Alameddine v Insurance Australia Limited t/as NRMA Insurance
[2024] NSWPICMP 828
•5 December 2024
| DETERMINATION OF REVIEW PANEL | |
| CITATION: | Alameddine v Insurance Australia Limited t/as NRMA Insurance [2024] NSWPICMP 828 |
| CLAIMANT: | Jenan Alameddine |
| INSURER: | Insurance Australia Limited t/as NRMA |
| REVIEW PANEL | |
| MEMBER: | Hugh Macken |
| MEDICAL ASSESSOR: | Paul Friend |
| MEDICAL ASSESSOR: | Surabhi Verma |
| DATE OF DECISION: | 5 December 2024 |
| CATCHWORDS: | MOTOR ACCIDENTS – Review of Medical Assessment; threshold injury; panic disorder with agoraphobia; specific phobia of driving in partial remission; persistent depressive disorder; prior medical history; panic attacks and anxiety; intrusive memory; prior medical disabilities; current functioning; personal care; social activities; poor concentration; prior medical history; marked reduction of daily functioning; diagnosis of panic disorder with agoraphobia; diagnosis of persistent depressive disorder, non-threshold injury; Held – certificate revoked and replacement issued. |
| DETERMINATIONS MADE: | CERTIFICATE OF DETERMINATION The Review Panel revokes the certificate of Medical Assessor Doron Samuell dated 3 August 2023 · Panic disorder with agoraphobia in partial remission. · Specific phobia of driving in partial remission. · Persistent depressive disorder. is a non-threshold injury for the purposes of the Motor Accident Injuries Act2017. |
STATEMENT OF REASONS
INTRODUCTION
Jenan Alameddine (the claimant) is a 30-year-old woman who was injured in a motor vehicle accident on 24 June 2021. Following the accident the claimant lodged an Application for Personal Injury Benefits and thereafter sought a concession from the insurer that her injuries would be considered non-threshold injuries. The insurer did not make this concession. This decision was confirmed after the review.
The claimant made an application to the Personal Injury Commission (the Commission) for an assessment of threshold injury and in due course, was examined by Medical Assessor Alan Home in respect to her physical injuries and Medical Assessor Doron Samuell in respect to her psychological injuries.
The claimant was examined by Medical Assessor Alan Home on 3 February 2023. In a Certificate dated 6 February 2023 Medical Assessor Home determined that the claimant had sustained a threshold injury in that the injury alleged to her left leg and lumbar spine were not caused by the motor vehicle accident.
Medical Assessor Doron Samuell examined the claimant on 25 July 2023 and, in a Certificate dated 3 August 2023, determined that the claimant suffered an adjustment disorder which is a threshold injury for the purpose of the Motor Accident Injuries Act2017 (the MAI Act).
The claimant sought a review of this determination and the matter was considered by the President’s delegate Rachel Brittliff who, in a decision dated 6 October 2023, determined that there is a reasonable cause to suspect the medical assessment was incorrect in a material respect. Thereafter the matter was referred to this Panel.
Noting that there was significant material which was before Medical Assessor Samuell but not before the Panel, directions were made on the parties to provide the material which was before Medical Assessor Samuell for the Panel to consider at its first telephone conference. This material was uploaded to the Portal and has been considered by the Panel.
The Panel convened on Wednesday 25 September 2024 at 4.00pm to consider what appropriate steps to take in this matter. It is the view of the Panel that there would be a re-examination of the claimant subject to the following clarification by the claimant as to which bundle of material which has been uploaded to the Portal is the bundle which is to be relied upon by them.
Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A “new decision maker” is defined in cl 14A(1) of the Schedule 1 of the PIC Act. As the medical assessment, the subject of the review, was made on or after 1 March 2021, the new review provisions apply.
The new review provision provide that a review panel consists of two Medical Assessors and a Member assigned by the Motor Accidents Division of the Commission.
