Alleman v Gunnedah Shire Council

CERTIFICATE OF DETERMINATION OF MEMBER
CITATION:	Alleman v Gunnedah Shire Council & Ors [2024] NSWPIC 70
APPLICANT:	Tatiana Alleman
FIRST RESPONDENT: SECOND RESPONDENT: THIRD RESPONDENT: FOURTH RESPONDENT: FIFTH RESPONDENT:	Gunnedah Shire Council Helena Rosalind Anne Jones Claudia Elizabeth Jones Isabella Alice Jones Cecily Susannah Margaret Gunn
MEMBER:	Rachel Homan
DATE OF DECISION:	20 February 2024
CATCHWORDS:	WORKERS COMPENSATION - Application for compensation in respect of death of worker; deceased worker had a pre-existing bipolar affective disorder and comorbid alcohol use disorder; excessive drinking at a work conference; subsequent stressful events in workplace; Federal Broom Co Pty Ltd v Semlitch, AV v AW, and BGV v Waverley Council referred to; Held – applicant failed to discharge onus of demonstrating on the balance of probabilities that employment was the main contributing factor to an aggravation of the deceased worker’s disease; award for the first respondent employer.
DETERMINATIONS MADE:	The Commission determines: 1. Award for the first respondent.

STATEMENT OF REASONS

BACKGROUND

Mr Paul Christian Jones (the deceased worker) was employed by Gunnedah Shire Council (the first respondent) as an Economic Development Manager. On 3 June 2021, the deceased worker died due to the combined effects of acute alcohol intoxication and mixed drug effect.
On 22 June 2021, solicitors acting on behalf of the deceased worker’s wife, Ms Tatiana Alleman (the applicant), wrote to the first respondent seeking compensation pursuant to ss 25 and 26 of the Workers Compensation Act 1987 (the 1987 Act) in respect of the death.
Liability to pay compensation was disputed in a notice issued pursuant to s 78 of the Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act) on
11 May 2022. That decision was maintained following internal reviews on 25 October 2022 and 4 April 2023.
The present proceedings were commenced by the applicant by lodgement of an Application in Respect of Death of Worker (the Application) lodged in the Personal Injury Commission (Commission) on 3 August 2023.
The Application identified the applicant’s three daughters (the second, third and fourth respondents) as dependants.
The Application was subsequently amended, amongst other things, to name the deceased worker’s daughter from a previous relationship as fifth respondent.

PROCEDURE BEFORE THE PERSONAL INJURY COMMISSION

The parties appeared for conciliation conference and arbitration hearing in Sydney on
15 December 2023.
The applicant was represented by Mr BSO Parker instructed by Ms Sabrina Morrell.
The first respondent was represented by Mr John Catsanos SC instructed by Mr Mick Franco.
The second respondent was represented by Mr Luke Morgan instructed by Mr Toby Tancred.
The third respondent was represented by Mr John Gaitanis instructed by Mr Toby Tancred.
The fourth respondent was represented by Mr Graham Barter instructed by Mr Toby Tancred.
The fifth respondent was represented by Ms Lyn Goodman instructed by Ms Ana Jaglic.
I am satisfied that the parties to the dispute understand the nature of the application and the legal implications of any assertion made in the information supplied. I have used my best endeavours in attempting to bring the parties to the dispute to a settlement acceptable to all of them. I am satisfied that the parties have had sufficient opportunity to explore settlement and that they have been unable to reach an agreed resolution of the dispute.

ISSUES FOR DETERMINATION

A large number of issues potentially requiring determination arise in these proceedings. The parties agreed, however, that the following issues ought to be determined before submissions were made in respect of the other matters:
(a) whether the deceased worker sustained an injury pursuant to s 4 of the 1987 Act, and
(b) whether his death resulted from injury pursuant to s 25(1) of the 1987 Act.
The first respondent withdrew its reliance upon notified disputes by reference to s 14(3) of the 1987 Act and whether the injury was wholly or predominantly caused by reasonable action taken or proposed to be taken by or on behalf of the first respondent with respect to discipline and/or dismissal pursuant to s 11A(1) of the 1987 Act.

EVIDENCE

Documentary evidence

The following documents were in evidence before the Commission and considered in making this determination:
(a)    Application and attached documents;
(b)    Reply lodged by the first respondent;
(c)    Reply lodged by the second respondent;
(d)    Reply lodged by the third respondent;
(e)    Reply lodged by the fourth respondent;
(f)    Reply lodged by the fifth respondent;
(g)    documents attached to an Application to Admit Late Documents lodged by the first respondent on 27 November 2023, and
(h)    documents attached to an Application to Admit Late Documents lodged by the applicant on 8 December 2023.
No application was made to adduce oral evidence or cross-examine any witness.

Applicant’s evidence

The applicant has provided statement evidence dated 10 October 2022, 17 January 2023 and 9 October 2023.
In her first statement, the applicant gave evidence that the deceased worker was diagnosed with bipolar affective disorder in 2009 and had a number of hospital stays for treatment in the past. The deceased worker would suffer episodes which would be triggered by something specific, such as a stressful event. The episodes would last a few weeks and then he would return to normal. Some episodes were worse than others and would require medical intervention.
Despite his condition, the deceased worker was able to work and was highly functioning, for the most part. He obtained a Masters degree from Cambridge University and held down long-term employment as a derivatives trader for Citibank as well as a number of other high level roles.
The applicant said the deceased worker was usually a responsible, social drinker. The only time he had problems with alcohol was when he was manic and this was considered a symptom of his bipolar disorder.
The applicant and her family moved to Gunnedah from Young on 23 January 2021. Prior to the move, the deceased worker had been discharged from mental health care services in Young as he no longer required intervention. He was in good mental and physical health and not receiving any treatment for any condition.
The deceased worker commenced employment with the respondent on a 12-month fixed contract on 25 January 2021. The deceased worker underwent a pre-employment medical assessment which included a drug and alcohol test which came back negative.
The family settled into their new community well and the deceased worker appeared to be making a favourable impression with his work colleagues and the wider business community. He was happy and content and told the applicant that the mayor had confided in him that he was very pleased that the deceased worker was in charge of economic development.
Between 16 and 19 March 2021, the deceased worker was required to attend a ‘Regions Rising’ conference in Canberra with his [redacted], BSO.
The applicant had no concerns about her husband’s drinking or his well-being attending the conference. He was in good physical and mental health before his departure. The deceased worker called the applicant when he arrived in Canberra and everything seemed normal. The applicant stated,
“He then called me later that evening at around 8:00pm and he was clearly intoxicated. I could hear that he was in a busy pub, he had slurred speech, he was repetitive and not making sense. He put me on the phone to BSO who was also clearly intoxicated. My husband was using my debit card on his phone via Apple Pay and I could see a number of transactions to the Bentspoke Brewing Company in Braddon ACT which upon further investigation is the trading name for the Braddon Brew Pub in Canberra.”
The applicant said that she was not alarmed, thinking this was probably a one-off event although she did find BSO behaviour extraordinary for a [redacted]. The applicant alleged that BSO was well-known in Council for having a drinking problem. During a visit to China as part of a delegation sent by Council, BSO had become so intoxicated that he had to get his stomach pumped. BSO was later put on a performance improvement plan and asked not to drink at work functions.
The applicant said she became concerned when her husband called at 7am the next morning and was clearly still drunk. The applicant said,
“From that point on, I lost contact with my husband who refused to take my calls. As this was completely out of character, I contacted the mental health access line and reported my concerns for my husband as excessive alcohol consumption can trigger a manic episode in which his behaviour could become reckless and irresponsible. I asked to be referred to the mental health services in our area in case we needed support when my husband returned.”
The applicant was later told by BSO that the deceased worker had emptied the entire contents of his hotel room minibar during their stay in Canberra. The applicant formed the view that BSO was encouraging the deceased worker to drink from text messages sent to the deceased worker by BSO which included the following:
“‘pint time mate, wake up!!’”
The deceased worker arrived home extremely intoxicated on 19 March 2021. He was not able to answer calls or texts and continued to drink excessively that weekend. He was so unwell that the applicant had to postpone the commencement of a new job. From that point onwards, the deceased worker’s attendance and performance at work started to suffer.
The applicant stated:
“Unfortunately, my husband never fully recovered from this heavy drinking episode which started in Canberra. Even if he had been medicated at the time for his bipolar, in my experience a drinking episode of this magnitude would have interrupted his medication regime and would likely have resulted in an overdose.
I believe this event, triggered a series of manic and depressive episodes which could not be managed despite the best efforts of his treating doctors and the intervention of every emergency service available at the time.”
The applicant said that the deceased worker was struggling to stay away from alcohol and felt immense pressure to drink in work contexts. There was always alcohol in the office and it was regularly consumed at work events. There was a ‘boys club’ amongst senior management and alcohol was always present and drinking encouraged.
The applicant described two other incidents at work which caused the deceased worker to become increasingly stressed and aggravated. The first was when the manager of communications emailed him regarding disciplinary action for a breach of conduct. The deceased worker was said to have approached media without the communications department’s authority. There was a private meeting and the allegations were later dismissed. From that time onwards, the manager’s attitude towards the deceased worker was negative.
The second issue was the lack of support in his role. An officer working for the deceased worker went on maternity leave and there was some difficulty replacing her role. The role was filled during one of the deceased worker’s absences with an officer who was not qualified for the role and who struggled to complete the simplest of tasks. The deceased worker expressed concerns regarding the need for effective administrative support to
BSO many times, even asking if the officer’s contract could be terminated within the probationary period. The deceased worker’s requests were declined and he was advised to performance manage the officer.
The deceased worker felt betrayed and let down by his superiors. He was slapped with disciplinary action and disgraced when he was clearly not well. Although the deceased worker did not disclose his illness until much later and lied about the cause of his frequent absences at work, it was very obvious that something was wrong and his mental health was in decline.
The deceased worker did return to work and completed some major projects despite being unstable and intoxicated. The deceased worker was taking alcohol from work. BSO later mentioned a meeting in which it was obvious that the deceased worker was intoxicated. The applicant was surprised to learn that no assistance had been offered to him in the circumstances.
By May 2021, the deceased worker was barely attending work and becoming increasingly divorced from reality. His performance was suffering and it was obvious that he was mentally unwell.
The deceased worker received a letter from Human Resources on 6 May 2021 regarding an alleged breach of contract. An employment lawyer, Kieran McArdle, was engaged to deal with Council. Mr McArdle disclosed the applicant’s psychiatric condition to Council. The deceased worker was not made aware of the alleged misconduct until 14 May 2021.
The applicant stated,
“This not knowing had a profound detrimental impact on his already failing health. During this week, Paul became manic, he stopped eating, sleeping and interacting with the family. He started to register his profile on internet dating sites and watched graphic pornography for hours on his phone. He was regularly withdrawing into his room. He stopped joining us for meals and reading to the kids at night. He was neglecting his personal hygiene and stopped driving the kids to school. Our youngest even confided in her teacher at school that she was worried about her dad.
There was nothing I could do to snap him out of this. In the past, I had always been able to manage his manic episodes which were characterised with drunken behaviour, gambling or excessive spending and would only last a few weeks. I have never seen this side to one of Paul's manic episodes, nor one last so long. It was heavily characterised by depressive symptoms and I could not manage him this time.”
The applicant said the formal accusations made in the letter dated 14 May 2021 were false and misleading.
The applicant resigned from her job in order to take care of her husband full-time. The applicant managed to get a community mental health team to treat the deceased worker remotely as it was difficult to get him to Tamworth. There were Skype consultations on
19 and 27 May 2021 where the deceased worker was put on a medication regime including Antabuse, diazepam, lithium and Seroquel.
A deed of release finalising the deceased worker’s employment with the respondent was signed on 28 May 2021 but not submitted until 1 June 2021. The respondent had begun readvertising the deceased worker’s position, which left him feeling worthless and despondent.
On 3 June 2021, the applicant walked into the deceased worker’s bedroom in the early evening to find him blue and unresponsive. An ambulance was called but he could not be resuscitated.
The applicant stated,
“It is my firm belief that had he not attended the Regions Rising Conference in Canberra from 16-19 March 2021 he would still be alive today. From the time he arrived in Canberra and for the whole duration of the trip, he engaged in what can only be described as dangerous binge drinking with his [redacted] BSO. I believe this triggered my husband's Bipolar Effective disorder and he never recovered. In my view, it was completely irresponsible for BSO to have encouraged and condoned the behaviour that went on, on a work trip in which he held seniority over my husband.”
The applicant said the deceased worker’s condition was not static and tended to fluctuate with particular stressors such as excessive consumption of alcohol or financial/emotional upset, regardless of whether he was medicated or not. The deceased worker’s final episode was triggered by an excessive and unreasonable drinking event.
There were absolutely no symptoms of mania or excessive alcohol consumption immediately before going to Canberra.

