Al-Suhairi v Allianz Australia Insurance Limited

DETERMINATION OF REVIEW PANEL
CITATION:	Al-Suhairi v Allianz Australia Insurance Limited [2024] NSWPICMP 147
CLAIMANT:	Sundus Al-Suhairi
INSURER:	Allianz Australia Insurance Limited
REVIEW PANEL
MEMBER:	Alexander Bolton
MEDICAL ASSESSOR:	Adeline Hodgkinson
MEDICAL ASSESSOR:	Christopher Oates
DATE OF DECISION:	12 March 2024
CATCHWORDS:	MOTOR ACCIDENTS – Review of decision of Medical Assessor (MA) Cameron dated 19 July 2022; MA had found a 4% whole person impairment for the claimant’s right and left shoulders but not for other injuries alleged to have been suffered to the claimant’s head, cervical spine, lumbar spine, abdomen and right and left legs; the claimant accepted the decision of the MA for all injuries other than a traumatic brain injury; clause 6.164 of the Motor Accident Guidelines considered in the assessment; claimant had pre-existing behavioural issues and sometimes evidencing mutism; following the accident on 1 February 2017 the claimant was assessed by attending ambulance officers with a GCS of 14/15 but was non-responsive to questions; insurer relied on surveillance evidence showing claimant to be undertaking normal activities before a medical assessment and then immediately prior to the medical assessment on the same day showing starkly different and restricted activities; claimant was medically examined but due to the non-response of the claimant it was unhelpful in elucidating cognitive function; Held – Panel not satisfied that the claimant had suffered a brain injury; certificate and reasons of MA Cameron affirmed.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION DETERMINATION 1. The Panel affirms the decision of Medical Assessor Cameron. 2. The claimant has not suffered a traumatic brain injury following the accident on 1 February 2024.

STATEMENT OF REASONS

Introduction

The claimant seeks a review of a certificate of Medical Assessor Cameron (the Medical Assessor) dated 19 July 2022.
The following injuries were referred by the Personal Injury Commission (Commission) for assessment:
(a)   brain - injury to brain / head. Cause or aggravation to, defect or decline in cognition, delusion, psychological function, disorientation, dementia, confusion and/or behaviour;
(b)   cervical spine - injury to neck. Chronic pain, soft tissue injury;
(c)   lumbar spine - injury to back. Chronic pain, soft tissue injury, restricted range of movement;
(d)   abdomen - injury to lower abdomen. Chronic pain, soft tissue injury, restricted range of movement;
(e)   shoulder - injury to left and right shoulder. Chronic pain syndrome, soft tissue injury, restricted range of movement, and
(f)    leg - injury to left and right legs. Chronic pain syndrome, soft tissue injury, restricted range of movement, frequent reliance on walking aids.
The Medical Assessor found the following injuries caused by the motor accident gave rise to a whole person impairment (WPI) of 4%:
(a)   head – soft tissue injury;
(b)   cervical spine – soft tissue injury;
(c)   lumbar spine – soft tissue injury;
(d)   abdomen – soft tissue injury;
(e)   right and left shoulder – soft tissue injury, and
(f)    right and left leg – soft tissue injury.
Regarding injuries (b)-(f) above, the claimant accepts the decision of Medical Assessor Cameron. The claimant only requires assessment of the claimant’s alleged injury to her head/brain.
The insurer makes no objection to the Panel reviewing only the alleged head injury of the claimant.
The Panel considered a re-examination of the claimant was required and this examination was conducted by Medical Assessor Hodgkinson on behalf of the Panel on

16 February 2024.

The accident

The accident occurred on 1 February 2017 at the intersection of Elizabeth Drive and Wilson Road, Bonnyrigg. The claimant was a rear left seat passenger in a car travelling along Elizabeth Drive. The driver of her car, her daughter, proceeded to make a right hand turn into Wilson Road when the insured car, travelling in the opposite direction in Elizabeth Drive, collided with the claimant’s car. It was a “t-bone” collision directly to the left rear door, where the claimant was sitting.
Both cars were not able to be driven after the accident.

Bundles of documents

The parties have each presented their respective bundles of documents upon which they rely. The Panel have read all the documentation. If a particular document is not referred to by the Panel, this does not mean that the Panel or a Panel Member has not read it, in much the same manner as parties not referring to or not specifically relying on a document in their own bundle and submissions.
The claimant produced documentation late. When the insurer was asked whether it consented or not to the admission of this documentation, it said the position was untenable but neither said it consented or did not consent to this documentation being admitted in evidence. The insurer has had ample opportunity to make submissions about this but has not done so. The Panel will therefore consider the documentation as part of its review.

The claimant’s submissions

The claimant referred the following injury for assessment: brain – injury to brain / head. Cause or aggravation to, defect or decline in cognition, delusion, psychological function, disorientation, dementia, confusion and/or behaviour.
With respect to the diagnosis of traumatic brain injury, pursuant to cl 6.164 of the Motor Accident Guidelines (the Guidelines) the claimant noted that the following are required:
(a) evidence of a significant impact to the head or a cerebral insult, or that the motor accident involved a high-velocity vehicle impact, and
(b) one or more significant, medically verified abnormalities such as an abnormal initial post-injury GCS score, or post traumatic amnesia, or brain imaging abnormality.
The claimant submits that the first component was clearly satisfied as the accident was a high velocity t-bone collision with the brunt of the impact directly on the claimant’s door.
The claimant referred to photographs of the claimant’s vehicle which were attached to the claimant’s application.
The claimant says that notwithstanding, Medical Assessor Cameron’s opinion that the GCS of 14, assessed after the claimant’s admission to hospital, is consistent with a non-English speaking person, the claimant submits that was overwhelming evidence of post-traumatic amnesia and other cognitive/behavioural changes throughout hospital and clinical records.
The claimant says that an ambulance report provides that a GCS was unable to be obtained correctly.
The claimant says that she was admitted to Liverpool Hospital on 1 February 2017 until

8 February 2017 following the motor vehicle accident. The progress notes from the hospital include the following notes: “MVA 6 day ago, has been mute since. States does not recall the accident. Patient believes she has been in Hospital for only one day.”
The claimant refers to her general practitioner (GP) summary which indicates that she had been diagnosed with cognitive impairment on 9 February 2017.
The claimant says that she was again admitted to Liverpool Hospital on 16 February 2017 and discharged on 6 March 2022. She was brought in by her daughter “due to change in behaviour, since MVA 2 weeks ago”. The admission summary includes the following notes “Appears to be confused; anxious and restless, distressed and teary, difficult to engage in conversation, poor eye contact, looks confused; unable to tell year or day, poor memory”.
The claimant says that progress notes from the admission summary indicate that the claimant was;
“referred by LMO with headache following MVA ½ associated with deficits in memory (unable to recall names of GP and son) and psychotic features (states things are trying to crawl out of her). Pt was admitted for 7 days due to inability to complete post-traumatic assessment due to short term memory deficit and disorientation. Modified PTA was then completed with the thought that memory deficit and disorientation was baseline for pt as per immediate family which had been present since meningioma excision in 2015…”
The claimant submits that she has been admitted numerous times to hospital following the motor vehicle accident and has presented with similar symptoms indicative amnesia/cognitive impairment since.
The claimant submits that the Medical Assessor did not provide adequate reasons for his conclusions that the claimant’s injury to her head is a soft tissue injury in light of the contemporaneous evidence which supports that at the very least the claimant had post-traumatic amnesia and/or other cognitive impairment.
The claimant submits that the Medical Assessor did not consider materials pertinent to diagnosis of the claimant’s traumatic brain injury particularly the contemporaneous evidence relating to the claimant’s post-traumatic amnesia and cognitive impairment.
The claimant submits that had the Medical Assessor considered the evidence, this could have resulted in a different outcome in respect of diagnosis of post-traumatic brain injury and subsequently could have resulted in a different assessment of whole person impairment.
Accordingly, the claimant submits that the certificate of the Medical Assessor is incorrect in a material respect and submits that the Medical Assessor’s failure to consider relevant materials, to provide adequate reasoning and to afford procedural fairness, provide the basis for finding ‘reasonable cause for suspicion’ that the assessment was incorrect in a material aspect.

Insurer’s submissions

The insurer says that the criticism of the Medical Assessor’s report is confined solely to his finding that the claimant sustained a soft tissue injury only to her head. The insurer says that his finding was that there was no evidence of a brain trauma, as set out in the criteria of the Guidelines, and therefore the claimant had a 0% WPI.
The insurer says the claimant does not refer to all of the factors and opinions considered by the Medical Assessor, including the report of Dr Smith, psychiatrist, dated

29 September 2020. The insurer says that the Medical Assessor refers to that quite accurately as a detailed report. The Medical Assessor records that Dr Smith noted a history of significant psychiatric illness, “He said there had been no significant change to this following the subject motor vehicle crash”.
The insurer says that the Medical Assessor also had regard to the report of Professor Mattick, neuropsychologist, of 1 February 2021. The Medical Assessor makes reference to Professor Mattick’s finding that “there was no reasonable evidence that Mrs Al-Suhairi sustained a brain injury”.
The insurer says that the Medical Assessor refers to the fact that Professor Mattick had video surveillance material at his disposal.
The insurer says that the Medical Assessor, and as was the case for Dr Smith and Professor Mattick, was unable to glean any meaningful history from the claimant. The insurer says that as a result, at page 5 under the heading “Causation and Reasons”, he set out the following:
“Causation for the injuries listed above is established with reference to the available clinical information.
It is not possible to obtain an accurate history from Mrs Al-Suhairi due to her other health conditions.”
The insurer submits that it is therefore clear that the Medical Assessor’s only option was to consider the available medical evidence in forming a diagnosis.
The insurer then addressed that the claimant then turned to the diagnosis of traumatic brain injury. The insurer refers to the claimant saying that according to the Guidelines the following are required:
(a) evidence of a significant impact to the head or a cerebral insult, or that the motor accident involved a high velocity vehicle impact, and
(b) one or more significant, medically verified abnormalities such as an abnormal initial post-injury GCS or post-traumatic amnesia, or brain imaging abnormality.
The insurer refers to the claimant submitting that the first limb is satisfied. The insurer says that may or may not be the case, but what is clear is that the second limb is not satisfied. The insurer’s says that as the claimant referred to at paragraph 11(g) of her submissions “the Glasgow Coma Score was noted. PTA assessment was passed”.
The insurer says that insofar as it is aware, there was no brain imaging performed as none was thought necessary.
The insurer says that the Medical Assessor also noted that the discharge summary records noted that as there were no significant injuries, the claimant was discharged. On this basis, the insurer says that the second limb of the test referred by the claimant, is not satisfied.
The insurer says that in the claimant’s submissions, she goes on to refer to other entries in clinical records which detail what the insurer refers to as the claimant’s bizarre behaviour post-accident and hospital referral.
The insurer says that these records were before the Medical Assessor. The insurer says that they were commented on in detail in the reports of Dr Smith and Professor Mattick. The insurer says that quite clearly, the Medical Assessor found that these were not related to the motor vehicle accident.
The insurer submits that the Medical Assessor’s findings were based on the clinical information that the claimant sustained a soft tissue injury to her head and probable soft tissue injuries to her cervical and lumbar spine.
The insurer says that if the claimant does have any cognitive issues, which in its submission is not borne out in the surveillance, then the Panel would find, as the Medical Assessor,

Dr Smith and Professor Mattick did, that these do not relate to the motor vehicle accident.