Part 5 of the PIC Act enables the Commission to make rules with respect to its practice and procedure including proceedings before a panel reviewing a decision of a Medical Assessor.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the matter solely based on the written application.
The review of the medical assessment is by way of a new assessment of all the matters with which the medical assessment is concerned.
STATUTORY PROVISIONS/GUIDELINES
Section 57 of the Motor Accidents Compensation Act 1999 (MAC Act) defines a “medical dispute” as a disagreement or issue to which Part 3.4 of the MAC Act applies.
Section 58 and s 60 of the MAC Act together with clauses 1.5-1.7 of the Motor Accident Guidelines (the Guidelines) set out the procedures for referral to one or more medical assessors and the principles to be applied at such assessments.
The claimant was examined online by Medical Assessors Paul Friend and Surabhi Verma on 23 October 2024. She was unaccompanied.
HISTORY
Psychosocial history and pre-accident history
Ms Alameddine was born and grew up in Sydney, living variously in the suburbs of Pendle Hill, Chester Hill and currently at Guildford. She completed school to the end of Year 12.
She worked as a receptionist at a family daycare business in Bankstown for three to four years and then changed to work in retail doing customer service. She initially worked for the DFO outlet centre at Homebush for three years, later in a shop in Parramatta selling makeup and skincare products, and at the time of the motor accident was working for a clothing shop, Zara, doing customer service on a casual basis, averaging about 25 hours each week. During her time in customer service, she completed a Certificate IV in Retail and Skincare and a Diploma in Childcare and Development.
Ms Alameddine lives at home. She has an older sister who is married and lives away from home. She lives with her parents, two sisters and two brothers living at home. She is the second in the sibship of five.
Previous medical history
Ms Alameddine had pre-existing back pain from about 2013 when she was being carried and was dropped. She was apparently determined at that time to have bilateral pars interarticularis defects at L5 which had not united.
The report of Dr Vijay Maniam, orthopaedic surgeon, dated 27 October 2021, states that she probably had a stress fracture when she was involved in the initial accident which has gradually worsened with further episodes of injury. It states the defects are moderately large and indicate this may not have occurred from birth.
Ms Alameddine was involved in three motor accidents prior to the subject motor accident. The first motor accident was on 21 March 2015. She could not recall much about the motor accident but thought she might have had pain in her neck and had a few days off work. The next motor accident was on 31 January 2018. She does not remember the motor accident and does not remember her injuries. The third motor accident was on 31 October 2019. She has no memory of that motor accident or any injuries.
Ms Alameddine could not remember if she had any previous psychiatric/psychological symptoms or treatment. She was asked about entries in the general practice notes from the NAS Medical Practice dated 12 February 2020 and 20 February 2020. The entry dated
12 February 2020 referred to panic attacks and anxiety, feeling tense, tight, having palpitations, difficulty breathing, fear and sweats during the day but more at night and being very sensitive. It states she was referred to a psychologist.
Ms Alameddine was adamant she had not attended a psychologist or had any psychiatric or psychological treatment prior to the motor accident. The entry dated 20 February 2020 states she is easily upset, tired and has difficulty sleeping, fast beat and is anxious and depressed. Ms Alameddine thought that she may have had “a phase” but does not remember having those symptoms.
She did remember that her aunt died in 2020 as noted in the entry dated 19 October 2020. She agreed that this had affected her and thought she probably had a bit of time off from work but that there were no ongoing symptoms.
Ms Alameddine was asked about the entry in her general practice notes of 20 April 2021 which states she had headaches, dizziness, a lack of sleep and impaired concentration. It was also noted that she had chronic otitis externa. She could not exactly remember that time and was not sure of the cause of those symptoms.
There is no mention of those type of symptoms or other psychiatric/psychological symptoms prior to the motor accident and it is noted on 28 May 2021 that she has back pain for a long time which was still present on 1 June 2021.
There is an entry dated 24 May 2021 which states that she had dizziness, felt sick, had no energy and was tired as well as headaches but this did not necessarily refer to a psychiatric condition and could be related to the back pain or the otitis externa.