First respondent’s witness evidence

BSO

The first respondent relies on written statements prepared by BSO dated 10 November 2021 and 17 January 2023.
In his first statement, BSO said he had been employed in local government for 22 years and had an impeccable employment record.
BSO described the deceased worker as a “very energetic and fast paced sort of guy” who regularly sent messages before, during and after work in relation to work and non-work matters. He maintained this level of energy throughout the time they worked together at Council.
BSO confirmed that he had attended a conference in Canberra with the deceased worker between 16 and 19 March 2021. They stayed at the same hotel but in separate buildings.
On the first night, BSO and the deceased worker had dinner and some beers together at a local brewery. They had between 10 and 12 pints of beer with dinner. The deceased worker was setting the pace and BSO was trying to keep up with him. BSO paid for the dinner and one round of beers on his personal credit card. The rest of the drinks were paid by BSO and the deceased worker in turns from their personal funds They went back to the hotel where BSO went to sleep.
The following morning, BSO had a strong hangover whereas the deceased worker appeared bright-eyed and perfectly fine.
That night, BSO and the deceased worker attended a conference dinner for about five or six hours, during which BSO consumed five or six beers along with a glass of red wine.
BSO told the deceased worker that he was going back to the hotel as he was tired and wanted to go to sleep. The deceased worker returned to the hotel with BSO in the same taxi. BSO expressed the belief that he and the deceased worker had about the same amount of alcohol that night. The deceased worker did not appear overly intoxicated. The deceased worker stayed outside the hotel smoking a cigarette while BSO went up to his room to sleep.
In the afternoon of 18 March 2021, the deceased worker approached BSO while he was on a zoom call and was very energetic and suggested they go for a beer. BSO responded that it was only 4pm and he was still working. He told the deceased worker to go back to his hotel room and rest up.
Later that night, BSO and the deceased worker went to a brewery for dinner. BSO paid for a pint for each of them each on his personal credit card. The deceased worker consumed his fairly quickly and went to the bar to order two more. The deceased worker returned without any drinks stating that the bar was not accepting cash and he did not have his card with him. BSO gave the deceased worker his personal credit card and he returned with two beers and two shots. BSO said he did not usually drink shots.
During dinner, BSO observed the deceased worker to be slurring his words and burping. As the deceased worker appeared quite intoxicated, BSO called a taxi and they returned to the hotel. While waiting for the taxi, BSO purchased a four pack of the brewery’s beers to try at home. When he went outside, a staff member commented, “You need to take this fella home”.
When they got back to the hotel, BSO said he was going to bed and encouraged the deceased worker to do the same. The deceased worker stayed outside, smoking a cigarette. BSO texted the deceased worker 10 minutes later asking if he was okay but the deceased worker did not respond.
The deceased worker also did not respond to a text message inviting him for a coffee the next morning. BSO called the deceased worker on his mobile phone on a number of occasions that morning, none of which were answered. BSO went to the reception desk and asked them to call the deceased worker’s room but he did not answer the phone. A short time later, the deceased worker arrived in the reception area walking in an unsteady sort of fashion. He commented that he had not gone to sleep until 5am that morning.
BSO and the deceased worker walked to a café where the deceased worker slumped into his chair and nearly fell off. When BSO went to order food at the counter the deceased worker was slumped over two other patrons of the café. BSO told the deceased worker that he needed to go back to his room and sort himself out as they were due to catch a flight later that morning.

The deceased worker did not show up at the agreed time to catch a taxi to the airport.
BSO tried to call the deceased worker’s mobile phone a number of times but he did not answer. Eventually, he answered a call on his room phone and came downstairs. The deceased worker said he had been in the shower. BSO asked the deceased worker if he had checked out and he replied that he had checked out at 5am that morning.
BSO was confused by this answer and while in the taxi asked his executive assistant to check whether the deceased worker had in fact checked out. She replied that the deceased worker had not checked out and that the hotel had advised there would be a fee charged for an extra night if he didn’t check out by 10am. The hotel had also advised her that the mini bar bill for the deceased worker’s room was $225.50.
BSO confronted the deceased worker about this and he said it was all sorted. The hotel later advised that BSO’ corporate card would be charged as it had been used to pay a bond for both hotel rooms. BSO told the deceased worker that Council had paid his mini bar bill but that he would need to pay this back. It had been made clear a number of times to the deceased worker that Council would not cover the mini bar bill. The bill was never repaid.
On 20 April 2021, BSO observed the deceased worker to be slurring his words and more energetic than usual. BSO smelled something sweet on his breath. The deceased worker had been out of the office for a period of about four or five hours that day. As a result of his observations, BSO became concerned about the deceased worker’s well-being and sent a text message checking on him.
Later that day, BSO and the deceased worker had a phone conversation in which he commented that it appeared the deceased worker had been drinking. The deceased worker said that his appearance was due to medication he was taking for a heart issue following a stroke. BSO had been told by the applicant on 24 March 2021 that that the deceased worker had been admitted to hospital and had suffered a stroke. BSO later learned that this was not true.
BSO indicated to the deceased worker that he would need to get a medical clearance from his doctor before returning to work if his medication had that effect. The deceased worker responded in an angry and aggressive manner and the phone call ended. The deceased worker did not come in to work for the next couple of days, explaining that he was sick with conjunctivitis.
BSO said the first occasion on which concerns regarding the deceased worker’s mental health were raised with him was in a message from the applicant on 21 April 2021 in which she mentioned she was having trouble getting the deceased worker in to see a general practitioner. BSO suggested that she take the deceased worker to the hospital.
BSO said he was aware that the mayor had raised some concerns about the deceased worker after he called the mayor several times in one night and was rambling and incoherent during the phone calls. The situation was managed by BMP.
BSO said the deceased worker never raised any concerns about his workload during his time with Council. His workload was not excessive and was manageable. The deceased worker had expressed unhappiness with his administrative assistant but never made any specific complaints. BSO told the deceased worker that he needed to manage her performance if it was substandard.
BSO denied engaging in dangerous binge drinking with the deceased worker during the conference in Canberra. BSO denied encouraging the deceased worker to drink or paying for all of his drinks. He considered them to be to grown men having dinners and drinks outside work hours as friends. He never encouraged or pushed the deceased worker to drink. BSO was not aware that the deceased worker had any previous issues with alcohol.
In his second statement, BSO again described the events during the conference in Canberra. BSO agreed that the deceased worker had called the applicant while they were at the brewery on the first night. At that point, they had only had around three beers.
BSO denied that he was emotional or slurring when speaking on the phone with the applicant.
BSO stated that during the first night, he and the deceased worker bought their own drinks with their own funds in reciprocal shouts.
BSO denied having a drinking problem and said this had never been raised as a concern by anyone, whether professionally or personally. Although BSO did attend trade delegation trips to China in 2017 and 2018, he never had to have his stomach pumped.
BSO did not know what the allegation made by the applicant in this regard was based on. BSO said he had never been on a performance improvement plan during his 24 years of employment in local government. At no stage had alcohol consumption been addressed with him as a work-related issue or concern.
BSO said he sent a text message saying, “pint time mate, wake up!” to the deceased worker after the deceased worker had earlier invited him to come out for a pint. BSO had been on a zoom conference at the time when the deceased worker initially asked him to come out.
BSO said the social club at Council had a fridge with beer which had been consumed in moderation on Friday afternoons by staff of Council before going home. BSO rarely attended these Friday afternoon gatherings. There was never any expectation or pressure for anyone to attend them. BSO was not aware of alcohol being consumed on Council premises apart from the Friday gatherings.

