matter was listed urgently before the Tribunal. JH attended the hearing in person and VL attended by telephone link. Both gave evidence and made submissions seeking orders that would clarify the situation so as to allow the preliminary treatment and surgical treatment to proceed in hospital in AL's best interests. JH gave evidence that the hospital had indicated that, provided that the Tribunal was able to confirm that JH and VL had authority to consent to the surgical treatment, it could proceed either the day following the hearing or the subsequent day.

The context of the AHD

12 JH gave evidence which was corroborated by VL that the circumstances in which the AHD came into existence were as follows. Prior to the date of the execution of the AHD (15 April 2014), AL was involved in an accident where he fell from a ladder and suffered a head injury. It appears that he spent a long time recovering from that injury which involved an extended period in hospital and then a series of placements in supported accommodation in the nature of transition, rehabilitation and/or nursing home facilities. It included some difficult times, including periods when he required mechanical restraint. He ultimately recovered sufficiently to return home. The evidence is that upon that return, he indicated to his family that he never wished to go through that sort of experience again if he were to have a similar kind of accident and he determined to record that intention by the completing of the AHD. It appears from the evidence of VL, that the handwriting on the AHD document is her handwriting and that she completed the handwritten insertions on the AHD form for AL in accordance with his oral instructions. She and AL then attended to confer with Dr L, AL's GP, with whom the document was discussed. The document was then signed by AL and witnessed by Dr L and VL. It is noted that Dr L has applied his personal stamp to the final page of the document adjacent to the references to the discussion of the document. The Tribunal is prepared to accept the presence of the stamp as confirmation that those discussions did take place.

13 It is noted that the hospital team has flagged a potential issue regarding the validity of the AHD. The evidence in support of this suggestion is unclear. The hospital team appears to have made an error regarding the date of the ladder fall and head injury. They have noted it as February 2016. This clearly cannot be right as the AHD is dated 15 April 2014. On the basis of the evidence from JH and VL, the injury clearly happened many months before that date. There is no evidence as to the effect of the head injury on AL's capacity. Even if one were to assume that there was an effect, there is no evidence as to whether the effect was such as would deprive AL of the capacity to execute an AHD. The team has also referred to a geriatrician's assessment of AL as lacking capacity in July 2016. No evidence in support of that conclusion is provided. It is some 18 months after the AHD was signed and there is no evidence as to whether the assessment by the geriatrician related to the effects of the head injury or whether they related to the separate dementia condition that emerged. In any event, it is not clear whether such an assessment included an assessment of whether AL had the capacity to execute an AHD.

14 The Tribunal is not satisfied that there is sufficient evidence to successfully challenge the valid execution of the AHD.

The legislative context

15 The GA Act allows for the making of an advance health directive under Pt 9B.

16 Section 110Q(1) of the GA Act sets out the formal requirements for an advance health directive. It provides in s 110Q(1)(a) of the GA Act that to be a valid document, an advance health directive is required to be 'in the form or substantially in the form prescribed by the regulations'.

17 Regulation 7 of the GA Regulations provides that the form prescribed for an advance health directive is the form in Sch 2 of the GA Regulations.

18 The form prescribed appears as follows:

Advance Health Directive

Notes:

• To make an advance health directive, you must be 18 years of age or older and have full legal capacity

• A person who makes an advance health directive is called the 'maker'.

This advance health directive is made under the

Guardianship and Administration Act 1990

Part 9B on

the .......................................... day of ........................................... 20.....................

by ............................................................................................................................

(maker's full name)

of

............................................................................................................................

(maker's residential address)

born on ...................................................................................................................

(maker's date of birth)

This advance health directive contains treatment decisions in respect of my future treatment.

A treatment decision in this advance health directive operates in respect of the treatment to which it applies at any time I am unable to make reasonable judgments in respect of that treatment.

Notes about treatment decisions

•

Treatment is any medical, surgical or dental treatment or other health care (including palliative care and life sustaining measures such as assisted ventilation and cardiopulmonary resuscitation.

• A treatment decision is a decision to consent or refuse consent to the commencement or continuation of any treatment.

• A treatment decision operates only in the circumstances that you specify.

• Treatment to which you consent in this advance health directive can be provided to you.

• Treatment to which you refuse consent in this advance health directive cannot be provided to you.