Ms Alameddine reported that she had commenced university in 2020 enrolling in a Nursing degree at Western Sydney University, attending the campus in Parramatta. She enrolled full time for 2020 and she changed to part time in 2021. She discontinued that degree at the beginning of 2022. Her goal was to qualify as a registered nurse. Ms Alameddine was not in a relationship at the time of the motor accident. She had lived at home all of her life.
Substance Use
Ms Alameddine was abstinent of tobacco, alcohol and illegal substances. She has approximately one cup of tea and one cup of coffee each day and no other intake of caffeine.
History of the motor accident
The motor accident occurred when Ms Alameddine was driving straight and coming home from work. An oncoming vehicle made a right hand turn in front of her, colliding with the front of her vehicle.
She initially felt shocked. She remained in her vehicle and subsequently drove into a side street on the left, got out and talked to the other driver. She telephoned her father and then drove home. Her vehicle was repaired.
History of symptoms and treatment following the motor accident
Ms Alameddine cannot remember much more about the motor accident because she felt shocked. She gradually over the following weeks she developed what she referred to as feelings of panic. The panic symptoms included her mind was racing, having a lot of emotions, not knowing what she was doing and feeling scared. She wanted to be alone and she avoided doing any activities away from home.
She had intrusive memories of the motor accident wherein she imagined that the collision was repeated and repeated until she could not get out of the vehicle. These intrusive memories mostly occurred when she thought about leaving home.
She stopped driving for a while, possibly about two to three months, and then was able to drive to the local Woolworths supermarket and buy groceries from time to time. She eventually was able to drive further afield, for up to ten minutes.
She felt scared particularly of a further motor accident when she drove. She felt less anxious and scared if she was driven by another person. She felt depressed or easily irritated most of the time.
She had difficulty falling asleep because she was fearful of having a nightmare about the motor accident. She had nightmares up to four times each week of the motor accident which would wake her from sleep and sometimes she would not be able to get back to sleep. She also woke from sleep without having a nightmare. During the day she felt low in her mood, had no energy, had no motivation and mostly stayed at home.
Ms Alameddine resumed working doing customer service at a skin and makeup store in Parramatta sometime after the motor accident. She was unable to say exactly when this occurred, but it was more than several months later.
She quit after a month. She felt quite anxious about driving to and from work which was 15 minutes each way. She worked part time about 25 hours each week. She described at that time feeling scared.
She continued her nursing studies but found travelling to and from the Parramatta campus very difficult because she was fearful of a further motor accident. This caused her to cease the course at the end of 2021.
Ms Alameddine had exacerbation of pre-existing back pain which was treated with physiotherapy and Lyrica. She believes that she was at some stage also prescribed Celebrex.
Ms Alameddine was asked why she had not mentioned the motor accident to her general practitioner, Dr Mahmoud Abdalla, until 7 October 2021. She replied that she did not want to be told she had something seriously wrong with herself.
She was asked why she had not mentioned any psychiatric symptoms until 30 November 2021 when she reported being easily upset, lacking sleep, forgetfulness and being anxious and depressed. She replied that she wanted to try to deal with it on her own.
Ms Alameddine was commenced on Lexapro 10mg daily after the motor accident but it was difficult to determine when this was first prescribed. She was referred to Mr Ayman Kassir, clinical psychologist, first attending on 4 February 2022.
The Allied Health Recovery Request dated 4 February 2022 refers to the motor accident and makes a provisional diagnosis of an Adjustment Disorder with Mixed Anxiety and Depressed Mood.
Ms Alameddine believed she had about 11 sessions of treatment apparently all during 2021. Ms Alameddine found the techniques she was taught were useful, but any relief of symptoms disappeared within a short period of time of ceasing using those techniques. She did not describe any ongoing benefit from that psychological treatment.
Details of any relevant injuries or conditions sustained since the motor accident
Ms Alameddine was assaulted it appears sometime early in November 2021.