BMP

The first respondent’s [redacted], BMP also provided written statements on
15 December 2021 and 17 January 2023
In his first statement, BMP described the deceased worker as “generally very buoyant and eager” in the early stages of his employment but more “guarded and volatile in his behaviour” towards the end of his employment.
BMP stated that following the conference in Canberra, BSO told him that the deceased worker had “cleaned out” the minibar in his hotel room, was very social and bounced around speaking to different people.
BMP said that the first respondent paid for reasonable meals and drinks such as a beer or wine with dinner but did not pay for mini bar bills during the conference. A debt for the mini bar bill was raised with the deceased worker but never paid.
BSO told BMP that both he and the deceased worker drank a fair amount of alcohol on the first night of the conference.
BMP said the deceased worker never raised any concerns about his workload although he was aware of some issues where the deceased worker had indicated that work had been completed when it had not.
BMP said he had been made aware of inappropriate phone calls made by the deceased worker to the mayor and the president of the Chamber of Commerce. The mayor contacted BMP and said that the deceased worker had sounded intoxicated on the phone and spoke in a somewhat aggressive manner. The deceased worker had also sent inappropriate text messages between late March and early May 2021.
BMP described attempts to arrange a meeting to discuss alleged breaches of the code of conduct and other interactions with the deceased worker’s legal representative during which the deceased worker’s mental health issues were disclosed for the first time. The allegations against the deceased worker were put in a letter emailed on 6 May 2021. The deceased worker was suspended on full pay. His last day at work was 4 May 2021. No formal disciplinary action was taken as Council and the deceased worker agreed to a separation agreement through his legal representative.
In his second statement, BMP denied any knowledge of drinking or conduct-based issues on BSO’ part. BSO had never been subject to any performance improvement plan and BMP was not aware of him having a reputation for heavy drinking at work events or in other settings.
BMP denied that there was a drinking culture at Council.

Marie Resch

Written statements were prepared by the former executive manager of people and culture, Ms Marie Resch, on 19 December 2021 and 18 January 2023.
In her first statement, Ms Resch said that in around late March 2021, BSO had approached her with some concerns about the deceased worker’s behaviour during a conference in Canberra. BSO expressed that the deceased worker was drinking heavily during the conference and he also had concerns about the general demeanour of the deceased worker during the conference. The concerns raised by BSO were of a general nature at the time and Ms Resch advised him to monitor the situation.
Ms Resch gave evidence about the events in early May 2021 leading to the deceased worker’s separation from his employment with Council.
In her second statement, Ms Resch referred to her conversations with BSO following the Canberra conference. Ms Resch said that her approach to the matter was influenced by the fact that BSO and the deceased worker were outside the workplace and in social settings at the time of the behaviour in question.
Ms Resch said she never witnessed any male drinking culture at Council although some staff were friends outside of work and socialised outside of work. There was a social club at Council but Ms Resch never personally saw anyone drinking alcohol in the workplace.
Ms Resch said she was not aware of any history or propensity for BSO to drink heavily and she was not aware of him ever being placed on a performance improvement plan.

Employer records

A letter from BMP to the deceased worker dated 6 May 2021 noted that he had been asked to attend a meeting with the executive manager of people and culture the previous day. The deceased worker had responded that he did not wish to attend the meeting and was unwell. Council had been informed the previous afternoon of a mental health condition and had received correspondence from McArdle Legal proposing that particulars of the meeting be provided in writing.
The letter advised the deceased worker that allegations had been raised concerning his recent conduct and that an investigation into the allegations would commence as soon as possible. The deceased worker was advised that he would be given a full opportunity to attend an interview to provide his response to the allegations at an appropriate time. The deceased worker was directed not to attend work but would be paid his usual remuneration. The deceased worker was advised that the investigation would be carried out in a confidential manner.
In a further letter dated 14 May 2021, BMP noted that Mr McArdle had requested that the allegations be outlined in writing in advance of a meeting now scheduled for 19 May 2021. The following allegations were disclosed:
“• On 4 April, 1 May and 2 May 2021 you sent inappropriate texts to the Mayor.
• The text on 4 April related to an operational matter, being a media interview. You subsequently asked to speak to the Mayor on a private basis. You called his mobile at 6.40pm – the call lasted 23 minutes and 36 seconds – and during this call you spoke to the Mayor about what you thought you could do to help him get elected.
• On 1 and 2 May you sent text messages to the Mayor indicating that you could help him with his campaign – quoting that you could get him 15% more votes.
• You have also contacted the President of the Chamber of Commerce in recent weeks, and during a telephone call to the President you appeared to be intoxicated and you were aggressive. The President terminated the call, but subsequently received a number of aggressive texts from you.”

Treating evidence

There is a large body of clinical material before the Commission which has been reviewed and considered in making this determination. Following is a summary of some of the material to which the parties made specific reference in their oral submissions.
A psychiatric report was prepared by Dr Adrianne Reveley, consultant psychiatrist, dated
5 October 2010, in connection with the deceased worker’s employment at Citibank in London. The deceased worker was noted to be responsible for his own trading book and to hold authority to undertake trades with very significant values, perhaps exceeding $100 million at the time.
The deceased worker reportedly did well at school and was deputy head boy. He went on to Downing College Cambridge where he obtained a degree in economics and made a lot of friends. The deceased worker became a trader and was headhunted for his job at Citibank from Merrill Lynch. The deceased worker had recently been through a divorce and had been prescribed antidepressants and Xanax for anxiety. The deceased worker had been diagnosed with bipolar disorder.
Dr Reveley stated,
“Bipolar Disorder is a recurrent psychiatric condition, characterised by intermittent periods of elation, or mania, as well as intermittent periods of depression in mood. Bipolar Disorder tends to be familial, and Mr Jones' family history is consistent in this regard.
…
If the degree of mania becomes clinically significant, distractibility and poor concentration impairs implementation of the creative ideas. Judgment also can be compromised; spending sprees, offensive or disinhibited behaviour, and promiscuity or other objectively reckless behaviours can occur. Subjective energy, libido, and activity typically increase but a perceived reduced need for sleep can sap physical reserves. Sleep deprivation also can exacerbate cognitive difficulties.”
Regarding treatment, Dr Reveley commented:
“The treatment of Bipolar Disorder is aimed at preventing recurrence. Psychosocial stress, usually stress with an emotive content such as a relationship break-up, can trigger an episode, and this appears to have been the case with Mr Jones, associated with his divorce. However in most instances there are no identifiable factors precipitating an attack of the illness. Employment is beneficial and contributes to mental stability. Most people with Bipolar Disorder are treated with lithium, which is a mood stabiliser, and modern atypical antipsychotics, such as quetiapine, are also used for mood stabilising, even where there is no psychosis. Mr Jones is on both lithium and quetiapine.”
Dr Reveley commented that the condition tended to worsen with time with episodes becoming more frequent and longer lasting. Consistent medication would improve the prognosis.
Regarding the triggers for relapse of the condition, Dr Reveley commented:
“As noted above, relapse can occur with no identifiable precipitant at all, even if the individual continues to take their medication, although medication makes this less likely. Forgetting to take medication for one or 2 days or even up to a week or so is unlikely to cause a problem, but after a month without medication the individual would be at risk of relapse. In general, emotional issues can be associated with relapse, whether or not the individual takes their medication. Employment is not generally associated with relapse; in fact the opposite is true. The challenge and intellectual interest involved in work is probably beneficial and contributes to mental stability.
Consumption of alcohol, in normal amounts, is not a risk factor. Sleep deprivation is a risk factor, however, and jet lag can sometimes trigger an episode.”
A Discharge Referral was prepared by Prince of Wales Hospital following a period of involuntary inpatient treatment on 9 August 2016. The referral noted a prior involuntary admission at Concord Hospital in April 2016, following which the deceased worker was placed on a Community Treatment Order (CTO).
The referral stated, stated:
“Paul prior to admission had not been taking his medications. This admission, Tatiana contacted the ACT at Camperdown (who he had been previously referred to after his admission in April) saying Paul was unwell. He was agitated, telling his wife and children to leave the house. Paul was noted to be posting inappropriate messages on Facebook. Paul had also been accessing his mother's credit card, which she had given him for emergency use because he is unemployed. Paul had not been taking his medications, had poor sleep, poor appetite and previously had risk taking behaviours (driving cars fast and engaging in risky sexual behaviour).”
Under the heading, “Current / recent substance use”, it was noted that normally alcohol intake was social and minimal but “drinks heavily when manic / elevated”.
A Clinical Report as to the Mental State of a Detained Person prepared by Dr Kieran Owens for NSW Health on 4 November 2017 recorded that the deceased worker had been brought in by police after trespassing at a neighbour’s apartment. The report concluded,
“Mania, relapse of BPAD, background medication non-compliance, risks include spending, sexual safety, legal risk (trespassing), and increased alcohol use.”
Records from Queensland Mental Health Services, dated 27 February 2018, noted:
“Multiple admissions for manic behaviour characterized by increased spending, heavy alcohol consumption and poor sleep. Deteriorates quickly when noncompliant with medication.”
On 5 April 2018, a note recorded a conversation with the applicant as follows:
“Tatiana reports:
-Paul is having a major manic episode
-Not sleeping
-Over spending
-Grandiose
-Highly sexually aroused, pornography every where, they have 3 small daughter's aged 7,5 and 4
-Self medicating with alcohol, heavily intoxicated every day
-Paul has been completely non compliant with his meds
-Yesterday Paul wanted to jump off the balcony, Tatiana had to lock all the balcony doors”
On the same date, at Gold Coast Hospital, it was recorded:
“He could not give a clear timeline of when he began to suffer the manic symptoms, however had reported that he has had increased EtOH intake for the past 1 months, which he reports is to help bring him down when he is too high. Reports that he has been drinking on average 3 bottles of wine per day. Today he reports drinking x2 bottles of Jim Beam, I note that on presentation to ED his BAL was 0.37.”
The deceased worker was noted to have asked when he could go home, denying the need for admission or medication. It was noted that the deceased worker had previous admissions for his condition in France, Hong Kong, Switzerland, Singapore and New Zealand. The deceased worker also had multiple admissions in Sydney, the last of which was six months earlier. It was noted that the deceased worker had a long history of poor compliance with medications. The medical officer commented:
“Relapse likely in the setting of medication non-compliance. Paul has a long Hx of medication non-compliance, reporting that he does not feel as though he need the medication and stating that all he gets is SEs.”
The applicant was recorded to have reported:
“States that Paul relapsed from non-compliance with his medication - he gets admitted, gets better, stops taking his meds after a couple of weeks of D/c and then starts to relapse.”
A treatment authority was made on 6 April 2018, allowing the deceased worker to be treated without his consent. The deceased worker was discharged on 9 April 2018 but readmitted on 16 April 2018 with a blood alcohol reading of 0.248 at triage.
At an interview on 17 April 2018 it was noted,
“Paul reported that he went out for drinks with his boss and had had a "really long lunch", which ended up in drinking a lot of vodka and being intoxicated. He then recalls waking up in bed by QPS and being brought to hospital. He did not remember making any threats to jump off the balcony.”
The medical officer noted the deceased worker had a history of heavy alcohol consumption when unwell. He was noted to have been experiencing financial issues recently. The applicant reported that she had counted the deceased worker’s tablet strips and he was behind on his medication.
In a letter dated 15 June 2018, it was noted that the deceased worker was relocating to Young, NSW for employment purposes and his care would be transferred to Young Mental Health Service. The letter noted,
“Paul has a long Hx of poor compliance with medications. He is traveling with his next depot injection and scripts. He lives with his wife, 3 children and mother in law. Paul is a non-smoker and has a heavy ETOH intake when unwell.”