Insurer’s MAS 2R submissions

The insurer submits that the claimant has had a fraught history. The insurer refers to documents from the Department of Immigration and from STARRTS (Service for the Treatment and Rehabilitation of Torture and Trauma Survivors) which the insurer says show that she was the subject of violent sexual abuse by her ex-husband. She also had a bullet wound in her left thigh.
The insurer says that the claimant and her four children applied to come to Australia as refugees. They were ultimately successful and arrived in Australia in January 2015. The insurer noted that the claimant almost immediately underwent brain surgery for a tumour. The insurer says that the claimant alleged she had problems with her eyes after that surgery. This claim, the insurer says, was met with great scepticism by her treaters who could find no basis for it.
The insurer says that the claimant had pre-accident admissions to hospital for psychological injuries. This included an admission to Liverpool Hospital in November 2015 when she was catatonic. The insurer says that the hospital records show that again, her treaters were sceptical about the validity of her condition.
The insurer says that it is its primary submission that the claimant is grossly exaggerating her problems from both a physical and psychological perspective, if not feigning them entirely. The insurer says that this is based on surveillance footage, which forms part of the evidence of this review.
The insurer noted that Professor Mattick had available to him for consideration, the surveillance. The insurer noted that Professor Mattick noted that what is seen on the surveillance is in stark contrast to her presentation to him.
The insurer says that Professor Mattick states that the claimant’s behaviour and responses were completely invalid. He believed the claimant was feigning this function. He thought it unlikely there was a head injury or any additional psychological problems. He thought it likely the accident had little if any ongoing effect on her.
It is the insurer’s submission that the claimant did not sustain a brain injury in the motor vehicle accident but any such symptoms to the extent to which they can be verified were pre-existing.
The insurer says that there is simply no evidence that the claimant sustained any physical injuries to the neck, back, lower abdomen, left and right shoulders or left and right legs.
The insurer relies, amongst other things, on a report of Dr Smith dated 29 September 2020.
The insurer says that Dr Smith concluded that the available documentary evidence indicated that there had been no qualitative change in the claimant’s presentation since the accident. The insurer says that her anxiety, depression, any post-traumatic stress symptoms and a tendency to fabricate symptoms were evident at least from the time of the surgery for her meningioma.
The insurer says that her fabrications may be arising on a subconscious basis and so be hysterical associative phenomena but there is ample evidence that there is a strong conscious element and so a degree of malingering.
The insurer says that Dr Smith recorded that any deterioration in the claimant’s symptoms since the accident had coincided with evidence of increased psychopathology in the family, her sons exhibiting increasing anti-social traits and possibly being more violent towards her.
The insurer says that in addition it is likely that the claimant’s third party claim is a significant motivating factor that is prolonging and/or exacerbating the expressions of her trauma based symptoms.

Medical evidence

An ambulance attended the scene, but the claimant was not taken to a hospital. Injuries were listed as lower stomach, both shoulders and both legs plus a psychological injury.
The Ambulance Service documents indicate that the ambulance service was notified of the accident at 10.51pm on 1 February 2017. At 10.56pm it is recorded that a 50-year-old female left rear seat passenger (the claimant) was trapped as the door of her car could not be opened. She was noted as being unconscious and breathing at 10.58pm the claimant remained trapped but was "conscious and breathing". At 11.10pm it was recorded that the claimant had a Glasgow Coma Scale (GCS) score of 14/15 but was “refusing to answer any questions due to language barrier”. By 11.27pm she had been released from the car. Her blood pressure was 140/80.
The Ambulance Report states that the claimant would not speak to the ambulance crew but it was noted that there were no obvious injuries. Ambulance officers were unable to obtain a GCS as she would not speak or move her limbs.
The claimant arrived at triage at Liverpool Hospital at 11.51pm. The Liverpool Hospital Trauma Assessment Form indicates that she complained of pain in the neck, chest and abdomen.
On examination she was fully conscious with a GCS of 15/15, her pupils were equal, her pulse rate was 50 per minute and her blood pressure was 120/67. She could not recall what medications she took. She was tender over the sternum, cervical and thoracic regions of the spine, and the pelvis. FAST and E-F AST scans revealed no thoracic or abdominal injury.
A CT Pan scan showed no abnormality apart from a right occipital subgalealhaematomaAt 11.56pm it was noted that she answered to her name. At 12.15am on 2 February 2017 it was noted that she would not answer questions or obey commands. At 1.00am her daughter reported that her mother spoke some English but was "just in shock".
The claimant was then seen by the Trauma Registrar who queried whether she suffered a head injury or any loss of consciousness. The trauma team then saw her and noted that she was alert and moving all four limbs but she was non-compliant, even with an Arabic interpreter.
At 11.15am a social worker noted that the interpreter reported that when asked about her social history she seemed unsure or else did not answer.
At 12.40pm it was noted that the claimant exhibited jerky movements and complained of dizziness. An occupational therapist noted that when orientation was tested with the aid of an interpreter she would not cooperate. She claimed not to be able to recall immediately the pictures of three objects. The claimant’s daughter then reported that her mother's cognitive function had not been optimal since her brain tumour surgery and she was not sure if her mother would have been able to answer orientation questions prior to the accident. From this it was deemed that further PTA testing was inappropriate.