She had driven to collect her sister from work at the Westfield Shopping Centre at Parramatta. Someone had tried to pull off her hijab and that of her sister. She was pushed, hit in the head and pushed to the floor. There was a lot of swearing. She became more anxious and her pre-existing nightmares became more frequent.
It also aggravated the back pain and the sleep disturbance but it appears there were no specific symptoms such as nightmares or intrusive images about the assault.
Ms Alameddine stated before the assault she still had difficulty with leaving home, still had nightmares, poor sleep, and limited her driving to driving no further than Parramatta.
She was unable to say how long that exacerbation of the motor accident caused symptoms lasted, but it was not ongoing.
Current symptoms
Ms Alameddine continues to feel anxious about twice each fortnight. She has what she refers to as random panic attacks every couple of weeks. She has disturbed sleep about twice a week. Her mood is still a bit down most days. She has low motivation and is irritable or easily irritated.
The panic attacks are characterised by tachycardia, shortness of breath, headache which feels like her head will explode, sweating, and her mind racing. The panic attacks occur when she thinks about leaving home.
She continues to have back pain every few weeks. She takes Lyrica when she gets back pain.
Ms Alameddine was unable to maintain working doing customer service at a skin and makeup store in Parramatta sometime after the motor accident. She obtained an online job working from home for NRMA, about 12 months ago She works four days each week, five hours each day, 20 hours each week. She takes telephone calls from people who need roadside assistance. She enters their details into a computer program. The telephone calls generally follow one after another. This job is less stressful and less irritating. She continues to have difficulty with concentration.
Current and proposed treatment
Ms Alameddine continues to take Lexapro 10mg daily which she reports as having some benefit in reducing her anxiety but not the depressive symptoms. Her sleep has not improved. She takes Lyrica when she has back pain every few days. Ms Alameddine was not receiving any treatment or taking any medication at the time of the motor accident.
CLINICAL EXAMINATION
Mental state examination
Ms Alameddine was on time, alert, orientated and cooperative with the assessment. She could not remember much about the previous motor accidents as noted above. Ms Alameddine feels very anxious about driving and is fearful of having a further motor accident.
It is difficult to fall asleep at least a couple of nights each week and she can wake during the night sometimes after a nightmare and sometimes for no reason. She has nightmares every couple of weeks.
She still feels a bit sad and depressed and lacking in motivation. She continues to have poor concentration. She was too uncomfortable about driving to work face to face and now works online. She continues to have low back pain.
Current functioning
Ms Alameddine can undertake her personal care. She can get up, have a shower and get dressed. She can prepare her breakfast and lunch for herself. Her mother usually cooks the evening meal or occasionally her older sister drops something off at home. She sometimes cooks for herself. She can do grocery shopping if required. She makes her bed and cleans her room, sometimes does her laundry and tries to help around the home with dusting and other cleaning. Ms Alameddine has never lived away from home.
Ms Alameddine prior to the motor accident went out with friends for dinner and for family and friend gatherings and attended the gym four times each week. The gatherings might be a celebration or just a gathering with friends. She now avoids gatherings and no longer attends the gym, not having the motivation to do so. Friends occasionally visit her at home. She will occasionally go out for a coffee with others.
Ms Alameddine can drive as far as Parramatta, which is 15-20 minutes travel, but not further. She can drive to the local supermarket when required.
Ms Alameddine has much less contact with friends and prefers to spend more time alone in her room and has less contact with her family. She has overall reported good relationships with her immediate family. She is not in a relationship.
Ms Alameddine reported that she has poorer concentration. She previously read books but no longer does so. She can read online for about 15 minutes. She can watch a movie with friends for about 15 minutes.
She can concentrate at work. She describes work as “fast paced” and that she does not have to think much, because the tasks are simple. She continues to work 20 hours each week over four days answering telephone calls and entering information about people requesting roadside service.