A progress note from Murrumbidgee Local Heath District (MLHD) Mental Health Services, dated 13 July 2018, recorded a conversation with the applicant as follows:
“Tatiana reports Paul is at work. Is working at Red Star insurance, works Mon-Friday 8-5:30. She stated that Paul will be unlikely to attend appointments due to work. States he is currently well, stable has been taking medication as prescribed. Tatiana reports when Paul ceases medication he rapidly deteriorates and usually starts to consume alcohol which causes further decompensation. Reports she recognises early warning signs such as not sleeping, increased spending, more alcohol use.”
On 23 July 2018, the deceased worker was admitted to Young Hospital. Triage notes recorded:
“PMHX Bipolar Affective Disorder
Decompensating
Excessive ETOH
Drink Driving
hasnt had meds for 1 /12”
Records from MLHD Mental Health Services during the first half of August 2018 indicate that the deceased worker had been terminated from employment after his boss smelled alcohol on his breath at work.
On 19 November 2018, a progress noted from MLHD Mental Health Services recorded a phone call with the applicant as follows:
“She reported she had kept him home from work today as he had started drinking on the weekend. She reported he was up drinking in the evening and then went to bed in the early hours and slept most of the day. She is concerned that this is exacerbation of depression not mania
Recent stressors included: death of grandmother 4 days ago, but Paul not notified of it, he found out about it via face book. Upset about family's communications with him and he is not in the will. Issues with tatiana's mother last week resulting in the mother leaving the house - an additional stress for Paul. Tatiana advises that up until this weekend Paul had been coping well.”
The deceased worker was discharged from Young Hospital following a further presentation on 11 March 2019. A discharge /transfer summary on that date referred to the bipolar condition having been “sporadically” treated. The deceased worker had recently failed to engage with Mental Health Services. Under the heading, “Substance use”, it was noted:
“Tuesday night- binge with boss in Griffith at work conference”.
The deceased worker was noted to be adhering with his medications and pleasant and cooperative at the time of discharge.
A progress note of a home visit conducted by MLHD Mental Health Services on 7 May 2019 recorded,
“Paul's wife Tatiana at home stated Paul had gone to work. She reports that Paul has been drinking excessively since Saturday. No longer on a probationary period with council and potentially celebrating same,
She stated that he has been intoxicated ++ over the three day period talking about having money in shares in the UK and that he could access 1.8million AUD. Wife describes conversation as grandiose however Paul was very intoxicated at the time.”
On 9 May 2019, a Mental Health Risk Re-assessment was performed and recorded,
“H/V to Paul due to the MH team being alerted to concerns from his wife due to low mood, excessive drinking and at times ?manic behaviour.
Paul denies any manic behaviour - states that he is "coming down from a high" and has now crashed - he needs 24 hours to recover and he will be fine.
Paul did confirmed that he has been drinking excessive ETOH - will hide it in the garden or the bathroom and down a bottle of wine in 5 minutes - He explains that when he is feeling high, the alcohol helps him to process it and reduce his own internal high - self-medicating - education given; however Paul has increased insight and is high functioning to take any advice on board; minimises everything.
Denies drink - driving. However, wife Tatiana refutes his claims - Had argument about it.”
On 5 August 2019, a call was placed to Murrumbidgee AccessLine in which the applicant was recorded to have reported:
“•manic episode end of last week -self medicating with alcohol -missed depot
•not on any medications
•Very aggressive
•staying out of his way -usually can be controlled with medications”
A Mental Health Assessment, dated 9 August 2019, was performed by a Mental Health Practitioner, Angela Spalding, following a home visit on 6 August 2019. The assessment noted,
“Hiding his alcohol consumption
Aggression shown to wife when drinking (Denies he is aggressive when under the influence. ‘My wife doesn't really know if I have been drinking or how much’)
…
Was adamant his wife and his children did not know the extent of his drinking
Selective denial
‘The children think I am tee-total’
‘No one at work would ever know I had had a drink.’
‘When my wife thinks I have had half a bottle I sometimes have had up to 4 - on a real binge I can drink up to 7 bottles - it doesn't seem to affect me.’”
A history of bipolar disorder, sporadically treated, with periods of disengagement from mental health services was noted. With regard to the pattern of his symptoms, the deceased worker was recorded to have stated:
“When asked to describe if he experiences a pattern to his bi-polar symptoms he says it tends to be on a 3- 6 month cycle. He rated his 'Highs’ as 9/10 and experiences his lows at about a 3/10.”
With regard to drug and alcohol use, the deceased worker stated:
“I self-medicate with alcohol
I drink red or white it doesn’t matter anything up to 7 bottles when I am on a binge - this happens every 3 to 6 months when I am ill.
I don't drink socially.”
The assessment concluded:
“His symptoms tend to have a pattern of elevated mood which illicits high risk behaviour and disinhibition. He reports self medicating by binge drinking is his main coping strategy - consuming up to 7 bottles in a session. This he does "secretly’ due to shame and guilt. However his wife reports him being verbally aggressive and moody. Paul reports he is unaware of any specific precipitating triggers - but is aware his use of alcohol is increasing and he is not as resilient to get over binging periods.”
On 22 February 2020, the deceased worker was taken to Young District Hospital by ambulance after being off work for three weeks due to his bipolar condition. The deceased worker had not slept in three days, appeared paranoid and intoxicated. A mental health assessment note recorded:
“Tatiana reports that Paul was doing well up until 3 weeks ago when the investigation started
Worried that Paul is going to loose his job
Being acused for Intoxicated on ETOH during work hours in September 2019
Tattiana reports that Paul has not had much ETOH recently
A glass of wine occasionally
Tattiana stated that they denies any of the accusation to the council on Thursday.”
The deceased worker was transferred to Wagga Wagga Base Hospital as an involuntary patient.
The deceased worker was admitted to Young District Hospital on 14 October 2020. The triage notes on this occasion recorded:
“BIBA, from home, Hx bipolar disorder, AF, HTN, ETOH abuse.
known to mH team in Young
ongoing challenges with ETOH
wife called ANSW, has alledged to have drank a bottle of wine and unable to account for 30 5mg valium tablets in the last 24hours, new to the house yesterday.”
The deceased worker discharged himself against advice before being brought back in by police later that day, after expressing homicidal thoughts directed towards the applicant.
The deceased worker was brought to Young Hospital by ambulance and police again on 21 October 2020 after expressing suicidal thoughts to a mental health worker. The deceased worker was scheduled under the Mental Health Act 2007 as he wanted to self-discharge against medical advice.
A MLHD Mental Health Services progress note made on 19 November 2020 recorded that the deceased worker was contacted by phone and was bright and reactive. He stated he was doing “really well” and no issues were raised.
A progress note on 1 December 2020 recorded that the police had made contact in relation to an AVO. The note recorded,
“Police informed Paul is not under a CTO and not voluntary engaging with CMHT but did attend GP appt for medication. Plan to discharge to GP once one more MSE completed (if stable).”
A progress note dated 10 December 2020 recorded that multiple attempts to contact the deceased worker had been made without success. A SMS was sent enquiring after his welfare and reminding him he was due for a depot injection on 18 December 2020. The deceased worker responded,
“Hi. I'm really well thank you. And thank you for the reminder.”
A progress note dated 24 December 2020 recorded that the deceased worker had not come in for his depot injection and did not have an appointment in the future.
A progress note dated 4 January 2021 recorded a home visit in which the applicant reported that the deceased worker appeared low in mood. The deceased worker reported, however, that “his mood was 10 out of 10 feeling great”. The deceased worker was unhappy with the unannounced home visit. The note stated:
“Tatiana said that he was becoming a bit depressed
I asked what symptoms was she observing.
She stated that he was sleeping more and was looking a bit low
I asked if this was early warning signs for him
She stated that she wasn't sure
I told her that he is 2 weeks behind in getting his medication
Tatiana appeared surprised and said ‘then yes I believe that it is’.”
A progress note dated 6 January 2021 recorded that the deceased worker had not received his depot on 6 January 2021 and was now 19 days overdue.
In a progress note dated 7 January 2021 a social worker recorded:
“Reports that his mood has been good over the Christmas period
Feels that he is doing well
Nil risk identified at time of call.”
Progress notes recorded that depot injections were missed on 18, 20 and 27 January 2021 at which point it was now 40 days overdue.
The deceased worker was discharged from MLDH Mental Health Services at Young on
4 February 2021. The discharge summary noted that the deceased worker had relocated to Gunnedah and stated:
“Thank you for reviewing Paul Jones a 45 Year old Male to be discharged on 04/02/2021 from YO MH Adult at MLHD Mental Health Services. Paul Jones presented to this facility with bipolar affective disorder following an admission to Wagga Wagga MHU due to a relapse in his mental health from non-compliance of medication and increased alcohol intake.
Summary of Care
Paul's engagement has been poor with community mental health services. Paul has been offered a number of psychiatric reviews with Dr Hong and has failed to attend these.
Paul and his wife have reported nil issues when a home visit occurred prior to Christmas. Discharge has been discussed with Dr Hong who has agreed to discharge.”
A discharge referral from Tamworth Hospital regarding an admission on 23 March 2021, indicated that the deceased worker was brought into Gunnedah District Hospital by ambulance with his wife who was concerned for his mental health. The deceased worker was noted to have a history of bipolar disorder which had not been medicated for three to four months. The deceased worker was noted to have been self-medicating with alcohol recently and have told his wife that he wanted to take his life. The applicant was noted to be concerned about hypomanic symptoms including risky alcohol consumption.
The record noted that the deceased worker had become aggressive and left before treatment was completed. The deceased worker had subsequently drunk a quantity of bleach and vomited and had been brought into Gunnedah Hospital by ambulance again. The deceased worker was transferred to Tamworth Hospital where he was admitted as a scheduled patient for further observation. The deceased worker was noted to have previously been on 400 mg of Abilify monthly.
The discharge referral noted:
“Paul unsure of how he was admitted to hospital, minimising events and stating that work colleagues pressuring him to consume large amounts of etoh at work conference -Ambivalent about intervention for alcohol consumption, but amenable to be liaised with drug and alcohol services on discharge -Denying thoughts of SH/SI/HI, paranoid or grandiose delusions -Given stat thiamine.”
A clinical note made by general practitioner Dr Ahmad Jawed Poya following a telephone consultation on 6 May 2021 records that the deceased worker was given a medical certificate valid until 14 May 2021, after reporting feeling down and tired for the last few days. The deceased worker said he had bipolar and was on medication but could not get in to see his usual general practitioner that day.
On 19 May 2021 Dr Poya recorded:
“states that yesterday his psychiartist changed his bipolar med< not sure of the dose his wife confirmed the change, states he has been a bit moody and poor concentration «drinks heavily alcohol< i expressed my concern wife states that psychiatrist told him that drinking is fine with his med I advised him to see a GP face to face and I do not feel comfortable to look after his health and will not see him again < drinking with med and living in Gunddeh not able to come face to face”
A further medical certificate was issued indicating that the deceased worker was unfit for employment until 26 May 2021.