X-rays of the right shoulder showed no abnormality. CT scans of the brain, neck, chest and abdomen showed no abnormality.
Both Dr Smith and Professor Mattick provided extensive summaries of the claimant’s medical history. The summary provided by Dr Smith follows:
“In 2014 it was recorded in the immigration file:
. . . I was shot in Jordan due to his beating there was a growth above my eye.
I need to have an operation or I will lose my eye. I had similar to a stroke
last year and my arm was paralysed.’
It was noted that both of her parents, two brothers and a sister lived in Australia whilst
a sister and non-dependent child lived in the USA. A brother lived in Iraq. Four nondependent
children lived in Jordan. It was further opined:
‘The applicants are from a religious minority and after the collapse of the
former regime they faced gruesome threats and are required to comply with
Islamic laws and wear head covers.
The principal applicant fears her daughter would be kidnapped as abduction
of young girls was common.
The principal applicants worked for the Election Commission and came
face to face with political groups.
The applicant is a single mother and the applicants cannot return
to Iraq because of the threat to their life and liberty.’
On 12/5/14 it was noted that the husband had been contacted. He stated that his wife
had filed for divorce and he would like to proceed with this.
The family arrived in Australia on 9/7/14.
Dr. Gregor noted on 10/1/15 that she had a swelling of the right forehead about two
inches in diameter that she reported had been present for five years and it affected her vision and sense of smell.
On 12/1/15 Dr. Gregor noted that she suffered abnormal near vision and
hypercholesterolaemia.
On 12/1/15 a CT scan of the brain and facial bones showed a large right frontal bony
lesion of unclear aetiology but most likely was an intra-osseus meningioma.
On 14/1/15 Mr. Musumeci, Optometrist, reported that her visual acuity unaided was
6/7.5 on the right and 6/6 on the left, correcting to normal 6/6 in each eye. No ocular
abnormality was detected. Visual field testing revealed bilateral superior defects.
On 15/1/15 she was seen by the NSW Refugee Health Service nurse. She reported that
she suffered a gunshot injury to her left leg in 2006 and there was scarring and possible
shrapnel in the leg. She suffered renal colic seven years ago. She had a six month
history of reflux. She had a history of mild asthma. She had continuous headaches
associated with a bony overgrowth of her forehead. She requested a dental assessment.
It was further noted:
‘Sundus gives us a history of being in a violent relationship with her
husband where she was hospitalised more than once. On one particular
occasion she suffered a decent head injury where she was unconscious for
a period of time. A basic neurological examination today indicates that she
has no obvious complications resulting from this. Along with this trauma
there are incidents of other psychological trauma from racial persecution
and civil unrest in her homeland. I have referred her to STARTTS for
counselling.’
On 15/1/15 it was recorded in the STARTTS file:
‘Traumatised from racial persecution in Iraq and ? Jordan. Also from
domestic violence during her marriage ...
Victim of severe domestic violence in Iraq now divorced. Hospitalised
from injuries ...
Sundus is presently being investigated by specialist for bony lesion on left
forehead. This is affecting her eyesight and gives her headaches.’
On 13/2/15 she reported to Dr. Gregor a pain in the right shoulder that had been present
for many years, and intermittent numbness and pins and needles in the fingers of the
right hand.
On 22/2/15 a further STARTTS referral form was completed stating:
‘ This referral is for 2 brothers and their mother. Left Iraq in 2005, lived in
Jordan for 10 years. In 2008 mother was shot in the leg and in hospital for
3 months. Father got remarried in the same year. Children exposed to a lot of domestic violence. Mother has a big lump on head that needs operating
Xxx son lives with father in Jordan. Children may be at risk from xxx who
mother claims is violent towards them.’
An ultrasound of the right shoulder on 23/2/15 showed a small partial thickness tear in
the supraspinatus tendon, on a background of tendonitis. There was significant
subacromial/subdeltoid bursitis and bursal impingement with abduction and moderate
acromio-clavicular degeneration.
On 24/2/15 Dr. Gregor recorded that she was tearful, suffered depressed mood, low self esteem, early morning waking, ‘bouts of amnesia’ and ‘feels anxious and tight’. He
prescribed the antidepressant Avanza (mirtazapine) 15 mg nocte.
On 28/2/15 Dr. Gregor noted that she had a partial tear of the supraspinatus tendon of
the right shoulder.
On 10/3/15 Dr. Gregor diagnosed a Major Depression. He prescribed Valium.
On 8/4/15 an MRI scan of the brain showed an enhancing mass lesion in the right frontal region with a broad dural base, with associated enhancement of the adjacent dura. The mass measured 4.3cm transverse, 3.1cm craniocordal and 1.4cm depth. It was associated with a marked hyperostosis of the right frontal bone that extended to the roof of the right orbit. The appearances were in keeping with a large broad based right frontal meningioma with marked associated hyperostosis of the frontal bone.
On 20/5/15 she was admitted to Liverpool Hospital and Dr. Darwich perforned a right
frontal craniectomy and removal of en plaque meningioma, with a titanium mesh
cranioplasty. In the admission checklist she indicated that she suffered "blackouts or
fainting" in 2014. She underwent a blood transfusion 25 years ago, and so presumably
in 1990. She reported that she underwent an appendicectomy when she was pregnant,
gave birth by caesarean section 15 years and 12 years ago, and had a tubal ligation 12
years ago. She was taking Avanza 15 mg nocte.
At operation the underlying brain was considered to be normal and healthy.
A CT scan of the head on 21/5/15 showed no brain damage, only some oedema of the
right frontal lobe. The right frontal sinus was opacified, most likely a post-surgical
change.
On 22/5/15 it was noted that her right eye was swollen. She was to lie flat because of a
CSF leak from her nose. She was started on antibiotics.
On 23/5/15 there was no further nasal leak.
She was discharged home on 26/5/15.
On 28/5/15 she told Dr. Gregor that her right eye vision was blurred as it was prior
to her surgery. But on 1/6/15 she stated that it was worse than before the operation. On
19/6/15 he noted that she was suffering dizziness and syncopal episodes ai1d was ‘quite depressed and: frustrated with son.’
On 3/7/15 Ms. Butterworth of STARTS recorded that Sundus had been interviewed
with the aid of an interpreter. She barely made eye contact and her right eye appeared
closed. Her mood was flat and "her body language was motionless’. It was recorded:
• Because her children were teenagers and young adults, they were more
demanding and this compounded her feelings of helplessness ...
• Sundus reported fleeing Iraq to Jordan where she lived for ten years.
She described this as very difficult to transition to a foreign country.
• Her husband left her in 2007 for another woman. He also took their
eldest son with him.
• Her husband remarried and they lived in USA.
• Sundus has only reunited with her son in the past year ...
• Her parents are both still alive and also relocated to Australia ...
• Sundus reports being close to all her family in Australia, but on the other
hand, still wants to be isolated from her siblings. They want to help her
but she feels her children are ‘in a different world altogether.’
• Her children heard about the freedom in Australia and apparently
‘parents are not in control’, so she feels as though she is losing control
• She was formerly an art teacher in Iraq, with relevant qualifications.
• She enjoyed painting and exhibiting.
• She wants to paint again but her arm and eye injuries would not allow
for it, along with limited materials and space at home.
• She is embarrassed and ashamed of her condition as she cannot hold a
paintbrush anymore.
• She reiterated feeling choked and exhausted, going to bed early while
the children continue to laugh and argue. She puts a blanket over her
head with a fan on, so she can breath easier ...
• She tried to get her daughter to be a carer, which was just approved last
week ...
• She takes 2 Panadol, 4 times a day for headaches.
• She also takes a ‘tranquiliser’ which is unknown exactly what it is.
• She also takes anti-depressants and medication for her arm ...
• Her surgery was 20 May 2015.
• Asked about why she required surgery she said her husband drank and
beat her.
• The last time he beat her was in Jordan. She was injured on her forehead
and it turned blue. She went to hospital but was discharged, but the
lump grew and affected her eyesight.
• She was unable to afford medical surgery and so the lump was untreated
for five years. In this time she was focused on her children and
prioritised their needs.
• In Australia upon arrival it was deemed so serious she had to have
immediate surgery to remove it, and was fast-tracked past the waiting
list ...
• She thanks God and her Mandean faith for keeping her alive ...
• Asked about her GP she could not remember his name, Dr Allan (unsure
of surname) in Fairfield, who was Iraqi. She said she was forgetful due to the lump as well.’
On 17/7/15 Ms. Butterworth recorded:
• She said she worked 17 years as a teacher and therefore ‘knows what
commitment is’...
• She said it was 40 days since her surgery and was embarrassed to show
herself because it was hard to see with one eye ...
• She reported an incident where she was very upset about paying $40 for
a pair of pants, which she thought was only $14 but misread the size for
the price tag. She was very upset the shop owner would not exchange
the pants and she was left feeling very upset, unable to pay for food for
her children and unable to sleep.
• She reported this event triggering her memories of being in Jordan,
where there was significant extortion and exploitation.
• She said she respects herself and does not want people to abuse her.
• She was mourning the loss of her independence and her eyesight, and
she was upset that she did not feel as functional as before.
• She was upset that such a simple event triggered such sadness and
despair.
Dr. Darwich reviewed her on 23/7/15. He noted that histopathology revealed that her
tumour was a grade I meningioma. She reported that one week after her surgery she
developed an almost complete loss of vision in her right eye. On examination she
resisted the opening of her right eye. Eye movements were full.
On 23/7/15 she was evaluated at the Ophthalmology Clinic at Liverpool Hospital. No
abnormality was found in the right eye to account for her claim of blindness.
On 23/7/15 she was readmitted to Liverpool Hospital. She was having an MRI scan
when she became unresponsive. She awoke after a sternal rub but was then very
drowsy.
She was seen by the Ophthalmology Registrar. She claimed no vision in the right eye
and the left eye acuity was 6/9. There was no ophthalmological abnormality and a
‘functional visual loss’ was diagnosed.
On 24/7/15 she was seen by the Neurosurgery Team complaining of an acute loss of
vision in the right eye. It was queried whether this was part of a conversion disorder.
At 1.30 pm it was noted that she was independent in the activities of daily living and
was moving independently around the room.
A CT scan of the brain on 27/7/15 showed no acute intracranial haemorrhage. An MRI
scan of the brain on 27/7/15 was limited as she became unresponsive during the
procedure but it showed a small area in the sub cortex of the anterior right frontal lobe
considered likely to be an area of gliosis. No organic basis was found for her complaint
and it was considered to be a functional vision loss.
She was discharged home on 28/7/ 15 on the antidepressant Avanza 15 mg nocte.
Dr. Gregor reported on 30/7/15 that she had no vision in her right eye, she had right eye
pain, and she suffered headaches and postural dizziness. He stopped her Valium and
prescribed Celebrex and continued the antidepressant Avanza.
On 7/8/15 she told Ms. Butterworth reported that one son stayed out late when she was
in hospital and her other son did not talk to her and did not eat because she "dobbed"
him into his school.
On 25/8/15 it was noted in the STARTTS file that Katherine Theodor was her
counsellor. On the FASSTT NMDS she was rated ‘Severe’ for ‘Family
dysfunction/difficulties and Pain/somatoform symptom and ‘Moderate’ for
Interpersonal difficulties, Traumatic stress symptoms, Anxiety symptoms, Depression
symptoms, Traumatic grief, Severe mental illness symptoms, and Disability.
On 28/8/15 she told Ms. Butterworth that her son had been prescribed dexamphetamine but he was having adverse effects with lost appetite, dry mouth and insomnia. On 25/9/15 she reported that her son had been mugged, losing money and his mobile phone.
He was distressed and wanted counselling.
On 10/9/15 she saw Dr. Ibrahim. He noted that appendicitis had resolved. She
complained of dizziness and feeling that she was about to collapse. An ECG showed
no abnormality
On the Multitask Questionnaire completed on 30/9/15 she was rated ‘Extremely’ for
35 out of the 41 items. Ms. Butterworth noted that her scores indicated clinically
significant levels of anxiety, depression and PTSD.
On 5/10/ 15 she was seen at the eye clinic again claiming to have no vision in the tight
eye. It was noted that a ptosis of the tight eye had been present since the surgery due
to limited movement of the frontalis muscle.
On 9/10/15 she told Ms. Butterworth that her husband had many mistresses and would
send her away so that he could have affairs, but she would find evidence on the bed.
He took the money she earned and spent it on his mistresses. His mother was also her
maternal aunt and she was in denial about his violence.
On 6/11/15 Ms. Butterworth recorded:
• Sundus arrived 20 minutes late after coming from an appointment with
Miriam at MRC. She made no eye contact and appeared very distressed.
• She began opening up about her husband's sexual abuse, and how he
would give Sundus sleeping tablets so she would sleep through the
incidents. The children all slept in the same room.
• Apparently her husband said he was drunk and begged for forgiveness.
• Meanwhile Sundus also reported numerous threats on her family's lives
and Sundus was even shot in her car while driving with her children.
She was shot in the leg and had to drive 6 hours to Jordan.’
In a phone call on 11/11/15 Ms. Butterworth noted:
• She reported severe forgetfulness and even getting lost after last
appointment. TI1e police found her and helped her get home ...
• She reported the fear that her in-laws would take her children away from
her, e.g. her son staying out late and her daughter having phone contact
with her other son in USA.
• Sundus also disclosed more atrocities committed against her by her ex-husband
including him stealing jewellery from her and also assaulting
her son.
• Sundus wanted a divorce but her family prohibited it.
• No Mandean priest would approve the divorce so she and her daughter
had to convert to Islam to have the divorce approved. This brought
much shame and rumours, and people believed that her daughter
converted because she wanted to marry a Muslim.
• Miriam suggested taking an AVO out on her in-laws as they recently
spat on her and threw eggs on her house.
• She confides in Miriam from LMRC and her cousin who is a social
worker in Liverpool
On 12/11/15 Dr. Gregor had a phone call with Miriam from the Liverpool Migrant
Centre and recorded:
‘Panic hysterical attacks.
Disorientated.
Nawras having foot problems and frequent falls.’
On 12/11/15 she was admitted to Liverpool Hospital. The history was obtained from
her cousin as she was not speaking. It was reported that since Halloween she had been bullied by local teenagers who had thrown eggs at her in her home. The previous day they broke into her home, swore at her and threw eggs around the home. She attended a refugee centre and then her cousin was called as she told her case worker that she could not stand up. When the cousin arrived she was lying across two chairs with her feet up. She then collapsed to the floor twitching in all four limbs for seconds to minutes but she sustained no head injury. When she "came around" she reported that she could not feel her arms or legs but otherwise was aphasic. She had exhibited similar episodes in the past.
On examination she was lying in bed not speaking and tearful and moaning.
Occasionally she shook both legs for a couple of seconds, but no neurological
abnormality was detected.
EEGs revealed no abnormality. A CT scan of the brain showed only the recent
operative changes.
On 13/11/15 the Night Resident Medical Officer was called as her level of
consciousness had supposedly declined. On examination she opened her eyes to voice.
She groaned intermittently. No neurological abnormality was detected. It was then
recorded:
On 18/1/16 it was noted in the STARTTS file that she had declined treatment because
of ‘high levels of stress related to moving house and overwhelming medical
appointments.’
On 18/1/16 she did see Dr. Gregor who noted that she had twice been admitted to
Liverpool Hospital with anxiety. She was depressed, had "anger issues" and discord
with the children. She had lived with her mother, father and brother, but had moved
with her children to her own home. Dr. Gregor completed a GP Mental Health Care
Plan stating that she was suffering ‘mixed anxiety and depression’ and had a K10 score of 47.
In a report to Dr. Kumar dated 27/1/16, Ms. Butterworth disclosed that Sundus had
revealed that her ex-husband would give her sleeping tablets at night so that he could
sexually molest the children while she was asleep. He was imprisoned at one stage but
paid a bribe for his release and he eventually left for the USA with their eldest son. Ms.
Butterworth noted that psychometric assessment confirmed that she was suffering
significant anxiety, depression and PTSD symptoms.
Dr. Kumar, Psychiatrist, saw her on 27 /1/16. She was living with a 26 year old daughter and three sons aged 16, 14 and 13 years. Dr. Kumar noted:
‘It was a difficult assessment. Sundus found the interview challenging and
was unable to provide details about her illness or treatment She was quite
depressed and teary during the assessment and did not engage well. She
reported that soon after her migration to Australia, she had a 'lump in her
brain' which was removed later. She is finding the responsibilities of a
single mother quite demanding and feels that it is adding to her symptoms.
Her 14 year old son also has ADHD and his illness has been very taxing for
her.
She then spoke about her life in Iraq and how she was threatened and shot.
She sustained a bullet injury in her leg. Her husband left her about 10 years
ago, which Sundus did not want to discuss at all.
She reported poor mood, poor sleep, reduced appetite, poor concentration
and anhedonia. She denied any thoughts of self-harm or suicide. The
history of psychosis was not clear.
She did acknowledge two hospital admissions to Liverpool mental health,
the last one being a month ago. She is also seen at STARTTS. Sundus said
she is now on Pristiq 100 mg daily for the last one month, after discharge
from hospital.
The details of her past or personal history were difficult to elicit due to her
reluctance, though she said she has two brothers and a sister.
On mental state examination, she presented as a middle-aged woman of
average build. She was dressed neatly and her overall grooming and
hygiene were fair. As I said earlier, it was difficult to engage her in
conversation and she did not provide details of her illness. Her mood is low and her affect was depressed and teary. She denied any thoughts of self-harm
or suicide.
Opinion: Major Depression. D/D: PTSD.
She was in contact with STARTTS on 8/2/16 and it was noted:
‘Client presented with severe trauma from DV marriage, along with
parenting/family conflict and overwhelm ...
Client made additional disclosures of abuse within her family by her ex-husband.
Client became increasingly distressed at harassment from in-laws
and unable to attend appointments in 2016.
On 16/2/16 she attended the Emergency Department of Liverpool Hospital supposedly
after falling downstairs. Her family reported that she would not talk when she felt
anxious or unwell. They heard but did not see her fall and it was uncertain whether she
ever lost consciousness. She had been given intravenous morphine by the ambulance
crew. She claimed that she was walking up some stairs, did not see the step and fell
backwards down five steps. She complained of pain all over her body. She had with