Comments on consistency
Ms Alameddine’s account throughout the examination was consistent. There were times when she could not remember previous events but these extended back as far as 2015 which the Review Panel felt was not unreasonable.
Summary of documents
The applicant’s submissions, which are undated, states that Ayman Kassir, clinical psychologist, in his report dated 4 March 2022 made a diagnosis of post-traumatic stress disorder with associated depression and anxiety.
The claimant submits that they suffer from post-traumatic stress disorder, which is a recognised psychiatric illness and not a minor injury.
The Personal Injury Commission Certificate by Medical Assessor Doron Samuell dated
3 August 2023 states the injuries sustained in the motor accident caused the condition of an Adjustment Disorder which is a threshold injury for the purposes of the MAI Act.
It states prior to the motor accident she consulted her family doctor and initially was told she was well but subsequently said she was getting worked up every time she was driving, had difficulty sleeping and eating and ceased work until September 2022.
She attempted to return to work but only lasted for a month, feeling there was too much pressure getting there and driving was an ordeal.
Her current symptoms are struggling to sleep, having a lot of things go through her mind and flashbacks and dreams. By this she means she has scenarios in her head such as she is driving and imagines being hit by someone, being trapped and keeps replaying it. She has nightmares two or three times each week which started a year ago although she was vague about the time of their onset. She later stated that the nightmares began a month after the motor accident.
Her appetite is okay but less than it was. Her weight is stable. Her mood is always irritable and on edge. She cannot read the way she used to.
She states she is working 20 hours per week and cannot cope mentally with full time work. She commenced work two weeks before the assessment.
When she is not working she can go out with friends or they come over to see her. She drives, and cooks once per week if she feels like it. She gets too worked up if she drives more than 15 or 20 minutes. She does not like being in crowded areas and feels there is a lot going on in her mind. She showers three to four times each day but washes daily.
The report by Ayman Kassir, clinical psychologist, dated 22 July 2022, states she presented with trauma, distress, depression and anxiety related to being involved in a motor accident on 24 June 2021. She was distressed during sessions, appeared worried, and her mood was flat.
The motor accident occurred when she was driving and was struck on the driver’s side by another vehicle that was turning into a side road. She was initially shocked, in tears and had trouble breathing. She parked her vehicle and exchanged details with the other driver. She then drove home from the accident.
She consulted her doctor after a few weeks because of pain in her back and knee and was referred for investigations. She commenced physiotherapy.
She had significant difficulty driving and was very worried about travelling in a motor vehicle as a passenger and driver and could only complete short trips in her parents’ car. She did not return to her job as a customer service assistant. She had flashbacks to the time of the accident which caused her to feel anxious and scared. She had a fear of enclosed spaces such as cars and elevators, especially since the motor accident. She used the emergency stairs when she attended sessions and was accompanied by a family member who drove her to appointments.
The results of various psychometric measures were as follows:
The Depression Anxiety and Stress Scale 21 Item (DASS-21) was reported as showing
· Depression – Moderate
· Anxiety – Extremely Severe
· Stress – Extremely Severe
The actual scores are not provided
The post-traumatic stress disorder Checklist for DSM-5 (PCL-5) has a score of 56. A score of 38 or greater is suggestive of post-traumatic stress disorder.
The Beck Depression Inventory Second Edition had a score of 26 which indicates depression in the moderate range for the two weeks prior to the date of administration.
The Beck Anxiety Inventory had a score of 40 which put her in the Severe range in the past week.
The Montreal Cognitive Assessment score of 20 was consistent with mild cognitive impairment.
The report by Dr James G Bodel, orthopaedic surgeon, dated 16 March 2022, makes a diagnosis of soft tissue injury to the neck and shoulders which has largely recovered. There was more significant injury in the lower part of the back which is persistent. She has non-verifiable radicular complaints in the left leg.
Dr Bodel assigns a whole person impairment of 5%.