Statement of police

Senior Constable Sally Wenborne of Gunnedah Police Station prepared a statement on
14 September 2021 in respect of the death.
The statement referred to the deceased worker’s attendance at the Regions Rising National Summit in Canberra on 17 and 18 March 2021 with BSO. The statement noted,
“According to his wife, whilst in Canberra; the Deceased was exposed to a large amount of binge drinking with all his drinks fully paid for, or at least subsidised by his work, and that upon returning home, he continued to drink heavily.”
Further,
“Concerned that the binge drinking may trigger a manic episode in the Deceased, Tatiana phoned the Mental Health Access line to alert them of the Deceased's heavy drinking and to seek advice from them about how best to help him.
After he returned home, Tatiana read several messages on the Deceased's phone, one sent by BSO which read, ‘Pint time mate, wake up' and another which read, “Make it back to your room?’ The most concerning message however was a text Paul received prior to catching the plane home, which read, "Best sort yourself out before we fly, they won't let you on the plane". Tatiana later spoke with BSO about this message to which he explained that the Deceased had consumed the entire contents of the hotel mini bar and payment for the consumption had been made using the corporate credit card. Tatiana believed that because he did not pay for the alcohol himself, there was little accountability on the part of the Deceased for his excessive drinking.”
The statement listed the deceased worker’s past interactions with NSW Police including events in October 2011, January 2012, July 2016, May 2017, July 2017, February 2020, October 2020, March 2021 and May 2021 where the deceased worker appeared to be intoxicated and/or affected by mental illness, including several occasions on which the deceased worker was managed under the Mental Health Act 2007.
A Provisional Apprehended Domestic Violence Order was applied for and served on the deceased worker on 14 October 2020. The final order was enforced by Young Local Court on 18 December 2020 current until 30 November 2022, and included an additional condition, stipulating that the deceased worker was not to be in the company of the applicant or his children within twelve hours of consuming alcohol/ and or illicit drugs.
Regarding the circumstances surrounding the death, the statement concluded:
“From witness accounts I am satisfied that the Deceased has returned home intoxicated and then consumed the normal amount of medication causing an adverse reaction within his body which has then led to his death. Despite the statements obtained from Tatiana and the information provided to me on the night by Paramedic Hayley HAUSFIELD I am not satisfied however that I am able to state whether the Deceased intentionally ended his life by overdosing on a combination of alcohol and his prescribed medication.”

Autopsy report

An autopsy report was prepared for the Coroner on 9 June 2021 by Dr Leah Clifton. The direct cause of death was identified as:
“The combined effects of acute alcohol intoxication and mixed drug effect (quetiapine and benzodiazepines).”
Bipolar mood disorder was listed as a significant condition contributing to the death.
According to the report, on the day of his death the deceased worker reportedly returned home heavily intoxicated. The applicant contacted the local mental health team asking for advice on whether or not to administer his usual medication given the level of intoxication. The applicant was advised to continue with the normal course of daily medication.
The deceased worker’s blood alcohol level (0.278g/100ml) was considered significant, even in a regular alcohol drinker and equivalent to more than five times the legal driving limit. The report stated:
“It is well known that alcohol and benzodiazepines have a synergistic effect in combination, and it is reasonable to expect a clinical effect of significant drowsiness, respiratory and central nervous system depression, coma and ultimately death.
The quetiapine level is considered slightly higher than therapeutic in a living person but not necessarily a 'toxic' level allowing for post mortem redistribution. The presence of quetiapine could have further worsened the clinical central nervous system depression and in addition, quetiapine is associated with QT prolongation and has the potential to produce a fatal cardiac arrhythmia.”

Dr Canaris

The applicant relies on medicolegal reports prepared by consultant psychiatrist,
Dr Christopher Canaris, dated 19 September 2022 and 6 March 2023.
In his first report, Dr Canaris took a comprehensive history from the applicant’s statement evidence, the respondent’s witness evidence, treating medical evidence and the Coroner’s report.
Dr Canaris described the injury and pre-existing medical condition as follows:
“Mr Jones had a long-standing bipolar disorder and comorbid alcohol use disorder which appears historically to have been a consequence of manic and hypomanic episodes as it seems to have been predominantly restricted to periods when his bipolar disorder was poorly controlled. The history on offer suggests a major aggravation of a pre-existing condition beginning at the time of the Regions Rising Conference.”
Dr Canaris said the deceased worker was reasonably well and had not had any mental health presentations since October 2020 at the time he commenced employment with the respondent. Alcohol seemed to have no longer been an issue and the condition appeared to be in remission. Dr Canaris did note:
“However, he was more vulnerable to relapse at the time because he had stopped taking psychotropic medication, hence his condition was unlikely to be stable.”
Asked whether the deceased worker’s employment was a substantial or the main contributing factor to an injury arising out of or in the course of employment, Dr Canaris responded:
“His attendance at a conference with the reportedly hard drinking colleague was a substantial contributor to his injury.
I also note that Ms Jones statement suggests a culture of drinking in the workplace at the Council. This would have made it much harder for Mr Jones to rein in his drinking.
I also note exposure to other stresses as detailed in Ms Jones’s statement.
At the same time, he was at risk at the time in question because he was not on any medication. That said, the level of drinking during and after the Regions Rising Conference (see also my comments in [4] below) would have placed him at significant risk of a relapse of mood disorder even if he had been medicated. It is worth noting in this context that at the time of his death he appears to have started back on medication and the Coroner’s report cites evidence of quetiapine (a mood stabiliser), lithium (a mood stabiliser), and benzodiazepines (sedative-hypnotic drugs). However, his bipolar disorder would have been much harder to manage at this point because of his drinking while the presence of a destabilised bipolar disorder would have made it much harder to deal with his drinking.”