her some dexamphetamine tablets.
On examination she was fully conscious with a GCS of 15/15 and no neurological
abnormality was detected. She then claimed not to recall the fall. Later she became
mute, unresponsive to pain and did not open her eyes but it was noted that she protected her face when her hand was dropped above her head (this ann drop test being an indicator of malingering), and she flinched when her eyelids were touched so that ‘all appears to be behavioural’. CT scans of the brain and spinal cord showed no acute abnormality. When an attempt was made to discharge her she slumped over in the wheelchair. She was discharged into the care of her family.
On 22/2/16 Dr. Gregor noted that she had sprained her right ankle in the fall and the
joint was swollen and painful. She claimed a mem01y loss for recent events and
reported increasing anger and loss of temper.
On 4/3/16 Dr. Sridharan recorded:
‘Presents for review with Dr. Gregor.
Whilst in waiting room, slumped in chair and unresponsive.
Not responding to sternal mb.
Breathing comfortably without airway obstruction ...
Have sent to hospital for further management with ambulance ... ‘
In his letter to the hospital Dr. Sridharan noted that with the arm drop test she did not hit herself in the face when the arm was let go.
The Ambulance Record states that initially she was unresponsive to pain. When they
tried to apply a nasopharyngeal airway she opened her eyes, pulled it out and then
‘continued to remain unconscious’.
The Emergency Department Discharge Summary for 4/3/16 indicates that in the
ambulance she had a Glasgow Coma Scale (GCS) score of 9/15 and when she arrived
in the emergency department a nurse conducted a sternal rub with which Sundus woke
up and swung out her arms but then claimed that she could not move her arms and she
had intermittent numbness in both legs. On examination her GCS was 15/15. A repeat
CT scan of the head showed no abnormality. She was discharged home.
On 8/3/16 she told Dr. Gregor that she ‘has memory loss but recovers memory later’.
On 17/3/16 it was noted:
‘Toothache.
Wants Health Summary.
Problems with Nawras her son who took a knife by mistake to school.
Police contacted.
Samer other son accused of stealing car.
Then found to be guilty.
House owner has accused them of stealing property.
Has complained at court.
Uncertain.
Frail.
Not coping.
Children not controlled.
Pains lower back and pelvis.
Right ear hearing impaired.
Patient ve1y emotional and unable to control her life."
On 17/3/16 x-rays of the lumbar spine, pelvis and abdomen showed only mild
degenerative changes in the spine and pelvis.
Dr. Gregor noted on 18/3/16 that there was a court hearing that day about her house.
On 23/4/16 he recorded that Nawras had been expelled from school. Dr. Gregor
provided a report stating:
‘In my opinion Sundus is suffering from severe depression and her son
Nawras has behavioural problems which makes it very risky for her sons
Nawras Sabri and Sam Sabri to go to school alone. Both boys will need
safe transportation provided to and from school.’
On 30/4/16 Dr. Gregor noted:
‘Father in law not on good terms.
They have asked Samer to work in a bar and he has started drinking.
Police got involved.
Sundus has appointment with Workskil Australia Liverpool.’
She told Dr. Gregor on 7 /6/ 16 that Centrelink had stopped her payments and she needed
to study. On 21/6/16 he recorded:
‘ ... Older son Samer working drinking with friends.
Younger son Nawras wants to be a policeman.
Daughter Riham and brothers not respecting their mum.
Younger son Sam was in a feud with a student about removing Hijab from
her by force/he was expelled from school for 2 days.
Prolonged counselling offered.
Husband used to beat her up and sexually abused daughter Riham and son
Nawras.
Husband now married to another in the US.’
She was again referred to STARTTS on 22/6/16 and the reason stated was:
‘Counselling re: war related trauma.
Feeling depressed/worried/anxious.
Increasing dissociation episodes ...
. . . Suicidal ideation and/or attempts - 2 months ago while in a dissociative
state. Currently no suicidal ideation.’
On 15/7/16 Dr. Gregor noted:
‘Samer her son was in court.
Samer has been untruthful to me as he said he is reforming.
‘In my opinion Sundus is suffering from severe depression and her son
Nawras has behavioural problems which makes it very risky for her sons
Nawras Sabri and Sam Sabri to go to school alone. Both boys will need
safe transportation provided to and from school.’
On 30/4/16 Dr. Gregor noted:
‘Father in law not on good terms.
They have asked Samer to work in a bar and he has started drinking.
Police got involved.
Sundus has appointment with Workskil Australia Liverpool.’
She told Dr. Gregor on 7 /6/ 16 that Centrelink had stopped her payments and she needed
to study. On 21/6/16 he recorded:
‘ ... Older son Samer working drinking with friends.
Younger son Nawras wants to be a policeman.
Daughter Riham and brothers not respecting their mum.
Younger son Sam was in a feud with a student about removing Hijab from
her by force/he was expelled from school for 2 days.
Prolonged counselling offered.
Husband used to beat her up and sexually abused daughter Riham and son
Nawras.
Husband now married to another in the US.’
. . . Suicidal ideation and/or attempts - 2 months ago while in a dissociative
state. Currently no suicidal ideation.’
She has tried to involve the police but feels powerless for any change. The
police apparently come to her house on a daily basis.
She reported once xxx went missing for five days and was with his
girlfriend.
She feels Australian culture is different from how her culture would have
implemented discipline.
She reported, ‘I feel like I've lost both of my children’ and ‘I want to live
away from everyone.’
Her last contact with STARTTS before her motor vehicle accident appears to have been on 13/1/17 when it was noted:
‘Sundus re-referred for the third time for counselling to process significant
trauma sustained in Iraq and Jordan, as well as ongoing child protection and
DV concerns within her family ...
‘Sundus was unable to commit to individual counselling and said that she
would be in contact with STARTTS when she felt less overwhelmed. This
is the third time this has occurred.’
Family History
The notes of Fairfield Chase Medical & Dental Centre state that her father suffered a
brain tumour and her mother had ‘RD’. (RD possibly refers to retinal detachment).
She told Dr. Ibrahim on 10/9/15 that her mother suffered diabetes and hypertension.
The immigration file contains a report dated 6/7/12 from Emad Girgis, Clinical
Psychologist, regarding Shaker Rishoodi, Sundus' father. It notes that he suffered
diabetes, hypertension, gastric problems. He had lost the sight in his left eye and had
glaucoma in the right eye. He complained of low mood, insomnia, irritability, low self esteem, low energy levels and poor motivation. It was considered that he fulfilled
DSM-IV criteria for a diagnosis of Major Depressive Disorder and that the degree of
his current disability was severe.
HISTORY OF THE ACCIDENT AND MANAGEMENT FROM THE
DOCUMENTS
The Motor Accident Personal Injury Claim Form signed on 30/6/17 is for a Mr. Sundus
Al-Suhari whose occupation was home duties. It was signed by her daughter Riham
Sabri who the Particulars state was driving the car. It indicates that the accident
occurred at 11.00 pm on 1/2/17. She was a passenger in a car wearing a seatbelt and
she had not had any drugs, including medication or alcohol, in the preceding 12 hours.
On 3/2/17 at 10.18 am a Physiotherapist noted that without warning Sundus ‘appeared
to gradually and controlled lowering self assisted by physio to floor.’ She did not hit
her head or sustain any injury but there was a brief loss of consciousness. She was
helped onto a chair and ‘regained consciousness quickly’. It was queried whether this
was a ‘behavioural event’.
At 10.43 am she was able to mobilise independently without any aids.
The daughter then told a Social Worker that her mother suffered PTSD but this was
caused by the problems with her husband rather than her refugee experience, and his
violence towards Sundus and herself had escalated. The daughter reported that since
the accident her mother had been unable to move properly, was less able to remember
events, did not interact when they visited and was not interested in conversation and
gave single word answers.
On 6/2/17 she told the Social Worker that she thought that she was in hospital because
she had fallen off the top of a building whilst pegging out the laundry. She claimed that
she was not in a car accident as the family did not have a car. When told that her
daughter was driving the car she claimed that her daughter and oldest son were only in
primary school and the other children were ‘still on the bottle’. She claimed that she
lived with her husband and four children, that she was currently working as a teacher,
and she was concerned that her husband notify the school that she was temporarily
unable to teach. She maintained that she was the primary carer for her husband and young family. When asked if she suffered bad dreams or thoughts, she stated that she
was scared as she saw her grandfather who had died years ago. She saw a man trying
to hammer a nail into her uncle's wife's head and she remembered someone, possibly
a nurse, trying to suffocate her then chasing her. She denied having any contact with
STARTTS.
The Social Worker then met briefly with Sundus' sister who reported that prior to the
accident Sundus was prone to anxiety, especially over her son's behaviour but she was
now confused. Her daughter then told the Social Worker that her mother was mixing
up her experiences in Iraq and Jordan with her current life.
On 7 /2/17 she was seen by the psychiatry team. She stated that she felt well and ‘I
want to go home.’ She claimed not to recall the accident and claimed that she had been in hospital only one day. It was noted, ‘Admits to experiencing nightmares whilst in hospital re-occurring themes of seeing her family dying.’ She denied feeling depressed and there was no evidence of mutism or catatonia. She smiled appropriately.
On 8/2/17 she told a Social Worker through an interpreter that she was separated from
her husband and resided with a daughter aged 24 years and sons aged 15 and 14 years.
She did not engage with the staff during her admission and was discharged home on
simple analgesic medication as required on 8/2/17,
On 9/2/17 Dr. Gregor prescribed the anti-inflammatory Brufen and recorded:
‘Patients after being admitted to Liverpool hospital following MV A 1/2/17.
She was back seat left side passenger.
Seat belt was on.
The car was hit on the left back door by another car at an impact of 60
km/hr.
She sustained head injuries with LOC.
No lacerations or bleeding.
No laceration.
Daughter says mental cognition is intermittent flashing to and back reality
and present time.
Pain left side of chest .. .
CT SCAN:
Right occipital scalp subgaleal haematoma.
Patient NOW:
Disorientated for time, place and person.
Conscious and in a good mood.
She appears to be having recent amnesia.
Neurological examination normal.
Cognitive impairment.’
On 14/2/17 she saw Dr. lshfaq with her daughter. She complained of pain generalised
to her whole body. It was noted that ‘she is bit forgetful and mainly discussing her past
life’. He referred her to a hospital and her daughter was to take her.
On 16/2/ 17 she was admitted to the Mental Health Unit of Liverpool Hospital. She
reported that she was becoming more frightened at home, she noted shadows running
in her house at night, could hear her name being called out, and saw her relative dying.
She reported ‘chronic suicidal thoughts with plan to burn self or jump from height’.
On examination she was distressed and cried at times. She was difficult to engage in
conversations and eye contact was poor. She ‘appears to be confused: anxious &
restless’.
She was to take Pristiq 100 mg and Serepax 15 mg.
When interviewed with the aid of an interpreter it was recorded:
‘Can see a dark large man, telling her to go with him, telling her that he
will bash in her head (as he had done to his brother), whilst on stated that
she saw this man chase his brother and then bash his head with a rock.
Stated that she can only remember a white light from the MVA, but
otherwise could not recall the event.
Had been initially very disorientated, stated she was in Baghdad, and
couldn't tell the year, believed she lived with all 5 children when actual fact
her oldest sone is in USA with the father.’
She was started on the antipsychotic Risperidone 0.5 mg nocte, then increasing to l mg
nocte and continued on Pristiq 100 mg. She was weaned off the Lorazepam
commenced in the emergency department.
On 17/2/17 it was noted in regard to her initial admission following the motor vehicle
accident:
‘Patient was admitted for 7 days due to inability to complete post-traumatic
assessment due to short-term memory deficit and disorientation. Modified
PTA was then completed with the thought that memory deficit and disorientation was baseline for patient as per immediate family which had
been present since meningioma excision in 2015.’
It was then noted:
‘Security officer who speaks Arabic states he spoke to her earlier and she
was verbally responding, he felt that she was confused.
Patient perplexed and preoccupied. Medical officer utilized an interpreter,
patient not speaking to him.
Attempted to counsel and reassure patient to no avail.’
It was then noted that she reported chronic suicidal thoughts with plans to burn herself
or jump from a height. She reported auditory hallucinations of family members saying
'help me' or knocking on the windows.
On 20/2/17 it was noted that prior to admission she had complained of things trying to
crawl out of body". She had nightmares of relatives crying out for help. When
interviewed with the aid of an interpreter, she stated that she was in a hotel in Baghdad, that all five children lived with her and her husband was ‘possibly dead’. Asked the current year and given some options she responded, ‘it could be anyone of them’. It was further recorded:
‘Admitted to hearing a voice - male voice, tall dark slim man, who's telling
her to ‘come with me, I'll take you to another world’ and told her not to
tell anymore, as he can hear her; stated he doesn't let her sleep at night, he
asks her to get out of bed, so he can lie there. Doesn't recognise the voice.’
On 21/2/17 she told a Social Worker that her husband was deceased and she lived with her daughter and four sons. She claimed that she was in a hotel in Baghdad. She
repo1ted auditory and visual hallucinations.
On 23/2/17 she stated that she had seen a large black man who tells her not to talk to
anyone or else he will take her far away. She had seen him three or four times and
usually at night. Rahim and Samer (Sameen in the text) were interviewed. Samer stated that his mother had claimed that she was currently pregnant with him. She did not remember the accident when the children spoke to her. At times she sat by the window, ostensibly waiting for Saifto come home, even though he lived in the USA. It was then noted that Sundus was cowering in a comer stating ‘he's here.’
On 24/2/17 she told a nurse that she was worried particularly about her 17 year old son
who she thought was taking drugs and sometimes went missing for five days so they
reported his absence to the police. She spoke about being a teacher in Iraq, of having
brain surgery for a tumour, and of the car accident but stated that she was happy that
her daughter acted as a second mother to the other children when she was not around.
On 25/2/17 it was noted that her mood was better and she smiled appropriately. She
spoke in broken English although it took her some time. She denied having any psychotic symptoms.
On 26/2/17 it was recorded:
‘Tidy; in euthymic mood; reactive on approach; engaged well despite
limited English; recounted the accident and how it affected her; became
shaky but responded to reassurance; states sleep is ok; admits to becoming
anxious and teary at times; denied thoughts of self-harm.’
A diagnosis was made of PTSD and ‘induced psychosis’ with ‘MVA induced
resurfacing of past trauma resulting in dissociative psychosis.
On 27 /2/17 she reported that she still saw the ‘tall black man’ who occupied the whole
corner of a room and she saw him also at home. It was further recorded:
‘Stated that she saw him talking to another woman (dressed in black) a few
days ago, and then she saw him chase down his brother, and when he
couldn't make it over the fence, he grabbed a rock and started beating his
head with it. She is scared that he will come after her. She doesn't know
this woman, or this dark figure. Asked if this was a dream, or whether she
saw this happen on the ward, she said that she is not sure.
She said that she will ask him to leave her alone, by telling him that she has
designed a few coats for him. She showed me a picture that she drew.
She said that she will leave it on the table, and he can see the coats; she said
she's too scared to talk to him ...
Asked her what happened before she came into hospital; she said ‘they said
I had an accident, but I cannot remember, all I saw was a bright light.’
On 28/2/17 she was ‘observed engaging well with co-patients, participated well in
games ... engages well in conversation but unable to express due to limited English, nil
overt psychotic symptoms noted, preoccupied with her thoughts, nil irritation or
agitation noted.’
On 1/3/17 she was heard crying in her room and was found staring at the black chair
screaming ‘there's a man’. She had in her hand a picture of a ‘black evil
shadow/ ghost’.
On 2/3/17 she again talked about the visions of the man she experienced and it was
noted:
‘Sundus was not seeing the man in Iraq. Started seeing him since being in
Australia.’
That day she went on a three hour leave with her brother and on return he stated that
things went well.
On 3/3/17 it was noted that her Pristiq was to be increased from 100 mg to 150 mg and her Risperidone from 0.5 mg bd to 1 mg nocte and she was to be weaned off Lorazepam.
From 3/3/17 to 6/3/17 she went home on leave.
She was discharged home on 6/3/17.
On 20/3/17 Dr. Gregor wrote:
‘Given medication at Liverpool hospital ? mental health.
Very calm.
When questioned barely answers.
Does not do any of the house duties like cooking or cleaning or laundry.
Does not do any of her hobbies like painting.
Boys and one daughter staying at home but middle son still has problems
with police.
Teary and emotional.
Having frontal headaches and says has memory problems."
On 22/3/17 she attended the Emergency Department of Fairfield Health Service. She
had argued with her son the previous day and locked herself in a room. She was found
in her room unable to mobilise and complaining of headache and her son reported that
she had probably suffered a fall. On examination she moved all four limbs but with a
generalised weakness and no neurological abnormality was detected. She then self discharged.
On 24/4/17 she was admitted to Liverpool Hospital as an involuntary patient. She was
referred by COMHET because of her deteriorating mental state, her children reporting
that she was low in mood and not able to care for them. When examined she was sitting in a room with a blanket over her head. She was ambulant with crutches. She claimed that she was in Iraq. She claimed that she had no children and did not recognise her son. She reported suicidal ideation.
On 26/4/17 she stated that she did not like it at her home as "they annoy me and they
hit me ... everybody who sees me, hates me." When interviewed with the aid of an
interpreter she stated that she had no children. She claimed that she heard people talking to her saying ‘get out’ or ‘eat don't eat’. She maintained that the previous day she hurt herself with fire at the direction of the voices. She stated that she forgot eve1ything.
She saw ‘black shadows’. She was unable to state whether she took her medications.
It was considered that she was exhibiting a ‘dissociative state’.
On 27/4/17 it was noted that she seemed to be interacting well with her daughter and son.
Dr. Khanbhai saw her on 28/4/17. Her daughter reported that she suffered amnesia and claimed that the children were younger than their real age. She had wandered from home on three occasions and forgotten her way home and at the time of this admission she was found wandering in a park. Since the accident she had not cooked or cleaned.
It was noted that she responded minimally to questions, claiming that she could not
recall information. Sundus reported that ‘the man in black’ wanted to kill her and
would tell her to do things like stop speaking, or to hurt herself and end her life. She