• Your enduring guardian or guardian or another person cannot consent or refuse consent on your behalf to any treatment to which this advance health directive applies.

1. Treatment decision

In the following circumstances:

.................................................................................................................................

I consent / refuse consent (cross out and initial one of these)

to the following treatment:

.................................................................................................................................

2. Treatment decision

In the following circumstances:

.................................................................................................................................

I consent / refuse consent (cross out and initial one of these)

to the following treatment:

.................................................................................................................................

3. Treatment decision

In the following circumstances:

.................................................................................................................................

I consent / refuse consent (cross out and initial one of these)

to the following treatment:

.................................................................................................................................

Notes for maker about signing and witnessing:

• If you are physically incapable of signing this advance health directive, you can ask another person to sign for you. You must be present when the person signs for you.

• Two (2) witnesses must be present when you sign this advance health directive or when another person signs for you.

• Each of the witnesses must be 18 years of age or older and cannot be you or the person signing for you (if applicable).

• At least one of the witnesses must be authorised to witness statutory declarations. For a list of people who are authorised to witness statutory declarations, see the Oaths, Affidavits and Statutory Declarations Act 2005.

• The witnesses must also sign this advance health directive. Both witnesses must be present when each of them signs. You and the person signing for you (if applicable) must also be present when the witnesses sign.

Signed by:

.................................................................................................................................

(maker's signature)

Witnessed by a person authorised to witness statutory declarations:

.................................................................................................................................

(authorised witness's signature)

.................................................................................................................................

(authorised witness's full name)

.................................................................................................................................

(authorised witness's address)

.................................................................................................................................

(occupation of authorised witness)

.................................................................................................................................

(date)

and by another person

:

.................................................................................................................................

(other witness's signature)

.................................................................................................................................

(other witness's full name)

.................................................................................................................................

(other witness's address)

.................................................................................................................................

19 (date)

Optional statement about legal or medical advice

Notes about statement:

•

You are encouraged (but are not required) to seek legal or medical advice before making this advance health directive

.

• If you wish to indicate that you have obtained legal or medical advice and wish to identify the person who gave you the advice, complete the relevant part of the statement.

• If you wish to indicate that you have obtained legal or medical advice but do not wish to identify the person who gave you the advice, cross out and initial the relevant part of the statement.

• If you do not wish to indicate whether or not you have obtained legal or medical advice, you may (but do not have to) cross out and initial the statement.

• If you do not wish to obtain legal or medical advice, you may (but do not have to) cross out and initial the statement.

• You do not have to say anything in this advance health directive about whether or not you have sought or obtained legal or medical advice. You can leave the statement blank and do not have to cross out or initial any part of it.

Before making this advance health directive, I obtained legal advice about making it.

I obtained that legal advice from ...........................................................................

........................................................................................................................

20 (Details of person who provided legal advice)

Before making this advance health directive, I obtained medical advice about making it.

I obtained that medical advice from .......................................................................

.................................................................................................................................

(Details of person who provided medical advice)

Optional statement about enduring power of guardianship

Notes about statement:

•

If you wish to indicate that you have made an enduring power of guardianship, put a tick (?) or cross (?) in the box next to the statement.

• You do not have to say anything in this advance health directive about whether or not you have made an enduring power of guardianship. You can leave the box next to the statement blank.

21 A consideration of that form indicates, in the view of the Tribunal, a legislative intention that an advance health directive be completed in the form of alternating recitals of particular sets of circumstances, followed by the treatment which is either consented to or refused in those particular sets of circumstances. In the view of the Tribunal, for treatment decisions expressed in an advance health directive to be valid and binding, this format needs to be followed so that each treatment decision is given a clear context. Although the use of the words 'or substantially in the form [prescribed]' in s 110Q of the GA Act allow for some limited variation in form and format, in the view of the Tribunal it is necessary for the particular circumstances in which each treatment decision is to be operative to be clearly set out and then for the treatment decision itself to be clearly set out.

22 As is provided for in s 110S(2) of the GA Act, subject to subsection (3), a treatment decision in an advance health directive operates only in the circumstances specified in the directive.

23 Given the potential significance of the decisions which might flow from the content of an advance health directive, it is understandable that there be a legislative focus on specificity and clarity with respect to each treatment decision and the circumstances in which that treatment decision should operate. It is understandable that what might at one level be regarded as a quite prescriptive form and format has been laid down in the legislation.