Asked whether the injury consisted of an aggravation, acceleration exacerbation or deterioration of a disease, Dr Canaris commented:
“Mr Jones had an established bipolar disorder with comorbid alcohol use disorder which had been quiescent for the preceding five or six months. This was very much aggravated by his exposure to very heavy drinking on the part of his colleague in that he himself started drinking heavily. I note in this context however that his alcohol use disorder seems to have been considerably more severe than it had been in the past. In so saying, I note his blood alcohol level was 0.278 g/100 ml or 0.278%. Bearing in mind the legal limit for driving is 0.05% and at levels between 0.3 to 0.4% are extremely hazardous and potentially fatal, he must have had considerable tolerance to be able to attain such a blood alcohol level. A non-tolerant individual would be physically unable to attain such a level. It was my impression that his drinking on this occasion was considerably more problematic than it had been in the past. For example, his blood alcohol level during his admission on 17 April 2018 was 0.156% which while certainly excessive is considerably more modest. Consequently, the severity of aggravation seems to be mainly a result of his alcohol exposure at the conference and in his workplace combined with exposure to a range of other workplace stresses.”
Dr Canaris was asked to comment upon the first respondent’s view that the deceased worker’s bipolar disorder in the months prior to his death was a manifestation of a long-term disorder and typical of what had occurred periodically throughout his adult life. Dr Canaris responded:
“Mr Jones is likely to have had further episodes of mood elevation and depression over the course of his life which might have been associated with alcohol excess. Bipolar disorder especially if untreated or inadequately treated is an inherently recurring illness. However, as noted in (3) and (4) above, Mr Jones’s alcohol consumption in association with the recurrence of his bipolar illness on this occasion seems to have been considerably more severe and hence much more hazardous than in the past. Its greater severity is arguably different from prior episodes.”
Dr Canaris expressed the view that the deceased worker’s injury did not arise predominantly from the respondent’s actions with respect to discipline and dismissal.
With regard to whether the death was caused by intentional self-inflicted injury, Dr Canaris expressed the view:
“Simply put, alcohol ingestion in an individual with an alcohol use disorder very rapidly loses any voluntary character once that person has a drink. The concurrent presence of a bipolar disorder further undermines the voluntary character of any drinking.
His ingestion of medication was voluntary, but it would appear undertaken in response to specific advice from the mental health team to take his tablets. Given what happened, this advice provided over the telephone in relation to a patient who had not ng. been seen for some considerable time is most concerning.”
In the report dated 6 March 2023, Dr Canaris was asked to comment on an opinion given by the respondent’s medicolegal expert, Dr Samson Roberts, commenting on the clinical records of Tamworth Base Hospital dated 24 March 2021:
“Overall, however, the admission documentation does not support the notion that Mr Jones’ had decompensated in relation to his bipolar illness. He appears to have been intoxicated rather than manic or depressed. Mrs Jones states that her husband’s mental illness had been in good remission. Periods of remission sometimes of months or longer duration can certainly happen in unmedicated bipolar patients. However, they are undoubtedly at significantly increased risk of relapse at those times if they remain unmedicated.”
Further,
“Dr Roberts writes that Mr Jones needed no encouragement in the past to drink saying that manic behaviour is by definition uninfluenced by consequences. While this may well be true of a patient in the full-blown manic episode, it is certainly not the case in patients going through milder episodes of mood elevation. Such patients may have less regard for consequences or need firmer limits. However, complete absence of conscience driven behaviour is not characteristic of mild manic or if you prefer hypomanic states. Such patients are certainly at risk when placed in an environment in which they are egged on as appears to have been the case at the Regions Rising conference.
Assuming that Mr Jones’s companion at the conference was in fact a very heavy drinker as asserted by Mrs Jones, the conference would have placed him at increased risk. An added factor apart from Mr Jones’ workmate’s drinking pattern would have included the reduced structure of a conference and quite possibly a culture of “letting down your hair”. The combination of these factors if in fact in play would have been highly detrimental.”
In response to Dr Roberts’ view that the events which occurred subsequent to the deceased worker’s cessation of work reflected the long-standing pattern of his mental health,
Dr Canaris stated:
“Clearly, Mr Jones’ bipolar disorder may well have relapsed and he may well have resumed drinking even if he had never attended the Regions Rising conference. However, given the circumstances at the time, he was placed in a high-risk situation culminating in a relapse of his condition and his eventual tragic death presumably attributable to the toxic combination of alcohol and medication. His resumption of very heavy drinking would not only have contributed to the relapse of his bipolar condition but also would have made the management condition much more challenging.”

Dr Roberts

The respondent relies on medicolegal reports prepared by general and forensic psychiatrist, Dr Samson Roberts, dated 24 June 2022 and 2 April 2023.
In his first report, Dr Roberts recorded a detailed summary of the lay and medical evidence before the Commission. Dr Roberts considered that the clinical material reflected a diagnosis of bipolar I disorder characterised by prominent manic episodes and an alcohol use disorder.
Dr Roberts said it was evident that assertive efforts were made to treat the bipolar disorder in the past, commenting,
“The prescription of an injectable antipsychotic in the treatment of Bipolar Disorder would not usually be required in a person who is compliant with treatment. Had Mr Jones maintained abstinence from alcohol and compliance with oral medication, a mood stabiliser such as lithium in addition to a modest dose of oral antipsychotic would likely have been sufficient to maintain his condition in a state of relative if not complete remission.”
Dr Roberts commented further,
“An objective impression of the pattern of Mr Jones’ illness supports the impression that Mr Jones’ admissions were typically too short to produce confidence in the stability of his condition. Within weeks of his discharge from involuntary treatment, he would become non-compliant with medication and resume alcohol consumption in the context of emerging manic symptoms. This would inevitably lead to re-admission to hospital, often with police involvement and coercive treatment under the Mental Health Act.
The longitudinal pattern of Mr Jones’ Bipolar I Disorder and his Alcohol Use Disorder, taken in conjunction with the description of his behaviour whilst away from the scrutiny of his wife during the work function of [May] 2021, indicates that he was more likely than not already suffering features of mania in the context of non-compliance with treatment. It is probable that he had already relapsed to alcohol use. Irrespective of whether this was the case, it is apparent, having regard for Mr Jones’ history, that his heavy alcohol consumption did not require encouragement or support of others. There is information to indicate that Mrs Jones’ allegations regarding the funding of his alcohol consumption are spurious. Irrespective, manic behaviour is, by definition, uninfluenced by consideration of consequences and the assertion that Mr Jones’ drinking would have been moderated if he had been held accountable by his employer is inconsistent with both of his diagnoses.”
With regard to the events that followed the conference, Dr Roberts commented,
“The events that occurred subsequent to Mr Jones’ cessation of work reflect the longstanding pattern of his mental health. There was no apparent change in the instability of Mr Jones’ condition. There is a well documented association between untreated Bipolar I Disorder, Substance Use Disorder and an increased risk of premature death and there is no basis upon which to ascribe Mr Jones’ death to events that arose at work. Namely, an objective assessment of the documents has not demonstrated any objective change in the natural course of Mr Jones’ psychiatric diagnoses due to events in his work environment.”
Dr Roberts was asked for an opinion as to whether the deceased worker’s pre-existing condition was aggravated in the course of employment, and if so, whether employment was the main contributing factor to the aggravation. Dr Roberts responded:
“…there was no change in the natural course of the psychiatric diagnoses consequent upon factors in Mr Jones’ employment.”
With regard to whether the death resulted from a work-related injury. Dr Roberts opined,
“It is not apparent that Mr Jones’ death on 3 June 2021 was in any way related to circumstances of his employment. His history indicates previous ingestions of alcohol and benzodiazepines and prior levels of intoxication that could have led to his death. He has previously ingested poison and there is information to indicate prior driving conduct of a reckless nature. It is unknown whether his death was the result of a suicide or the inadvertent outcome of excessive ingestion of a combination of substances.”
In his supplementary report, Dr Roberts was asked to review, amongst other things, the applicant’s statement of 10 October 2022 and the report of Dr Canaris dated
19 September 2022.
Dr Roberts observed that the documentation available at the time of his first report disclosed 20 psychiatric hospitalisations between 2010 and 2020 with significantly more occasions between 2015 and 2020 than during the earlier period of his illness. Dr Roberts speculated that this may have been a reflection of better compliance with treatment during the earlier period of his illness or a deterioration of the condition over time.
Dr Roberts considered that the applicant’s account of the deceased worker’s functioning was inconsistent with the objective evidence before him. In particular, it was noted that the deceased worker was unemployed from 2015 until his admission to Prince of Wales Hospital in mid-2016. Specific details of his employment between 2016 and 2021 had not been provided. The impression given by the evidence was that the deceased worker was, at best, only intermittently employed in this period.
With regard to the applicant’s observation that the deceased worker’s episodes of mania would be triggered by something specific such as a stressful event, Dr Roberts commented,
“Whilst psychiatric instability in Bipolar Disorder may at times be precipitated by a stressor, this is not invariably the case in Bipolar Disorder which, by its nature, represents a condition characterised by unpredictable relapse and remission manifesting with periods of mania and periods of depression.”
Dr Roberts maintained his opinion that the deceased worker was already developing mania in the context of non-compliance with treatment and had probably already relapsed to alcohol use prior to his attendance at the conference:
“…it remains my opinion, supported by Ms Jones’ statement and Dr Canaris opinion, that it is probable that Mr Jones had already suffered a relapse in the period leading up to the Regions Rising Conference. In the context of his Bipolar relapse he exhibited his characteristic pattern of relapse to excess alcohol consumption.”
Dr Roberts gave the opinion that non-compliance with treatment would be accepted by the overwhelming body of psychiatric opinion to represent the most reliable predictor of relapse. Further,
“…if Mr Jones had been compliant with treatment, it is unlikely that he would have developed mania and therefore it is unlikely that he would have engaged in excessive alcohol consumption. Indeed, his wife expressed the opinion that when psychiatrically well he “was a responsible, social drinker.”
Dr Roberts concluded,
“As stated above, the most reliable predictor of relapse is non-compliance, a consistent feature in Mr Jones. According to his wife and supporting the understanding derived from contemporaneous clinical documentation, excess alcohol consumption historically reflects a response to episodes of mania and not a cause of episodes of mania. To assert that it was the heavy drinking at the Regions Risings Conference that caused Mr Jones’ psychiatric decline is contrary to the clinical evidence and contrary to Ms Jones’ description of his historical pattern of illness. The cause of Mr Jones’ psychiatric deterioration was non-compliance with treatment on a background of deteriorating Bipolar I Disorder.”
Dr Roberts commented that the applicant’s opinion that on the occasion of the Canberra conference alcohol excess caused the deceased worker’s mania was contrary to every other episode in which a manic event caused relapse to heavy alcohol use.

Oral submissions

The parties each made oral submissions at the conciliation conference and arbitration hearing on 15 December 2023. Those submissions were recorded and are not recited in full here, although they have been taken into account in their entirety.