claimed that she had purchased a knife and cut herself with it and she had burnt herself on a stove. It was considered that she had possible psychotic experiences, had an exacerbation of post traumatic symptoms, and had dissociative experiences with
amnesia and fugue state. Brain damage from the accident had to be excluded. She was switched from diazepam to Jorazepam.
On 2/5/17 it was noted:
‘She was quite well prior to the brain operation. After the operation - she
lost the vision, she was feeling dizzy, generalised weakness.’
It was later that day reported that she was "observed selectively mute during the shift"
On 5/5/17 she was observed talking to someone in the room and asked her "friend" to
wave at the doctor and nurse. She stated that if she did not listen to this friend he would hurt her or threatened her with a knife or strangulation. When she tried to touch him her hands passed through him. At times he reminded her of her ex-husband.
On 6/5/17 she was observed ‘reading and writing learning English’.
On 10/5/17 she claimed that only recently she had learned that she had three children.
She collapsed into the arms of the Occupational Therapist. She complained of bilateral
leg pain. On examination hip flexion was 3/5, knee flexion was 4/5 but knee extension
and ankle extension were normal and she had normal sensation and reflexes so that it
was questioned whether she was presenting with the ‘somatic presentation of anxiety’'
On 11/5/17 she was noted to be ‘bright and reactive when family present.’
On 12/5/17 it was noted:
‘Most likely symptoms are from conversion:
She complains of headaches (likely secondary from jaw clenching and
teeth grinding in her sleep)
Right eye vision loss (post meningioma resection around 2-3 years ago;
but this was not secondary to surgery and was thought to be psychosomatic.
Leg weakness gradually developed since tumour resection; and
worsened since the discharge from last admission (2 months ago).
Currently has no recollection of her family; except of her ex-husband and
oldest son; thought she is currently in America. Her trauma is from
domestic violence (stated feeling she was going to die many times), being shot in the thigh, refugee experience (from Iraq).
Has been quite independent prior to her MVA (2 months ago); she used to
paint/draw, and her brother states that her pictures were on display in a
gallery (?location).’
On 14/5/17 it was noted that she continued to have special nursing because of the risk
of falls. It was further noted that she was brighter when the family visited and talked
and laughed with them in her room, but ‘becomes selectively mute with nursing staff'.
On 17 /5/17 Dr. Ariyaratne wrote a Request for a 6 week Involuntary Patient Order. She was currently taking Risperidone 3 mg nocte, Pristiq 150 mg mane and Aripiprazole 10 mg mane. It was stated:
"Sundus was scheduled by COMHET due to deterioration in her mental
status over the preceding 3 weeks and was brought to Liverpool Hospital
emergency department on 24/04/2017. During the initial assessment by the
on call psychiatric registrar she had been sitting in the emergency room with
a blanket over her head and had presented detached, disorganised and
dishevelled. She had not acknowledged the clinician or her 14 year old son
who had been in the room. She had engaged poorly. She reported that she
did not like it at home reporting ‘they annoy me and they hit me. Everybody
who sees me, hates me. If I don't listen to him, he will hit me.’ She was
disorientated and denied having a family or children. She was unsure
whether she had been compliant with her medications. She reported
hearing voices and people talking to her and she reported that the day prior
she had hurt herself with fire in response to the voiced. Her insight and
judgment was impaired. Her daughter reported that Sundus had been
complaining about the voices for about a year. Her daughter reported that
Sundus had been ‘normal’ until she had the motor vehicle accident and
since then she had been forgetful. CT brain that had been done after the
motor vehicle accident did not show any acute intracranial pathology. Her
daughter reported that she had been forgetful, had not attended to any
household duties and that she had wandered and walked off 3 times and had
forgotten her way home. On admission she had been wandering in the park.
Sundus had reported that she is being hit at home by her family (including
her children) and denied to describe what happened. Her daughter denies
knowing about her being hit at home.
She was admitted as a mentally ill person under the mental health act for
dissociative experiences with associative amnesia and fugue state and
psychotic symptoms.
Progress:
She was initially admitted to the PECC unit when she had been under the
care of Dr. Khanabai (Consultant Psychiatrist). The dose of risperidone
was increased to 2mg nocte and she was commenced on diazepam 5mg
TDS. Sundus had been mobilising on crutches. Sundus reported that the
‘man wearing black robe wants to kill her’ and that this man comes to her
all the time and orders her to do things. She reported that ‘the man wearing black robe’ had commanded her to hurt herself and end her life and that she
had tried to end her life before and also reported buying a knife to cut herself
and that she burnt herself with the stove when nobody is around at home ...
She still reports of seeing a man wearing a black robe and she becomes very
scared and teary and hypervigilant, looking around and telling ‘he will hurt
her’. She reported that since ‘this man wearing black robe’ has hit her right
eye, she cannot see from her right eye. She reported seeing this ‘man
wearing black robe’ inside the mental health unit and she reports that this
man can travel through doors, walls and ceiling. Her mood is depressed
and labile. She reports that she continues to hear voices and seeing the
‘man wearing black robe’. She reported of having suicidal ideations. She
reported wai1ting to shoot ‘the man with black robe" by getting together
with the Anny.’
It was considered that she was suffe1ing dissociative symptoms as part of a conversion disorder.
On 21/5/17 she denied having any paranoid ideas or auditory or visual hallucinations
and stated that her mood was alright. It was recorded:
‘Monitor patient's visitors (sons) activities in the ward (suspected of drug
dealing, if possible, may need to be banned.’
On 22/5/17 she was noted to be walking around the courtyard, mobilising independently on crutches. She stated that she was feeling better and wanted to go home soon. No overt psychotic features were evident.
On 24/5/17 she reported that her mood was "good" and was not experiencing any
auditory or visual hallucinations, or any feelings of banning herself or others. She
mobilised well on crutches. She had a right-hand tremor. She denied any dizziness.
Her Pristiq was increased to 200 mg mane and it was then noted:
"Was less preoccupied about the strange experiences about the man with
the black robe. When inquired further about that became more childish and
regressed in behaviour. Said she misses him as he is not seen much now,
'he is a friend, I am also scared'. When inquired about family said "two
people came to see her, said they are daughter and her mother, I can't
remember, but they are very kind, I love them.' ‘Can you send me to school
so I can be clever.’ Towards the latter part of review became more and
more regressed in behaviour.
Denied suicidal ideas.’
On 24/5/17 an MRI scan of the brain showed no acute intracranial abnormality.
Dr. Ariharatne saw the daughter on 26/5/ 17 and recorded:
‘Since the MV A had noticed changes, patient is forgetful, patient does not
remember things, patient has thought her sons are still small children and had been asking the daughter to make milk for the sons, patient had been scared of the light, patient does not remember the details of the accident but remembers a big light.’
On 29/5/17 she reported that she was scared of a female patient who had been knocking on her door and talking to her when she was in the common areas.
On 30/5/17 Dr. Atapattu saw her with the aid of an interpreter. It was recorded:
‘Said she may be in her 30s/20s and she is not married or does not have any
children. Said ‘they come to visit me and say they are my daughter and
mum’, ‘but I can't remember’.
Was teary at times.
Reported she is scared to stay in the hospital mainly as she is worried that
other people will harm her but did not talk about the ‘man with black robe’
or any other auditory/visual phenomena.
No obvious psychotic symptoms.
Presentation is more compatible with PTSD, depression and dissociative
symptoms. But an organic cause cannot be completely excluded ...
Reduce risperidone 2 mg nocte ... ‘
That day she scored 15/30 on the RUD AS assessment, a score of <23 suggesting likely cognitive impairment and that she might require 24 hour supervision.
On 1/6/17 it was noted that when she did a home visit with the Occupational Therapist
the previous day she claimed not to recognise her home. The daughter claimed that she had seen little improvement in her mother, claiming that she was fully functional prior to the MVA.
On 2/6/17 she told Dr. Ariyaratne that she was waiting for the main in the black robe to
give her eye back. She then told Dr. Chung that she did not have any children and when asked about the daughter who visited her, she stated that this was a girl who brought her food.
On 5/6/17 she told Mr. Barker, Psychologist, that she had been on leave with people
who claimed to be her children, but she could not remember them.
On 6/6/17 an MRl scan of the spine showed mild degenerative changes in the lower
cervical and lumbar regions.
A cerebral SPECT/CT scan on 6/6/17 showed only a focal area of gliosis in the right
frontal region. There was mild diffuse hypoperfusion in the left superior frontal region of uncertain clinical significance.
On 8/6/17 it was noted that she seemed bright and reactive and had spent time in the
common areas, interacting ‘selectively’ with others.
On 9/6/17 she stated that she remembered now that she had children and recalled their names, and that they had visited her in hospital, and her daughter bought her food. She was then reviewed by Dr. Barker with the aid of an interpreter. She told him that she had forgotten aspects of her past. She did not recall being an art teacher and she could not remember how to draw. She reported a fear of crowds and of being assaulted.
On 20/6/17 her daughter reported that she had improved over the course of her
admission, she made more sense when she spoke, she recognised her children more,
and she no longer talked about hearing voices. Her Pristiq was reduced to 150 mg as it
‘may be contributing to jitteriness’.
On 21/6/17 it was noted that the Neurology Team were of the opinion that her various
neurological complaints were of a dissociative/conversion nature.
She went on extended leave.
On 29/6/17 it was noted that her aripirazole medication had been suspended because
she developed akathisia.
On 4/7 /17 she was reviewed at the hospital with the aid of an interpreter. The daughter
reported that the previous day her 14 year old brother (presumably Sam) was arrested
and taken away by police as he was out the front of their house wielding a toy gun in a
threatening manner. He had returned home that day. Sundus was tearful but stated that she wanted to be discharged
On 4/7 /17 it was noted in the STARTTS file:
‘The client arrived walking with crutches and asked for the door to be open.
The client presented with symptoms of psychosis. The client's behaviour
included anxiety, suspiciousness, agitation, hypervigilance, repetitive
movements and restlessness. The client's condition included confusion,
disorientation, memory loss, slowness in activity, difficulty thinking and
understanding. The client's mood included general discontent and a limited
range of emotions. The client appeared fearful and nervous. The client
made no eye contact with the counsellor or and [sic] some eye contact with
the interpreter. The client's speech was deficient and limited to one word
or a few word answers to direct questions. The client presented with hand
tremors in both hands, was scratching her head and face and clenching her
jaw and opening it with her hand. The client reported no visual or auditory
hallucinations ...
The Client was tearful and requested to te1minate the session early ...
The Client has PTSD and refugee trauma which has recently been triggered
by a car accident. The Client also has underlying personality traits.’
She was discharged on 11/7/17 and referred back to ST ARTTS. It was noted:
‘She experienced trauma as a refugee and has current physical health
complaints related to an MV A she was involved in in Feb 20 I 7. She has
an extensive history of DV from her ex-husband and was shot by intruders
in Iraq.’
It was recorded in the Discharge Summary that ‘She has not returned to her baseline
level of functioning (as previously entirely independent prior to MVA) but it
improved.’ She was to take Pristiq 100 mg mane and Avanza 15 mg nocte. She had
developed akathisia, tremor and restlessness on Aripirazole and this had been
suspended.
On 17 /7 /17 it was noted ‘STARTTS are unable to provide crisis management and
follow up and cannot take duty of care for the client since the client is highly
symptomatic and not stable enough for talk based trauma therapy. The counsellor urged CoMHET to refer the client for a psychiatric assessment and review at the mental health unit.’
ON 20/7/17 Dr. Gregor added the antidepressant Avanza 15 mg nocte. On 21/7/17 she
arrived on crutches stating that he legs were too weak and shivery for her to walk. She
exhibited mutism.
On 26/7/17 it was noted in the STARTTS file that she did not want to engage with the
service. She was discharged from the service ‘since she is not ready for trauma
counselling due to not being well enough with her mental health symptoms’.
On I 1/8/17 her Avanza was increased by Dr. Gregor to 30 mg nocte.
Dr. Dowla, Neurologist, saw her on or before 15/8/17. She indicated that she could
speak only a few words and could not walk without crutches. On examination cranial
nerve function was normal. A subsequent EEG showed no abnormality.
At 3.06 pm on 4/1/18 it was noted that she was being interviewed by a
Neuropsychologist at Liverpool Hospital for a Disability Support Pension. She made
little effort during testing and seemed overwhelmed by anxiety. When the assessment
was terminated, she fell to the ground and started twitching. Her daughter reported that
she had exhibited a similar episode two weeks prior and recovered after a few hours.
She was admitted and restarted on Risperdal 1 mg nocte as well as Mirtazepine 15 mg
nocte and Pristiq 100 mg mane.
At 3.24 pm it was noted that she was shaking her right arm and holding both hands in
a claw-like grip. Her eyes were rolling back into her head but when her eyes were held
open they returned to the midline. She exhibited a positive hand drop test. When the
lights were turned off and interaction with her stopped, she stopped the shaking and eye rolling. It was considered that she was exhibiting a ‘pseduoseizure’.
At 3.33 pm it was noted that she had a GCS of 15/15.
At 6.39 pm it was noted that she shook her right arm when the staff was present but
stopped when there was nobody around. She was hyperventilating but this settled when she was given 2 mg of intravenous midazolam.
At 6.48 pm it was noted that she was alert but not communicating with the staff. She
then had runs of irregular pulse on the cardiac monitor but it was considered that this
was ‘behavioural’ and caused by breath holding. At 9.4 7 pm it was noted that she was
known to hold her breath for up to one minute.
At 9.56 am on 5/1/18 it was recorded:
‘Patient is unable to recall yesterday's events.
States feels slightly more settled than yesterday, feels safe in the Hospital.
Reports hearing a voice calling out to her 'mamma' looks around and no
one is there.
States has had poor sleep for the past weeks mostly secondary to nightmares.
Denies any recent flashbacks.
Currently denies any suicidality or self harm thoughts.
States has had a low mood for the past 2 weeks.
Counselled and reassured with some effect.
Denies any current acute stressors.’
On 6/1/18 she was seen with an interpreter. It was noted:
‘Stated that she cannot recall why she is in hospital, but she knows that she
is in hospital and wants to go home.
Denies feeling depressed - spends her days with her children, enjoys
watching cartoons. Hears her name being called out - consistent with her
trauma history. Feels safe at home and well looked after by her family.
Denies disturbances in sleep and appetite. Objectively she comes across as
childlike and regressed, but this seems to be chronic in nature. Denies
suicidal and homicidal thoughts.
Spoke to her daughter: she does not feel that her mother should stay in
hospital and should come home with her. She has no concerns about her
mental state and would bring her back to hospital if she was concerned.
On 25/5/18 it was noted in a Social Work Progress Note:
‘This individual was listed at the Liverpool Local Area Command
SAFETY ACTION MEETING on 24/05/18 UNDER PART 13A of the
Crimes (Domestic and Personal Violence) act 2007. File has been reviewed
by Safety Action Meeting.’
On 6/6/18 she was again referred to STARTTS and it was noted that she suffered:
‘Severe PTSD symptoms of anxiety, hypervigilance, sleep disturbance,
nightmares, flashbacks, dissociation, ongoing positive, negative and
cognitive symptoms of psychosis.’
On 10/7/18 she informed STARTTS that she did not wish to attend counselling at that
time and wanted to stay home. She claimed not to know the organisation, even after
she was reminded of her previous attendances. She had been referred by the Liverpool
Mental Health service.
On 12/7/18 she was reviewed at Liverpool Hospital by Dr. Tier. She resided with her
adult daughter and two teenage sons, the other son having an AVO against him to
protect Sundus and her daughter. A Guardianship Hearing was scheduled on 27/7/18
for Riharn to obtain guardianship. She was known to have a PTSD with dissociation
and conversion phenomena and a Major Depressive Disorder with psychotic features
and catatonic features (psychosis in remission). Her mobility had declined since the
MVA although she sustained no significant injury. It was reported that she continued
to experience nightmares and flashbacks to her traumatic experiences. She continued
to exhibit episodes of dissociation.
Dr. Tier noted that she ‘presents as she usually does: she is very childlike in her manner, appears anxious and engages only minimally with me, allowing her daughter to talk for her the most part. She mobilises with crutches and has a coarse nodding tremor evident throughout.’ When the option of physiotherapy was raised she clung to her crutches stating, 'No. I need to use these.’ And Dr. Tier considered this to be ‘evidence of her clinging to a sick role.’
On 21/7/18 Dr. Gregor noted that she had been seen at the Liverpool Eye Clinic and no
organic pathology was found to account for her claim of right eye blindness.
Dr. Dewan saw her on 19/8/19. She indicated that she was stressed and anxious and
was planning to move interstate "seeking better life". She had a tension like headache.
She slept poorly. She had difficulty concentrating. She was prescribed the hypnotic
Temazepam and given a letter requesting help with relocation to another state. On
9/ 12/19 she complained of right shoulder pains and was prescribed the anti-inflammatory Mobic. On 19/12/19 it was noted that an ultrasound of the right shoulder
showed tendonitis. Temaze was stopped and Mersyndol prescribed.
On 6/9/18 Dr. Walsh noted that she claimed no vision in the right eye and 6/9 acuity in
the left eye. There was some atrophy of the right macula with ganglion cell layer loss
but, she noted, ‘however, I do not think that this would account for the severity of the reduction of vision in her right eye.’
Dr. Hua saw her on 22/10/18. It was reported that she suffered insomnia, that she was
‘always scared, crying a lot", and "using crutches - because pain in legs’. Her daughter
was her full time carer and assisted her in the activities of daily living including
toileting, showering, cooking and eating.
Dr. Dewan saw her on 10/1/19. She complained of suffering palpitations for six weeks
and experiencing problems with her vision and short term memory.
On 12/9/19 Dr. Ozoa noted, ‘Patient's daughter interpreted that both patient's parents
have a stroke, and had it as well 3 months ago. Patient's daughter added that patient
had chest pain a month ago and was seeing another doctor.’
On 29/10/19 Dr. Nashed reported that an echocardiogram showed no significant abnormality. An ECG was normal”