The meaning of AL's AHD

24 The interpretation by the hospital that in the AHD, AL has 'in effect … said that he does not want to go to hospital and does not want any treatment of any kind' is, in the view of the Tribunal, not correct.

25 The document in question needs to be interpreted by reference to its specific language but also by reference to the context in which it was made.

26 The Tribunal has no reason to disbelieve the evidence given by JH and VL concerning the background to the making of the AHD by AL. It appears from their appointments under the EPG and EPA that AL trusted them both and there is no information before the Tribunal concerning their actions or behaviour to date that would cause the Tribunal to question what they have said in this regard.

27 The Tribunal has no reason to go behind the validity of the document. There is no evidence that at the time of it being made, there was any question regarding AL's capacity. To the contrary, the evidence of his family is that he had recovered from his head injury at the time that the document was signed. This is corroborated by the involvement of his GP at the time of the execution of the document and his preparedness to be a witness to the document.

28 It is necessary then to consider sequentially the treatment decisions contained in the AHD. In the view of the Tribunal, each decision stands on its own and needs to be considered separately in view of the legislative intention referred to above.

29 The first treatment decision referred to in AL's AHD reads as follows (the words inserted into the printed form of EPG in handwriting appear in italics):

1. Treatment decision

In the following circumstances:

No body to ring for ambulance should I be involved in an accident

[insertion 1]

I refuse consent to the following treatment:

to be treated in any hospital

[insertion 2][.]

30 In the view of the Tribunal, this first treatment decision in the AHD is a refusal to be treated in any hospital. The designated circumstance in which the treatment refusal is operative is a circumstance where AL is involved in an accident.

31 What is meant by 'an accident' should, in the view of the Tribunal, be interpreted by reference to the usual meaning of the words taken in the context in which the AHD was made by AL.

32 The Macquarie Concise Oxford Dictionary (4^th ed, 2004) defines 'accident' as follows:

1. an undesirable or unfortunate happening: casualty: mishap.

2. anything that happens unexpectedly, without design, or by chance.

33 In context 'accident' as used by AL means an unexpected and unforeseen incident such as a major fall, a car accident or some other significant event, causing injury that requires complex treatment and rehabilitation.

34 Arguably, the words in insertion 1 include a second treatment decision, namely the refusal of treatment by ambulance paramedics or transport by ambulance for treatment elsewhere if involved in an accident.

35 In the view of the Tribunal, because of the placement of the relevant words after the words 'in the following circumstances', in the first paragraph of Treatment Decision 1, the words cannot be interpreted as a refusal of treatment decision. In the view of the Tribunal, this purported treatment decision has not been validly expressed. Alternatively, it is uncertain. In either event, it is not articulated in a way that renders it legally binding. In the view of the Tribunal, it falls away.

36 The second treatment decision referred to in AL's AHD, reads as follows (the words inserted into the printed form of EPG in handwriting appear in italics):

2. Treatment decision

In the following circumstances:

nobody to instruct doctors to administer any treatment [insertion 3]

I refuse consent to the following treatment:

to be put on any life support machines [insertion 4][.]

37 Treatment Decision 2 in the AHD purports to be a refusal of any treatment involving being put on life support machines (insertion 4). However, there is no designated circumstance specified in which the treatment refusal becomes operative. In the view of the Tribunal, the words inserted at insertion 3 do not constitute a designation of circumstances in which the decision expressed at insertion 4 becomes operative. Therefore, in the view of the Tribunal, the purported treatment decision at insertion 4 has not been validly expressed. Alternatively, it is uncertain. In either event, it is not articulated in a way that renders it legally binding. In the view of the Tribunal, it falls away.

38 Arguably, the words in insertion 3 in fact constitute a third treatment decision, namely the refusal of any treatment by a doctor. In the view of the Tribunal, because of the placement of the relevant words after the words 'in the following circumstances', in the first paragraph of Treatment Decision 2, the relevant words cannot be interpreted as a refusal of treatment by a decision. In addition, there is no designated circumstance specified in which any such purported treatment refusal becomes operative. In the view of the Tribunal, this treatment decision, if indeed it could be interpreted as a treatment decision has not been validly expressed. Alternatively, it is uncertain. In either event, it is not articulated in a way that renders it legally binding. In the view of the Tribunal, it falls away.