Applicant

The applicant noted that the liability disputes had been narrowed to whether the events at the Canberra conference were work related and whether there was, in a causative sense, an aggravation of the deceased worker’s pre-existing condition as a result of that event. The applicant noted that there were other stressful events in the workplace after the Canberra conference. The evidence in relation to those events was all one way and now the s 11A(1) defence had been withdrawn, the first respondent could not succeed. The applicant referred the Commission to the authority in State Government Insurance Commission v Oakley[1] in that regard.
[1] (1990) 10 MVR 570.
The applicant acknowledged that the deceased worker had an underlying condition. Although he was not taking his medication around the time of the conference in Canberra, he was managing the condition well. The deceased worker was then placed in a situation where he was drinking with his boss, which triggered an aggravation of his bipolar disorder and ultimately his death.
The applicant submitted that she was in the best position to give evidence as to the relevant events and referred the Commission to her written statements. In particular, it was noted that the deceased worker’s bipolar disorder was characterised by manic episodes, triggered by something specific from which he would “bounce back”.
The applicant submitted that the historical treating evidence demonstrated that there were specific triggering events that happened to cause exacerbations which would last a few weeks before the deceased worker returned to normal, sometimes with medical intervention.
The applicant referred to the entries in the clinical material in late 2020 and early 2021 and submitted that the evidence demonstrated that the deceased worker had recovered from a prior episode and was not experiencing any mania at the time he commenced employment with the first respondent. The applicant’s evidence was that the deceased worker had been discharged from mental health care services in Young as he no longer required intervention. He was in good physical and mental health when he commenced employment with the first respondent. A drug and alcohol test had been passed prior to the commencement of employment.
The applicant’s evidence that the deceased worker was doing well before the Canberra conference was corroborated by the first respondent’s witness evidence. Objectively, the deceased worker had been well enough to secure new employment and relocate his family. No concerns regarding the deceased worker’s behaviour were raised by his employer prior to the Canberra conference.
It was uncontroversial that the deceased worker’s health deteriorated commencing with the Canberra trip. BSO’ statement evidence and his text messages to the deceased worker confirmed that consuming alcohol was a big part of the trip. The applicant called the mental health access line during the trip due to her concerns about the deceased worker. There was no evidence of this service being accessed prior to the trip.
Upon his return from Canberra, there was a complete change in the deceased worker’s presentation. The discharge referral from his admission to Tamworth Hospital recorded that he had been self-medicating with alcohol recently and was seen for alcohol induced mental health concerns. The applicant told hospital staff that he felt pressured to drink by his work colleagues.
Subsequently, concerns were raised regarding the deceased worker’s behaviour in the workplace. The treating evidence referred to the deceased worker feeling down and tired and, although the clinical notes were not detailed, it could be inferred that this was due to the stressful events at work, given the evidence of investigations and the prospect of disciplinary action, leading to the cessation of employment.
The applicant submitted that the absence of more detailed clinical reports during the period between the Canberra conference and the deceased worker’s death was not surprising given the longevity of the deceased worker’s pre-existing condition. The first respondent’s witnesses recorded their own observations of a deterioration in the deceased worker’s condition.
The applicant referred to Dr Canaris’ opinion that there had been an aggravation of the deceased worker’s pre-existing condition. Dr Canaris noted the significance of the exposure to a toxic drinking culture both at the Canberra conference and later in the workplace.
Dr Canaris did not consider the injury arose predominantly from any disciplinary action.
The applicant submitted that drinking was incidental to and encouraged by the employer during the conference as a form of bonding. BMP confirmed that meals and drinks with meals were paid for by the first respondent. It could not be suggested that the deceased worker was out of the course of employment during the dinner on the first night. The meal was paid for by the employer and he was there with his manager. The injury commenced with that dinner.
The Tamworth Hospital records following the deceased worker’s return from the conference indicated that he perceived a pressure to drink. Whether that perception was accurate was not relevant. The deceased worker was a new employee on a work trip with his manager.
BSO’ own evidence was that he drank excessively on the first night.
There was no disciplinary action taken in respect of the excessive drinking when the deceased worker and BSO returned from the conference. There appeared to be a heroic element and a camaraderie to the excessive drinking. There was a social drinking club in the workplace and alcoholic gifts exchanged, indicating a workplace culture in which drinking was encouraged. It could not be suggested that the drinking on the first night of the conference was outside the course of employment.
The only evidence contrary to the applicant’s claim that employment aggravated the deceased worker’s condition was the opinions of Dr Roberts. Dr Roberts’ opinions were addressed by Dr Canaris and based on unfounded speculation that the applicant would not have been aware of the full extent of the deceased worker’s indiscretions and that the deceased worker would have been consuming alcohol to a greater extent than was known by the applicant. Rather, the evidence suggested that the applicant was quite attuned to the deceased worker’s condition.