Dr Smith is a psychiatrist. His opinion is of limited assistance to the deliberations of this panel, dealing with a possible traumatic brain injury. He has however provided a very detailed analysis of the claimant’s medical condition and for that reason, it has been repeated and is relied upon by the Panel.
Dr Smith concluded that the available documentary evidence indicated that there had been no qualitative change in the claimant’s presentation since the accident. In his opinion, her anxiety, depression, any post-traumatic stress symptoms and her tendency to fabricate symptoms were evident at least from the time of the surgery for her meningioma. Dr Smith said that the claimant’s fabrications may be arising on a subconscious basis and so be hysterical dissociative phenomena. However, he said that there is ample evidence that there is a strong conscious element, and so a degree of malingering. Dr Smith said that it was unclear whether there had been a quantitative change in the claimant’s symptomatology in the form of increased disability. He said that this was because the account provided by the claimant’s daughter could not be trusted.
The Panel has considered all of the documentation and medical evidence provided by the parties. The Panel is satisfied that for the purposes of understanding all of the complexities of the issues before it, the summary provided by Dr Smith, a psychiatrist retained by the insurer, assists this purpose.
Professor Mattick, in his report of 8 December 2020 which was prepared at the request of the insurer, stated that on “a Brief Cognitive Status Exam, her responses would suggest that she is suffering marked and severe cognitive impairment. However, clearly she is not. The fact that she can move about her community, going to a shopping centre, purchasing goods, paying for the goods without any apparent difficulty, indicates a mismatch between her poverty of performance on the Brief Cognitive Status Exam and her functioning”. These comments were made in light of the surveillance observations.
Professor Mattick also said that it was not possible to establish her cognitive status for two reasons. Firstly, she was non-compliant. Secondly, she was not making any reasonable attempt to perform adequately.
His diagnosis was that the claimant was feigning dysfunction. He doubted that she had any worsened wellbeing given, he said, the mismatch between her claimed symptoms and presentations to medical examinations and the surveillance material.
Professor Mattick said regarding any cognitive impairment, he thought that the claimant was feigning dysfunction. He said that she had pre-existing marked psychological and psychiatric impairments. He did not trust that she had any cognitive impairment from the motor vehicle accident given that there was no evidence that there was any damage to the structures that subserve memory or intellect.
Professor Mattick said that if the claimant were affected by a functional or a hysterical psychosomatic condition then this would present fairly consistently. He said that the fact that she presented reasonably normally on video material and then an hour or so later in the central business district (CBD) of Sydney she presented as markedly impaired showing that the claimant was deliberately presenting herself poorly. Professor Mattick said that this was not a functional or hysterical reaction. He said it was feigned impairment.
Professor Mattick said that given the claimant’s failure to comply with the assessment, despite the fact that she could obviously interact normally elsewhere, he concluded that there was no basis to suggest the accident in question had caused her any disability, particularly in the context of her marked poor problems. He said that she was feigning dysfunction in a gross, bizarre, and marked way.
Professor Mattick said that the claimant would no doubt improve markedly once her claim was settled. He said that there was clear evidence of feigned dysfunction on the surveillance material.
By way of summary, Professor Mattick said that on examination the claimant was unable to tell him when she was born, where she was born, her first language, where she was currently (thinking that she was in Iraq), and had great difficulty telling him details of her family members or their names or ages, thinking that they were one year of age, three years of age and that she had one baby. He confirmed that the claimant’s children were all adults. The Professor said that elsewhere in the assessment the claimant appeared unable to respond, cowering as if she was being threatened by some imminent, real, and horrible danger. He said that this was in stark contrast to her presentation on video material showing her quite at ease and able to get into her daughter’s car to travel to the CBD for the assessment on the morning of the assessment.
Professor Mattick said that on the Wechsler Memory Scale-Fourth Edition Australian and New Zealand Language Adaptation (WMS-IV A&NZ) Brief Cognitive Status Exam, the results would suggest that she was dementing, which he said she is not. Professor Mattick said that clearly the claimant could function day-to-day given that she goes shopping on her own quite happily, without any impairment.
Dr Smith, a psychiatrist who was retained by the insurer, said that it was clear that from the time the claimant first saw Dr Gregor in 2015 up to the time of the accident, she exhibited evidence of significant levels of anxiety and depression and was considered to be suffering post-traumatic stress disorder symptoms related to her experiences in Iraq, as a refugee, from a violent marriage, and from conflict with her parents in law. In addition, she exhibited fabricated physical symptoms in the form of neurological complaints such as blindness, inability to move limbs, sensory changes, episodes of supposedly unconsciousness and falls, as well as complaints of episodic amnesia for past and present events. She also stated later, on 2 March 2017, that she started having visual hallucinations of the man in black when she arrived in Australia. Dr Smith noted that on 17 May 2017, the claimant’s daughter reported that her mother had been complaining of voices for about a year, suggesting that they commenced in early 2016.
Dr Smith said that these fabricated symptoms could have been produced on either a conscious, and so malingering basis, or a subconscious, and so hysterical, basis. However, the observations of the doctor in November 2015 when she was apparently in a catatonic state and then looked at her bandage when she thought that she was not being observed while supposedly unconscious, a repeated protection of her face when the arm drop test was used during her episodes of supposed unconsciousness, and her removal of the airway when she was again supposedly unconscious in the ambulance in March 2016, all indicated that there was a considerable conscious element to her presentation.
Dr Smith commented that the claimant and her daughter were grossly unreliable historians and his evaluation relied heavily on the documentation.
The Liverpool Hospital admission summary gave a history of the accident to the effect that the claimant was a restrained back right seat passenger when her car was t-boned by another car travelling at 60 to 70 kmph on the right-side rear of the car. From photographs in the claimant’s bundle of documents, impact would appear to have been on the left rear side of the car. The police report said that the claimant was on the left rear side of the car and could only be extricated with the assistance of the fire brigade. The claimant reported a loss of consciousness, but this could not be confirmed. When attended by the ambulance officers, seven minutes after being called, she was not unconscious.
A note of progress during the admission recorded that the claimant passed rapid
post-traumatic amnesia testing by an occupational therapist.
The claimant had CT scans of her head, neck, chest and abdomen. It was concluded that she had no intracranial haemorrhaging, no soft tissue organ injury and minor chest wall changes consistent with the trauma described.
An MRI scan of the brain completed on 24 May 2017 showed no acute intracranial abnormality. This was reported on by Dr Dowla, the claimant’s treating physician, on
12 October 2017.
Emergency Department case history notes of 22 March 2017 provide a background of post-traumatic stress disorder, hypervigilance, nightmares, and intense fear as well as motor vehicle accident induced resurfacing of past trauma resulting in dissociative psychosis. It was also noted that in 2015 the claimant had brain surgery for resection of a benign tumour which had resulted in loss of vision in her right eye.
It was confirmed by Dr Verma on 11 September 2018 to Dr Gregor by way of history that the claimant had significant major depressive disorder prior to the accident.
Dr Lim, GP, made a note on 18 June 2021 and raised the question of a brain injury and he requested a ceretec perfusion. This was carried out on 27 August 2021 and “no scan evidence of significant posttraumatic brain injury or neurodegenerative disease. There appear to be non-specific small bilateral cortical defects as described above possibly in keeping with microvascular ischaemia. Right frontal hypoperfusion probably corresponding to the meningioma”.
The claimant obtained a medico-legal report from Dr Dryson of 9 November 2021. The doctor is an occupational physician. He commented that the claimant presented as a woman of 55 years. He attempted to carry out an assessment of cognition but reported that the claimant did not know where she was. She did not know what the day of the week was. She did not know who her support person, sitting next to her, was. She was, during the course of the consultation, staring blankly and occasionally would make a startle response, as if she was afraid of something.
Dr Dryson concluded that the claimant had dementia, no apparent neurological abnormality and probable chronic pain syndrome. He said,
“She clearly sustained a significant loss of cognitive function. Although she had a previous history of brain surgery, an MRI scan of 11 December 2020 did not show any new injury to explain her cognitive decline and there is no recurrence of her previous meningioma. The neurological examination that I was able to carry out, including reflexes, plantar responses, eye movements, did not show any abnormality. There was no rigidity or paralysis. The dementia may be due to psychological reasons, but I am not a psychiatrist and will not be able to comment further in that regard.”
Dr Dryson concluded,
“Ms Al-Suhairi clearly has a significant dementia. The MRI scan of the brain does not show a reason for this. It may be on a psychological basis. I am however not a psychiatrist and I am not able to confirm this. Ms Al-Suhairi is reporting widespread body pain. She may well have suffered a chronic pain syndrome as a result of the subject accident. Observation of her neck movements during the course of the consultation did not show any significant restriction in range of movement. Attempting to assess range of movement in the lumbar spine was made difficult by her inability to comprehend my instructions but it did seem likely that she had impairment in range of movement in the lumbar spine. As such she is unable to undertake activities requiring standing and walking, and indeed needs to use a walker for these purposes. She would clearly be unable to undertake activities such as lifting, carrying, pulling, pushing.”
Dr Dryson assessed WPI of 5% which related to the claimant’s lumbar spine only.
Dr Dryson did not comment on surveillance records of the claimant. This may not have been available to him.
The Medical Assessor provided a certificate dated 19 July 2022. He noted that the claimant had a presentation that was difficult to assess.
The Medical Assessor said that the most accurate details with reference to her injury were those recorded soon after the accident of 1 February 2017. The Medical Assessor said that the claimant sustained a soft tissue injury to her head and probable soft tissue injuries to her cervical and lumbar spine.
The Medical Assessor said that there was no convincing evidence of other significant injuries, although given the mechanism of injury, other soft tissue injuries could have occurred.
Regarding the soft tissue injury to the claimant’s head the Medical Assessor said that this had resolved. He said that the head injury was not assessable as causing permanent impairment. The Medical Assessor said that while the claimant had an impact to the head there were no recorded abnormalities in her GCS, noting, he said, that a score of 14 is consistent with a non-English speaking person. He also said that there was no post-traumatic amnesia or brain imaging abnormalities associated with brain trauma. He said that the criteria set out in section 6.164, page 34 of the Motor Accident Guidelines, were not satisfied.
The Medical Assessor assessed only a WPI for the claimant’s right and left shoulders at 4%.