39 The conclusion of the Tribunal is thus that the only validly express treatment decision contained in the AHD is a refusal to be treated in any hospital in circumstances where AL is involved in an accident (the valid decision).

40 In the view of the Tribunal, notwithstanding that all other purported treatment decisions contained in the AHD fall away for the reasons expressed above, the valid decision can stand alone within the document. The failure by the maker of the AHD to express the other three purported decisions validity does not invalidate the document as a whole.

41 The consequence of this is that, the AHD does not prevent the guardians appointed under the EPG from consenting to the proposed surgical and any other treatment in hospital as the designated circumstance contained in the AHD, namely that AL have been involved in an accident, does not come into play. The decision which the guardians wish to make is a decision that forms part of medical treatment required by AL as a result of an existing medical condition. His diabetes has caused deteriorated blood circulation in his extremities which has in turn caused his toe to become gangrenous. A suppurating wound has developed causing infection risk, significant pain (particularly with impact) and limited mobility. There has been no 'accident' involving AL which has brought on the need for treatment such as to enliven the refusal of treatment decision contained in his AHD.

Alternate approach

42 Section 110S(3) of the GA Act provides that:

Subject to subsection (4), a treatment decision in an advance health directive does not operate if circumstances exist or have arisen that

(a) the maker of that directive would not have reasonably anticipated at the time of making the directive; and

(b) would have caused a reasonable person in the maker's position to have changed his or her mind about the treatment decision.

43 In the view of the Tribunal, on the facts of this case, it would be open to argue that, if for some reason the terms of the current AHD did prevent treatment in hospital, the context in which the AHD was made provides an understanding of the type of treatment that AL was seeking to avoid in the future. It seems to the Tribunal, that an argument could be successfully mounted that medical circumstances, such as those the subject of this application, were not in the mind of AL at the time that he made the AHD and indeed that he or any reasonable person in his position would not have sought to bar the kind of medical treatment to which the guardians wish to consent.

44 Given that the Tribunal is of the view that the current AHD is not enlivened, it is not necessary to make a determination relating to the application of s 110S(3) of the GA Act.

The s 110Z(1) application

45 This section provides that:

The State Administrative Tribunal may declare that a treatment decision in an advance health directive is taken to have been revoked under section 110(S)6.

46 Section 110S(6) of the GA Act provides that:

Subject to section 110T, a treatment decision in an advance health directive is taken to have been revoked if the maker of the directive has changed his or her mind about the treatment decision since making the directive

47 Section 110T of the GA Act provides that:

For the purposes of this Act

(a) a treatment decision in an advance health directive is not taken to have been revoked; and

(b) the maker of the directive is not taken to have changed his or her mind about the treatment decision since making the directive,

merely because the maker subsequently makes an enduring power of guardianship (whether about the same matter as the treatment decision or a different matter).

48 In the view of the Tribunal, s 110S(6) of the GA Act does not assist the applicant. In the view of the Tribunal, the change of mind referred to in the section is a competent change of mind. The very purpose of an advance health directive is to allow a person's health care to be managed according to their wishes as laid down at a time when they were of full capacity, for example, in anticipation of the loss of capacity. If that competent preplanning was able to be rendered ineffective by a different wish not underpinned by competent judgment and expressed after the loss of capacity, the whole intent of these legislative provisions would be lost.

49 It having been determined by his doctors that AL has lost capacity, a change of mind expressed by him does not have the effect of automatically revoking a treatment decision in his AHD.

Orders

GAA 939 of 2017

1. The application is dismissed.

GAA 946 of 2017

1. The advanced health directive does not operate to prevent the joint guardians [VL] and [JH] appointed pursuant to an enduring power of guardianship dated 20 March 2014 from making treatment decisions for [AL] in relation to his current gangrenous toe or toes (including decisions electing surgical and medical treatment in hospital) including but not limited to amputation, angiogram and angioplasty, anaesthesia including general anaesthesia, pain relief, antibiotic administration and any other associated or ancillary treatment.

2. The Reasons for Decision will be published.

I certify that this and the preceding [49] paragraphs comprise the reasons for decision of the State Administrative Tribunal.

___________________________________

MS H LESLIE, MEMBER

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AL [2017] WASAT 91

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