The Allied Health Recovery Request by Ayman Kassir, clinical psychologist, dated
4 February 2022, makes a diagnosis of adjustment disorder with mixed anxiety and depressed mood.
The list of symptoms are ruminations, nervousness, anxiety, emotional distress, excessive worry, distressing memories, hypervigilance, fatigue, restlessness and heart palpitations. She also has low mood and sleep concerns.
The report by Dr Simon Dimmick, radiologist, of an MRI scan of the lumbar spine dated
19 October 2021, concludes there is a bilateral non-acute L5 pars interarticularis defects. No bone stress in the lumbar spine.
No intervertebral disc or facet joint pathology.
The colour photograph of vehicle registration AT46KR shows damage and deformation of the left hand side bumper bar extending up to include the bonnet which is lifted.
The clinical notes of Dr Abdalla from 7 August 2015 to 20 September 2021 include the following entries:
The entry dated 7 August 2015 states that there was an MRI of the cervical spine which showed disc bulging it appears at C4/5 and she was referred for physiotherapy. She needs massage to her neck. Her lumbar spine is not too bad.
The entry dated 3 June 2015 appears to refer to a motor accident in which another vehicle crashed into the driver’s side of her vehicle.
The entry dated 19 March 2020 refers to a motor accident on 31 October 2019. It states this occurred at a T-junction and the other driver did not stop. The ambulance did not attend and she did not attend hospital. It states she went home but a few days later had neck pain and headaches and left shoulder pain. She was prescribed medication and had physiotherapy. It appears to say she has resumed driving.
The entry dated 20 September 2021 states she has low back pain which has been increasing. It is worse with sitting. She also has pain in the left knee and the pain radiates into the left lower limb. The clinical notes are all handwritten and difficult to decipher.
The clinical notes from the NAS Advanced Medical Centre from 4 February 2013 to
23 August 2022 include the following:
The entry dated 21 March 2015 states she had a motor accident a few hours ago with pain and now has pain in the right side of her neck and her body and mild headache. She was driving out of a carpark and turning left. A vehicle coming straight hit her vehicle.
The entry dated 18 May 2015 states she has had neck pain referred to the right side and difficulty moving her neck. She has a tender cervical spine with painful restricted movements.
The entry dated 3 December 2015 states she has neck pain, shoulder pain, upper back pain, difficulty moving her neck, back and shoulders. She has tender cervical and thoracic spine and shoulders and painful restricted movement. A Centrelink medical certificate was written.
The entry dated 11 March 2016 describes similar pain and also says a Centrelink medical certificate was written.
The entry dated 1 February 2018 states she was involved in a motor accident on
31 January 2018. She hit the car in front of her vehicle. She developed neck and back pain and has difficulty moving her neck and back. There is pain on the side of her neck and she has difficulty with walking. She is tender over the cervical spine and the thoracic and lumbar spines. She was prescribed Voltaren Emulgel, Panadol and Nurofen.
The entry dated 1 November 2019 states she was involved in a motor accident on
31 October 2019. A vehicle collided with the right side of her vehicle on the right back door.
She has neck pain and referred to the lower jaw, has difficulty moving her neck and a tender cervical spine which restricted movement. She reported similar symptoms in the entries dated 4 November 2019 and 8 November 2019.
The entry dated 23 December 2019 states she had neck pain, difficulty moving her neck and has a tender cervical spine.
The entry dated 12 February 2020 states she has panic attacks and anxiety. She feels tense, tight everywhere, has palpitations, difficulty breathing, fears and sweats. This can be throughout the day but more at night. She is sensitive and takes things personally. She cannot recall the triggers. She agreed to a referral to a psychologist.
The entry dated 20 February 2020 states she is easily upset, tired and has difficulty sleeping. She has a fast heartbeat, is anxious and depressed.
The entry dated 6 March 2020 states she has pain in her shoulders, difficulties moving her head, and has a headache and is depressed.
The entry dated 19 October 2020 states her aunty died on 13 October. She is sad, depressed, easily upset and has a lack of sleep.