Surveillance evidence

Several tranches of surveillance were undertaken on behalf of the insurer. The Panel has viewed and reviewed this.
The claimant was seen at various times to be walking her dog, to push an empty shopping trolley near her house while walking her dog, to walk from the vicinity of her home to a shopping centre and to walk home with her purchases in shopping trolley, pushing that trolley. She was able to converse and act in what appeared to the Panel to be an unrestricted manner. She was seen to be laughing and smiling whilst apparently engaging in a conversation on her mobile phone.
The claimant was also seen to be in conversation with people at her home, possibly family members.
The observations of the Panel are that the claimant walked and talked in an unrestricted and unremarkable manner.
The Panel also noted observations on 12 August 2020 when she was observed early in the morning at her home acting in what the Panel considers was an unremarkable and unrestricted manner. The claimant was then picked up by a car driver. That car was followed to the Sydney CBD. Out of the car and in the street the claimant was seen to be mobilising on crutches in each hand and requiring the assistance of the car driver. The date of
12 August 2020 is significant as it was the first examination day by Professor Mattick. The claimant was observed again, five days later, walking with no aids and in a completely unrestricted manner.
On 22 September 2020, the claimant was observed at her home. She appeared unrestricted although the surveillance operative said that he observed the claimant with a right leg limp. The claimant travelled by car to the Sydney CBD again. There she was observed using a wheel walking and conversing freely with the female driver of the car who was transporting the claimant.
This attendance in the CBD would most likely have been for the medical examination by
Dr Smith, for the insurer.
The claimant’s solicitors have confirmed to the Panel that it is the claimant who is observed in the surveillance film. This surveillance was undertaken in 2020.
The claimant’s daughter, Acelia Sahi, formerly known as Riham Sabri, provided a further statement on 5 September 2023. She said that the claimant might sometimes be almost like herself in the mornings but by the afternoon would change and be argumentative. She might be good for a few hours, sometimes a few days, and then behave strangely and delusional. The Panel saw no evidence of this except, when the claimant was seen to be attending medical examination, she demonstrated physical disabilities.

Panel medical examination

The claimant was examined on behalf of the Panel by Medical Assessor Hodgkinson. Her report follows:
“Sundus Al Suhairi
M10544335/22
Report following clinical examination 16/2/2024.
Sundus Al Suhairi attended the appointment with her son, Samer, a support worker and the Arabic interpreter. The interpreter identified herself as May Dabliz, Arabic interpreter, and presented her NAATI accreditation card.
Sundus agreed to be interviewed with just the interpreter for support. She walked unassisted into the clinic room, although she sought emotional reassurance that the interpreter would be with her. At times holding the interpreter’s hand.
She appeared anxious and teary. Occasionally tapping her foot and rocking. She was distracted admiring the interpreter’s nail polish. She had very little eye contact with the Assessor. She focused on the floor, the interpreter, and the window. She was well groomed.
When asked if she understood why she was attending the appointment she stated she did not know. She expanded on this to say the doctor gives her injections. She volunteered that she was forgetful.
The clinical interview then proceeded in a somewhat chaotic manner – jumping between distracting thoughts, comments and responses to questioning.
She was able to state that her son, Sam, was living with her but then she admired a painting of a rose on the wall. Then speaking of her past interest in painting.
Exploring whether she experienced hallucinations, she reported that she dreams of a man dressed in black who is menacing in nature. Voices tell her to ‘go’, ‘walk’. She is often scared at night and worried about intruders. She sometimes sees people at the window.
Regarding physical symptoms she described headaches ‘constantly’. She described being dizzy. She could give no timeframe to the symptoms, speaking only of current symptoms.
She stated she had carers who help her during the day, (these may be funded by NDIS). She gave their names as Fatima, Dalma and Nooma. She states they help her with cooking.
Historical memory – stated that she did not understand English; that she believed she was in Iraq and that she did not know how long she had been in Australia. She denied knowledge of operations or of a car accident. It was at this stage she asked to leave the appointment and commenced ‘rocking’ behaviour.
She stated she was lonely, had no friends and that her daughter was busy with her new family and visits less often.
She stated she was looking forward to a train trip on the following day – to visit the beach and have kebabs with her sons.
When the interview ended, she expressed childish delight. ‘I am so happy now’. She exited the interview room unaided.
The need for the clinical assessment was to assess whether the claimant, Sundus Al Suhairi, has sustained a significant traumatic brain injury in the subject accident.
Usual clinical assessments eg of memory, historical memory, physical findings and general behaviour were not helpful in contributing to the assessment as the claimant did not attempt the tasks.
The clinical presentation in the assessment contributes to assessment of consistency of current symptoms and signs with the findings at the time of the accident, past and current medical history.
Medical history prior to the accident:
Sundus al Suhairi was born in Iraq, married and then left Iraq as a refugee with her husband and children. They stayed some time in Jordan. She then was accepted as a refugee into Australia. She came to Australia with ?3 of her children. She was diagnosed with post-traumatic stress disorder due to domestic and war related trauma.
In 2015 she has a right frontal meningioma resected. Following this she developed ‘blindness’ of the right eye. Despite extensive investigations no organic cause was found and there was no clinical consistency of blindness. It was assessed as psychological in nature and responded to psychological support.
There was an admission for catatonic depression in December 2015.
History of the accident:
Initial trauma assessment identified areas of concern as a tender sternum , neck and back. There was no identified head trauma on both clinical assessment and radiological imaging. Imaging did show evidence of past neurosurgery in the right frontal lobe. There was no intracranial haemorrhage and no skull fracture. A subgaleal haematoma (a soft tissue injury) was reported on in the initial CT Brain , supporting the daughter’s assertion that Sundus sustained a blow to the head but not meeting the criteria of a brain injury
It is recorded that she was a rear seat passenger in a motor vehicle accident , 1 February 2017. On presenting to Liverpool hospital her GCS was 15/15, on initial trauma survey but then on subsequent occasions was 14/15, losing 1 point for no verbal response. Due to her Non English-speaking background and lack of head trauma this was of uncertain significance. Further assessments were attempted. PTA (Post traumatic amnesia) testing was commenced but discontinued due to the lack of verbal responses. Mutism alone is not diagnostic of a brain injury and was attributed, after psychiatric examination, as due to a dissociative psychiatric condition.
With the reassurance of her family that she was back to baseline she was discharged home. Two weeks post injury she returned to the Liverpool Hospital with ongoing difficulties (continued mutism). She was diagnosed as having a dissociative psychosis induced by the motor vehicle accident. She was again discharge home to return shortly after with auditory and visual hallucinations. She was admitted as a mentally ill person under the mental health act for dissociative experiences with associative amnesia and fugue state and psychotic experiences regarding persecutory symptoms.
Neurological consultation and further investigations concluded that there was no organic cause or brain injury related to the motor vehicle accident. Medications and supportive management resulted in eventual discharge home following resolution of the psychotic symptoms.
A further psychiatric admission occurred in January 2018 when she collapsed during a neuropsychological assessment. This was accompanied by signs of anxiety – hyperventilation, shaking and groaning. She was discharged home at the request of her daughter who stated that a supportive home environment was required.
Conclusion:
The clinical examination was unhelpful in elucidating cognitive function. Some inconsistencies were noted. Recollection of her carer’s names, despite complete amnesia. Her cognitive and psychiatric changes are unable to be attributed to the head trauma. The child like responses and report of auditory hallucinations is consistent with the diagnosis of a mental health condition.
Assessments – clinical and radiological did not identify a traumatic brain injury. Neurological consultation during her prolonged mental health admission in 2017 supported the psychiatric diagnosis and excluded the brain injury.
Past and subsequent mental health admissions suggest a psychiatric diagnosis is the cause of her past and current presentation. Some cognitive abnormalities may be present and related to the postsurgical changes of gliosis in the right frontal lobe documented pre-motor vehicle accident. Formal neuropsychological assessments have not been able to be performed due to the over-riding symptoms related to her PTSD and Dissociative psychosis.”