The entry dated 1 June 2021 states the CT scan of the lumbar spine showed a disc lesion and mild osteoarthritis. She has back pains down her left leg, difficulty moving and walking and a tender lumbosacral spine.
She has similar symptoms on 20 August 2021 which states she is staying in bed most of the time.
The entry dated 7 October 2021 states she has back pains down her left leg, difficulty moving and walking.
She had a motor accident on 24 June 2021 and subsequently had back pain referred to her left leg and difficulty moving her back and walking. She has been unable to work since the motor accident. It appears that an oncoming vehicle turned in front of her vehicle and collided with her vehicle.
She did not see doctors for some time. She has a history of back pain and it was not that bad and she was working.
The entry dated 5 November 2021 states she was allegedly assaulted by people at Westfield Shopping Centre, Parramatta, when she went to collect her sister from work. She was hit in the face and pushed down on the floor. She has neck pain, back pain, shoulder pain and a scratch on her upper eyelid. She has difficulty moving her neck, back and right shoulder. She has tender cervical and thoracic spines.
The entry dated 30 November 2021 states she has back pains down her left leg, difficulty moving her back and walking and is easily upset, has poor sleep and is forgetful. She is anxious and depressed and has a tender lumbosacral spine.
The report by Dr John Ly, radiologist, of a CT scan of the cervical spine dated
1 November 2019 concludes there is no fracture or malalignment. There is no traumatic disc protrusion, neural impingement, spinal canal or foraminal stenosis.
The Vitamin D level dated 9 November 2013 is 29 (normal range 50 – 150).
The report of Dr Vijay Maniam, orthopaedic surgeon, dated 27 October 2021, states Ms Alameddine has had pain in the lumbar spine since her teens. This is due to bilateral pars interarticularis defects at L5 which are not united.
A bone scan shows there is no evidence of acute fracture or activity in the pars defects. It states it was likely there was a stress fracture when she was involved in the initial accident and it gradually worsened by further episodes of injury. The defects are moderately large and indicate this may not have occurred from birth. She complains of pain after prolonged sitting, standing and repetitive bending. It recommends she have treatment with physiotherapy and an exercise program for strengthening but it may be necessary for her to have surgery.
The report by Dr Vijay Maniam, orthopaedic surgeon, dated 21 September 2021, states she has been previously seen in 2015 and 2020.
On 21 March 2015 she sustained a whiplash injury to her cervical spine.
On 31 October 2019 she suffered a further injury to her cervical spine in a motor accident.
Her current problems with her lumbar spine commenced in her early teens. She was being carried by her friends when they suddenly dropped her. She has recurring pain which has been further aggravated by the motor accident. The pain has come to the fore recently and she has been aware of it radiating to her left leg.
The CT scan of the lumbar spine shows un-united L5 pars defects and mild disc herniation of L5/S1. There is mild to moderate stenosis in the neural exit foramina which a suspicion of impingement on the exiting L5 nerve roots bilaterally.
The report by Dr Samer Ghattas of an MRI scan of the cervical spine dated 23 March 2020 concludes there is no significant central canal or foraminal stenosis throughout the cervical spine. There is no evidence of cervical ligamentous injury.
The report by Dr Jane Carrick of an endoscopy dated 15 April 2016 states there is oesophagitis of the lower end of the oesophagus. The lower oesophageal sphincter is lax. There is bile reflux in the upper stomach. There are scattered haemorrhagic erosions in the mid stomach. There is distal duodenitis.
The report by Dr E Berley of an X-ray of the right wrist dated 24 February 2011 states there is a small break in the cortical margin of the distal medial aspect of the radial styloid. This is probably due to an incompletely fused epiphysis but a fracture cannot be excluded. If the pain persists she should have repeated X-rays in two weeks. She should have comparative views with the left side.
The Certificate of Capacity/Certificate of Fitness dated 8 November 2021 regarding the motor accident on 24 June 2021 lists the injuries as MVA and back injury.
The insurer’s submission dated 16 November 2022 state that Mr Ayman Kassir made a provisional diagnosis of post-traumatic stress disorder.
The motor accident was low speed and low impact.
There was a history of anxiety and depression reported by the complainant prior to the motor accident.
The claimant did not report the motor accident to a general practitioner for some three months post-accident despite attending the surgery on multiple occasions.
She was assaulted in the shopping centre on 5 November 2021 and subsequently was easily upset, anxious and depressed.
The Police Report dated 18 October 2021 regarding the motor accident on 24 June 2021 states it was reported on 8 October 2021. It was a front passenger side accident turning right.
The Application for Personal Injury Benefits dated 12 November 2019 regarding the motor accident on 31 October 2019 states the injuries sustained were neck pain due to whiplash because of the impact, recurring headaches and neck stiffness.
The clinical notes of the NAS Advanced Medical Centre from 4 February 2003 to
23 August 2022 list the current medications as Nasonex nasal spray and Panamax tablets. The past history includes Vitamin D deficiency since 2016 and ear wax in 2013.
DETERMINATION
Diagnosis and reasons
The Review Panel considered all the evidence and determined that Ms Alameddine met many of the criteria for a diagnosis of post-traumatic stress disorder but did not reach Criterion A - exposure to actual threat and death, serious injury. The Review Panel accepted she was involved in a motor accident and was shocked but her vehicle was subsequently driveable. It was repaired and the colour photograph of the vehicle supplied did not indicate serious damage to the vehicle.
The Review Panel did accept that Ms Alameddine had a marked reduction of her daily functioning which will be described later. She had panic attacks characterised by shortness of breath, tachycardia, sweating, shaking and fearfulness. She did have nightmares at night which caused disturbed sleep. She avoided going out because she would feel panicky.
The Review Panel determined she met criteria for a diagnosis of panic disorder with agoraphobia or agoraphobic avoidance but this was in partial remission because she had been able to resume leaving home and travelling to a degree.
The Review Panel also determined that following the motor accident she did not drive for a period of probably a couple of months and therefore met criterion for the condition of a specific phobia of driving in that she completely ceased driving herself and preferred to be driven by others but had gradually been able to overcome that condition and was able to drive for 15-20 minutes and therefore this condition was also in partial remission. She had not regained her full pre-accident abilities to drive wherein she could drive into the city or anywhere she wished.
The Review Panel noted that she had various depressive symptoms, low mood, lack of motivation and sleep disturbance, poor concentration and low levels of energy.
The Review Panel determined that she did not meet criteria for a diagnosis of a Major Depressive Disorder but did reach criterion for a diagnosis of a Persistent Depressive Disorder. The Review Panel accepted that perhaps closer to the time of the motor accident she may have reached criterion for a diagnosis of Major Depressive Disorder but determined that she currently did not meet those criteria.
The Review Panel accepted that her current psychiatric/psychological symptoms arising from the injuries sustained in the motor accident had caused impairment of her day to day functioning.
Causation and reasons
Ms Alameddine reported that she was working casually about 25 hours each week and was attending university part time at the time of the motor accident.
She had been involved in previous motor accidents but there was no clear evidence that these led to any ongoing impairment in her day-to-day functioning or were causative of her current conditions.
She was subsequently assaulted some time before 5 November 2021 but as far as could be determined this did not cause any ongoing symptoms and did not cause any specific symptoms related to that trauma. The review panel determined that the assault did not lead to ongoing exacerbation of the psychiatric/psychological symptoms following the motor accident on 24 June 2021.
The Review Panel concluded that the motor accident on 24 June 2021 was the cause of the current psychiatric conditions and impairment of functioning.
The following injuries WERE caused by the motor accident and are non-threshold injuries:
· Panic Disorder with Agoraphobia in partial remission.
· Persistent Depressive Disorder.
· Specific Phobia of Driving in partial remission.
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