The Panel adopts the report and findings of Medical Assessor Hodgkinson.

Causation

The claimant was involved in a collision which appears to be one of some force and impact. On 4 March 2016 the claimant was in a doctor’s waiting room when she slumped in a chair and became unresponsive. She was transported by ambulance to hospital. GCS was 9/15. The claimant said she could not move her arms and had intermittent numbness in both legs she then had a GCS score of 15/15. In the subject accident of 1 February 2017, the insured car was said to be travelling at between 60-70 kmph although that is unverified. In any event, the claimant was not able to be released from her car as a rear seat passenger, without the aid of the attending Fire Brigade officers.
It is the finding of the Panel that it would not be unreasonable for her to be moved from side to side in the car and to suffer an injury to her head, as well as to other parts of her body. It is the finding of the Panel that the accident has had a more than negligible cause of the claimant’s injuries. However, the Panel is not satisfied that the extent of head injury claimed to have been suffered by her has been established.
The claimant’s daughter said that her mother was unconscious after the accident but did not say for how long. When the ambulance officers arrived, the claimant was conscious. She had a GCS of 14 and later at hospital, she had a GCS of 15. Measurement of post-traumatic amnesia was discontinued due to invalid responses.
The comments of Dr Smith and Professor Mattick about the claimant’s responses to them when replying to questions, cannot be reconciled with the surveillance observations of the claimant before and after the examinations, and at other times when she conversed freely and moved freely.
The Motor Accidents Guidelines relevantly provide:
“6.6 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, therefore, involves a medical decision and a non-medical informed judgement.
6.7 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.”
If the claimant suffered an injury to her head, the Panel is satisfied that given the nature of the forceful impact to the car door immediately beside the claimant, such an injury could be considered to have been caused by the accident. The Panel is satisfied that the accident had a material contribution to the claimant’s injury to her head which is more than negligible. However, the Panel is not satisfied that the clamant suffered a brain injury as a result of the accident for the reasons more fully set out in the report of Medical Assessor Hodgkinson. The claimant has suffered a soft tissue injury only to her head.
This review goes to the question whether the claimant suffered a traumatic brain injury in the accident on 1 February 2017.
The attending ambulance officers were not able to retain a completely accurate GCS assessment as the claimant’s responses are mute. They did however derive an assessment of 14/15. The Medical Assessor said that there are no recorded abnormalities in the claimant’s GCS on that score of 14/15 because it was consistent with the non-English-speaking person’s background. The Medical Assessor also said that there was no post- traumatic amnesia or brain imaging abnormalities associated with a brain trauma.
Liverpool Hospital notes, following a second admission of the claimant after the accident, recorded that memory deficit and disorientation had been present since a meningioma excision 2015.
Professor Mattick found there was no reasonable evidence that the claimant sustained a brain injury.
The claimant, before the accident, had been admitted to hospital in November 2015 when she was catatonic. There are pre-accident admissions to hospital for psychological issues.
As the insurer has submitted, Professor Mattick observed that what was seen on surveillance was in stark contrast to what was presented to him on examination, by the claimant.
On examination of the claimant at triage at Liverpool Hospital, on the day of the accident at 11:51pm, she was noted to be fully conscious with a GCS of 15/15. The pupils were equal, the pulse rate was 50 beats per minute and her blood pressure was 120/67. The claimant’s daughter reported at the hospital that her mother’s cognitive function had not been optimal since her brain tumour surgery and she was not sure if her mother would have been able to answer orientation questions prior to the accident.
From the notes of Dr Smith the Panel observes;
(a)   on 23 July 2015 the claimant was admitted to Liverpool Hospital and had an MRI scan which he suddenly became unresponsive. She awoke after a sternal rub was very drowsy;
(b)   on 24 July 2015 the neurosurgery team at the hospital queried whether the claimant’s complaints were part of a conversion disorder;
(c)   on 10 September 2015 the claimant had an ECG after complaining of dizziness and feeling that she was about to collapse. There was no abnormality;
(d)   on 30 September 2015 the claimant completed a multitask questionnaire. In her answers, she rated “extremely” for 35 out of 41 questions it was reported that her scores indicated clinically significant levels of anxiety, depression and post-traumatic stress disorder;
(e)   on 12 November 2015 the claimant was reported to have panic hysterical attacks and was disorientated. She was also suffering frequent falls;
(f)    on 12 November 2015 the claimant was omitted to Liverpool Hospital. A history had to be taken from her cousin as she was not speaking. The previous day she had been at a refugee centre and she could not stand up. She was lying across two chairs with her feet up. She then collapsed to the floor twitching in all four limbs four seconds to minutes. It was reported she had exhibited similar episodes in the past. EEG’s revealed no abnormality. A CT scan of the brain showed only the recent operative changes;
(g)   on 13 November 2015 the level of consciousness had declined. On examination she opened her eyes to voice. She groaned intermittently. No neurological abnormality was detected;
(h)   on 8 February 2016 it was noted that the claimants presented with severe trauma from domestic violence in her marriage along with parenting/family conflict;
(i)    on 16 February 2016 the claimant attended the emergency department at Liverpool Hospital after falling down stairs. The family reported that she would not talk when she felt anxious or unwell;
(j)    on 4 March 2016 the claimant was in a waiting room when she slumped in a chair and became unresponsive. She was transported to the emergency department of Liverpool Hospital by ambulance. Her GCS, taken by the ambulance officers, was 9/15. On arrival at hospital her GCS was 15/15. The claimant was not conscious when she arrived at hospital and was given a sternal rub. This caused her to wake up, swinging out her arms but then she claimed she could not move her arms and had intermittent numbness in both legs;
(k)   on 22 June 2016 there is a STARTTS record that two months previously she had been in a dissociative state;
(l)    on 26 February 2017 a diagnosis was made of post-traumatic stress disorder and induced psychosis with “MVA induced resurfacing of past trauma resulting in dissociative psychosis”;
(m)     on 2 May 2017, whilst a patient at Liverpool Hospital she was observed to be selectively mute. She was noted to be bright and reactive when her family was present on 11 May 2017 and on 12 May 2017 it was reported that most likely her symptoms were from conversion. It was also recorded that her leg weakness gradually developed since a tumour resection and had worsened since the discharge from the last admission two months previously. It was recorded that her trauma was from domestic violence with the claimant having reported that she felt she was going to die many times, she had been shot in the thigh and she had a refugee experience from Iraq;
(n)   on 14 May 2017 it was recorded that the claimant was brighter when her family visited and talked and laughed with them in her room but “comes selectively mute with nursing staff”;
(o)   a record from Dr Ariyaratne 17 May 2017 recorded that the claimant reported hearing voices and people talking to her and that she reported that the day before, she had hurt herself with fire in response to the voices. Her insight and judgment was said to be impaired. The claimant’s daughter reported that the claimant had been complaining about the voices for about a year. The daughter said that the claimant had been normal until she had the motor vehicle accident and since that time had been forgetful. The claimant was admitted as a mentally ill person under the Mental Health Act for dissociative experiences with associative amnesia and fugue state and psychotic symptoms. It was considered that the claimant was suffering from dissociative symptoms as part of a conversion disorder;
(p)   on 22 May 2017 the claimant was noted to be walking around the courtyard, mobilising independently on crutches;
(q)   on 30 May 2017 it was recorded that the claimant’s presentation was more compatible with post-traumatic stress disorder, depression and dissociative symptoms however an organic cause could not be completely excluded;
(r)    on 8 June 2017 the claimant was observed to be interacting selectively with others;
(s)   on 21 June 2017 the neurology team was of the opinion that the claimants various neurological complaints were of a dissociative/conversion nature;
(t)    on 15 August 2017 the claimant was seen by Dr Dowla, neurologist. Examination showed that cranial nerve function was normal. A subsequent EEG showed no abnormality;
(u)   on 4 January 2018 the claimant was being interviewed by a neuropsychologist at Liverpool Hospital for a disability support pension. She was noted to make little effort during testing. Then she started shaking her right arm and holding both hands in clause like grip. Her eyes rolled back into her head but when her eyes are held open and returned to the midline. When the lights were turned off and interaction with her stopped, the claimant stopped shaking and eye rolling. It was considered that she was exhibiting a “pseudo seizure”. She had a GCS of 15. Later, approximately three hours, it was noted that she shook her right arm when staff are present but stopped when nobody was around;
(v)   on 12 July 2018, when reviewed at Liverpool Hospital, it was noted that the claimant’s condition had declined since the accident although it was reported that she sustained no significant injury. She was reported to mobilise with crutches and had a coarse nodding tremor evident throughout. It was suggested to the claimant that she might undertake physiotherapy but in response, she clung to her crutches and said “no, I need these.” Dr Tier, the examining doctor, considered that this was evidence of her clinging to a sick role, and
(w)   on 21 July 2018 Dr Gregor noted that the claimant had been seen at Liverpool eye clinic. There was no organic pathology found to account for her claim of right eye blindness.
In the finding of the Panel, the claimant had a pre-existing condition that is evident now and has been evident since the time of the accident. The Panel does not find that the claimant’s condition has been made worse by the accident.
The surveillance observations show that the claimant can lead a normal life, performing usual day to day activities without restrictions and without assistance. She can walk her dog, walk to the local shops and go shopping and bring that back home, and she can converse with people without difficulty.
The Panel does not accept that on one morning of observations, the claimant can appear to lead a normal life and then later, that afternoon, be in what appears to be in great physical difficulty and demonstrating a near catatonic state. These conditions were evident since the claimant had surgery to remove a meningioma in 2015.
The Panel is not satisfied that the claimant’s condition has been made worse from the physical aspect, by the accident.
The claimant’s condition may be of a psychiatric basis but it is not a neurological basis and she has not suffered a traumatic brain injury.
Clause 6.164 of the Guidelines, with respect to central nervous system assessment, says;
“For an assessment of mental status impairment and emotional and behavioural impairment there should be:
(a) evidence of a significant impact to the head or a cerebral insult, or that the motor accident involved a high-velocity vehicle impact, and
(b) one or more significant, medically verified abnormalities such as an abnormal initial post-injury Glasgow Coma Scale score, or post traumatic amnesia, or brain imaging abnormality.”
Clause 6.165 requires that the results of psychometric testing, if available, must be taken into consideration. Such results from Professor Mattick, do not establish that a traumatic brain injury occurred.
The Panel is not satisfied that there was a cerebral insult. No scan taken of the claimant’s head, at any stage after the accident, indicated an insult to that area other than a subgaleal haematoma.
The Panel is satisfied that there was a high velocity impact, said to have been a “t-bone” collision with the insured car travelling at approximately 60-70kmph.
However, regarding one or more significant, medically verified abnormalities such as an abnormal initial post-injury GCS, post-traumatic amnesia, or brain imaging abnormality, the Panel is not satisfied that any such abnormality has been demonstrated. GCS is a clinical tool that is used to assess the level of consciousness. An appropriate verbal response will give a full score for the verbal component. If a patient is selectively mute, or unable to respond with an appropriate verbal response for a physical or a language based reason then the score of 14/15 needs to be interpreted on clinical grounds. In this case of NESB and voluntary mutism the 14/15 is assessed as a normal level of consciousness. Measurement of PTA was likewise affected by the "mutism" and lack of cooperation. Statements by her daughter that this was her "usual level of function" were also made.
On the basis of these conclusions, any assessment of whether that claimant has suffered a traumatic brain injury would attract a 0% WPI given that no traumatic brain injury has been suffered.

Conclusion

The claimant has not suffered a traumatic brain injury following a collision on

1 February 2017.

Determination

The Panel affirms the decision of Medical Assessor Cameron.
The claimant has not suffered a traumatic brain injury following the accident on

1 February 2024.

[2024] NSWPICMP 147

12 March 2024