Justice Kitto also considered what constituted an exacerbation of a disease in that case, stating:
“There is an exacerbation of a disease where the experience of the disease by the patient is increased or intensified by an increase or intensifying of symptoms. The word is directed to the individual and the effect of the disease upon him rather than being concerned with the underlying mechanism.”
Similarly, Windeyer J said,
“[t]he question that each [aggravation; acceleration; exacerbation; deterioration] poses is, it seems to me, whether the disease has been made worse in the sense of more grave, more grievous or more serious in its effects upon the patient.”
Applying Semlitch, Burke CCJ in Cant v Catholic Schools Office;[8] said:
“The thrust of these comments is that irrespective of whether the pathology has been accelerated there is a relevant aggravation or exacerbation of the disease if the symptoms and restrictions emanating from it have increased and become more serious to the injured worker.”
[8] [2000] NSWCC 37.
Where there has been a relevant aggravation of a disease in the course of employment, it is also necessary to establish that employment was the main contributing factor to the aggravation. In AV v AW,[9] Snell DP at [65]-[78] discussed the authorities on the ‘main contributing factor’ test in s 4(b)(ii) and noted:
“It follows that the test of ‘main contributing factor’ involves consideration of whether there were competing causal factors (both work and non-work related) of the aggravation, and whether on a consideration of relevant causal factors the employment represented the main contributing factor.
The following may be taken from the above:
(a) The test of ‘main contributing factor’ in s 4(b)(ii) is more stringent than that in s 4(b)(ii) in its previous form, which applied in conjunction with the test in s 9A. There will be one ‘main contributing factor’ to an alleged aggravation injury.
(b) The test of ‘main contributing factor’ is one of causation. It involves consideration of the evidence overall, it is not purely a medical question. It involves an evaluative process, considering the causal factors to the aggravation, both work and non-work related. Medical evidence to address the ultimate question of whether the test of ‘main contributing factor’ is satisfied is both relevant and desirable. Its absence is not necessarily fatal, as satisfaction of the test is to be considered on the whole of the evidence.”
[9] [2020] NSWWCCPD 9.
More recently in the decision of BGV v Waverley Council[10] (11 January 2024), Snell DP confirmed that it is the worker who carries the onus of proving an injury within the meaning of s 4(b)(ii):
“It is relatively common, in cases involving psychological injury, to find a mixture of causative factors, both work-related and not. If the appellant were correct on this point, then the burden of proving ‘main contributing factor’ in such circumstances would effectively be borne by the employer. The employer would carry the onus of “disentangling” the work-related component of the injury as a cause. I do not accept that s 4(b)(ii) should be read in this way. I accept the respondent’s submission that the appellant carried the onus of proving ‘injury’ within the meaning of the subsection: “he who asserts must prove.”
[10] [2024] NSWPICPD 2.
It is uncontroversial that the deceased worker in this case had a pre-existing ‘disease’ in the nature of bipolar affective disorder and co-morbid alcohol use disorder. The deceased worker’s conditions are well documented in the clinical material before the Commission. The conditions waxed and waned and, as noted by Dr Reveley, the bipolar condition was characterised by intermittent periods of elation, or mania, as well as intermittent periods of depression in mood.
It is also uncontroversial that the deceased worker experienced a period of intense symptoms commencing from the time of the Regions Rising conference in Canberra, which persisted until the time of his death.
Given the inherently fluctuating nature of the deceased worker’s pre-existing conditions, there is some question as to whether this period or episode is appropriately characterised as an aggravation, acceleration, exacerbation or deterioration for the purposes of s 4(b)(ii) of the 1987 Act. Dr Roberts’ has, for example, observed that there was no objective change in the natural course of the deceased worker psychiatric diagnoses.
The authorities cited above, however, establish that an aggravation or exacerbation occurs for the purposes of s 4(b)(ii) of the 1987 Act where there is an increase or intensifying of symptoms and their impact upon the worker. This was clearly the case with the episode commencing in Canberra, whether or not that episode was more severe than previous episodes.
I note in this regard that both Dr Canaris and the applicant have expressed the view that the deceased worker’s final episode was more severe than previous episodes. I am not, however, persuaded that the intensity of symptoms, including the extent of the co-morbid alcohol misuse was more severe. During previous documented episodes, the deceased worker was noted to have had higher blood alcohol levels than at the time of his autopsy and also to have engaged in some significantly more risky and problematic behaviour. I would, however, be prepared to accept that the duration of the episode may have been longer than those experienced previously.
In any event, it is not necessary to determine whether the relevant episode was distinguishable from those that preceded it. I accept that that there was an aggravation or exacerbation of the deceased worker’s diagnosed conditions which coincided with his attendance at the Canberra conference.
The next question is whether that aggravation occurred “in the course of employment”.
There was no real challenge to the proposition that the relevant events in Canberra occurred “in the course of employment” in the first respondent’s submissions.
I accept that the deceased worker travelled to the Canberra and attended the conference as part of his work duties. Applying the authorities in cases such as Hatzimanolis v ANI Corporation Ltd[11] and McGrath, and in the absence of submissions to the contrary by the first respondent, I would also be prepared to accept that the dinners and the stay at the hotel which are described in BSO’ evidence were either incidental to the conference or occurred during an interlude within an overall work period.
[11] [1992] HCA 21.
Although there is a suggestion in Dr Roberts’ reports that the deceased worker may have been symptomatic before the conference, there is little doubt in my mind that an intensification of symptoms or “aggravation” of the deceased worker’s pre-existing conditions commenced, temporally with the Canberra conference.
The real issue on which this case turns is whether employment was “the main contributing factor” to the aggravation.
A number of potential contributing factors to the aggravation are identified on the evidence. These include the fact that the deceased worker had not been taking his medication for a period of more than three months at the time of the conference. The submissions made by the applicant, second, third, fourth and fifth respondents also identified the following employment related factors:
(a)    a general culture in the workplace in which drinking alcohol was encouraged or viewed favourably;
(b)    the funding of meals and alcoholic drinks by the employer and BSO;
(c)    direct pressure from BSO to drink alcohol, including the “pint time” message;
(d)    indirect pressure to drink alcohol arising from BSO’ own heavy drinking and the power imbalance between the deceased worker and BSO, his recent employment, the fact that he remained within his probation period and the lack of job security arising from his fixed term contract, and
(e)    the reduced structure of the conference environment.
Dr Roberts’ evidence also raises the proposition that the aggravation was idiopathic.
I am not satisfied that each of the above “employment-related” factors identified by the applicant is made out on the evidence.
The assertion by the applicant that the first respondent’s workplace was characterised by a toxic culture in which drinking was encouraged and excessive drinking viewed as heroic is contradicted by the respondent’s witness evidence. While I do accept that there was a social club and a fridge containing beers in the workplace, the weight of evidence does not indicate, that there was any overt encouragement or inducement to participate in the consumption of alcohol by the employer, or that consumption of alcohol in the workplace was a more widespread occurrence.
I note that the applicant was not herself an employee of the first respondent. Her perception of the workplace culture was likely to have been through the lens of her husband’s particular experience. The applicant’s perception also appears to have been informed by an understanding that BSO drank to excess on a work trip to China leading to him having his stomach pumped, had a reputation for heavy drinking and was placed on a performance improvement plan as a result. Each of these allegations is refuted by BSO and the first respondent’s other witnesses denied any knowledge of such matters. The applicant does not identify the source of her information. In all the circumstances, I am not satisfied that her evidence as to these matters is reliable.
Submissions were made by the applicant suggesting that the first respondent’s failure to take disciplinary action against the deceased worker and BSO for their conduct at the conference was further evidence of a toxic drinking culture. Ms Resch has explained that her approach to the matter was influenced by her view that BSO and the deceased worker were outside the workplace and in social settings at the time of the behaviour in question.
Ms Resch also gave evidence that the concerns raised by BSO behaviour were of a general nature at the time. Ms Resch encouraged BSO to monitor the situation. The deceased worker was required to repay the mini bar bill, although the debt was not pursued after his death.
Weighing the evidence, I am not satisfied that the first respondent’s workplace did have a culture wherein drinking alcohol was encouraged or viewed favourably, although I do accept that the consumption of alcohol did occur.
In considering the extent to which this circumstance contributed to the aggravation, it is relevant to note that there is no suggestion that being exposed to the consumption of alcohol in the workplace, whether in the context of the social club or otherwise, had contributed to an increase in the deceased worker’s symptoms at any time prior to the conference.
The applicant’s evidence, including the reports of Dr Canaris and Snr Const Wenborne suggested that the deceased worker’s drinks during the conference were fully funded, or at least subsidised, by the employer. This assertion is contradicted by the first respondent’s witness evidence.
That evidence indicates that although the employer funded meals and a drink with dinner during the conference, it made clear that it would not fund the hotel mini bar. Although
BSO’ corporate credit card was eventually charged for the deceased worker’s mini bar, as it had been used for a bond, a debt was raised against the deceased worker for that expense. The remainder of the drinks consumed by the deceased worker during the conference were paid for by the deceased worker and BSO in their personal capacities. BSO’ evidence was that they paid for drinks in alternating shouts, apart from an occasion when the deceased worker claimed he had forgotten his credit card and the bar did not take cash.
In light of the first respondent’s witness evidence, I do not accept that the deceased worker’s drinks were fully funded by the employer. I do, however, accept that some of his drinks were paid for by either by the employer or BSO.
The applicant’s claim that BSO encouraged or explicitly pressured the deceased worker to drink heavily during the conference is also not borne out on the evidence before me.
BSO’ evidence was that the deceased worker set the pace with the drinking and he struggled to keep up. BSO gave evidence that the deceased worker approached him to go drinking one afternoon while he was still working. BSO had declined the invitation and his “pint time” message was sent later once he finished work as a response to the deceased worker’s invitation. BSO stated that he actively encouraged the deceased worker to go back to the hotel and go to bed. BSO’ evidence and the circumstance of the mini bar having been “cleaned out” suggest that the deceased worker continued drinking even when not in BSO’ company.
In weighing the competing evidence from the applicant and BSO, I note that only
BSO was present during the conference. The applicant’s evidence must be based on the account given to her by the deceased worker, assumptions drawn from information such as the text messages on the deceased worker’s phone, or the applicant’s understanding of BSO’ prior drinking history. As indicated above, I am not satisfied that those assumptions were accurate.
I have also given weight to the evidence contained in the Tamworth Hospital records that the deceased worker reported that his work colleagues were “pressuring him” to consume large amounts of alcohol during the conference. By that stage, however, the deceased worker was in the throes of his relapse and apparently intoxicated. While I have given it significant weight, I am not satisfied, in all the circumstances, that the deceased worker’s recorded account is to be preferred to that of BSO.
Weighing the evidence, I am not satisfied that there was any direct or explicit pressure on the deceased worker to consume large quantities of alcohol from BSO.
I am, however, satisfied that BSO did himself consume a very significant quantity of alcohol during the conference, particularly during the dinner on the first night. I also accept that BSO was the deceased worker’s superior. I accept that the deceased worker had only recently commenced employment with the respondent, remained within his probation period and lacked job security due to his fixed term contract. I accept that each of these circumstances may have provided some indirect inducement or encouragement to drink.
Similarly, I accept that the the reduced structure of the conference environment, and being away from his family and usual routines, may have provided the deceased worker with a greater opportunity to drink than would otherwise be the case.
The clinical evidence does not, however, indicate that the deceased worker had any problem managing his alcohol intake when he was well. The applicant has consistently indicated that the deceased worker did not drink excessively and was only a social drinker when he was not symptomatic. The applicant’s own evidence is that the only time the deceased worker had problems with alcohol was when he was manic and this was considered a symptom of his bipolar disorder. There are records in the clinical material of the deceased worker stating that he did not drink socially but would binge every 3-6 months when ill. There is no evidence that drinking alcohol, exposure to alcohol or exposure to others drinking it had, in the past, triggered the deceased worker’s symptoms.
There is, however, a large and consistent body of evidence that the deceased worker drank alcohol excessively during periods when his psychiatric conditions were already florid.
The Prince of Wales Hospital records from August 2016 recorded that normally the deceased worker’s alcohol intake was social and minimal but was heavy when manic or elevated.
Records from NSW Health and Queensland Mental Health Services, over the years that followed, consistently recorded increased alcohol use during periods of mania.
There is evidence of both the applicant and the deceased worker reporting that the deceased worker self-medicated or attempted to manage his symptoms of mania with alcohol. In 2018, for example, records from Gold Coast Hospital noted that the deceased worker increased his alcohol intake to “bring him down when he is too high”.
In a record from MLHD Mental Health Services dated 13 July 2018, the applicant was recorded to have reported that when the deceased worker ceased medication he rapidly deteriorated and usually started to consume alcohol which caused further decompensation.
A risk assessment performed on 9 May 2019 recorded that the deceased worker had explained that when he was feeling high, alcohol helped him to process it and reduce his internal high. A similar account was given in an assessment dated 9 August 2019. That document recorded that “binge drinking” was the deceased worker’s main “coping strategy”.
This evidence tends to suggest that the deceased worker may have already started to experience symptoms of mania around the time of the Canberra conference and his consumption of alcohol at the conference was the result of those symptoms already in place.
That proposition has been refuted by the applicant and the other respondents, who note that there was no evidence of manic symptoms prior to the Canberra conference. The deceased worker had been able to obtain new employment, relocate his family to Gunnedah, and was reportedly settling into his new role well and making a favourable impression. Similarly, none of the first respondent’s witnesses suggest that the deceased worker had exhibited any inappropriate behaviour prior to the conference.
The deceased worker was, however, described by BMP as “very buoyant and eager” during the early stages of his employment. BSO gave evidence that the deceased worker was “very energetic” and “fast-paced” and would regularly send messages before, during and after work about work and non-work related matters. BSO had told BMP that the deceased worker was “very social” and “bounced around” the conference speaking to different people. Ms Resch said BSO had disclosed to her concerns about the general demeanour of the deceased worker during the conference.
While the deceased worker was observed to have a high level of energy before and during the conference, I accept that his behaviour was not observed to be problematic prior to the conference. There is also no evidence of increased alcohol use prior to the conference. There is no evidence of the deceased worker or the applicant engaging with any treatment providers in the lead up to the conference following the commencement of employment with the first respondent.
I do, however, note that there are multiple references in the clinical material to the deceased worker reporting that the extent of his drinking was not known to his family or co-workers and he was able to conceal his drinking well. I accept, therefore, that there is support for
Dr Roberts’ view that the deceased worker had started to be symptomatic prior to the conference, leading to his excessive drinking and subsequent decompensation at the conference.
Dr Roberts’ opinion necessarily involves a degree of speculation, but there is an evidentiary basis for it. While I am not prepared to find that the deceased worker was symptomatic or using alcohol prior to a decompensation at the conference, I accept that it is a real possibility.
I do accept that the deceased worker was symptomatic at the conference and in the period that followed, notwithstanding Dr Canaris’ view that the Tamworth Hospital records from
24 March 2021 suggested that the deceased worker may have simply been intoxicated rather than manic or depressed at the time of that admission.
Those records show that the applicant was, at that time, concerned for the deceased worker’s mental health. The applicant reported that the deceased worker had been “self-medicating” with alcohol and that he told he that her wanted to take his life. The deceased worker was reported to have been aggressive at Gunnedah Hospital and subsequently drank a quantity of bleach.

There was some considerable time spent in submissions on the question of whether there needed to be a trigger for the aggravation.
The clinical material before the Commission demonstrates that, at times, the deceased worker’s episodes appeared to be triggered by, or coincided with, a precipitant such as, his divorce, the death of a relative, financial stress or the successful completion of probation in a new job.
There are, however, numerous occasions recorded in the evidence whether there was an onset of symptoms or decompensation in the absence of any identifiable trigger.
This pattern in the clinical material is consistent with Dr Reveley’s evidence that psychosocial stress, usually with an emotive content could trigger an episode in patients with bipolar disorder. However, Dr Reveley suggested that in most instances there are no identifiable factors precipitating an attack of the illness. Dr Reveley observed that the condition tended to worsen with time, with episodes becoming more frequent and longer lasting.
Similarly, Dr Roberts has commented that whilst psychiatric instability in bipolar disorder may at times be precipitated by a stressor, this was not invariably the case. By its nature, bipolar is a condition characterised by unpredictable relapse and remission. Dr Canaris also acknowledged that bipolar disorder, especially if untreated or inadequately treated, is an inherently recurring illness.
The deceased worker was recorded in the clinical material to have observed that his bipolar symptoms tended to be on a 3- 6 month cycle.
I do not accept, after a consideration of all the evidence, that the deceased worker’s episodes were always triggered by something specific. I do not accept that there must necessarily have been some form of trigger for the onset or aggravation of symptoms. I accept that it is possible that the aggravation was idiopathic.
The evidence before me does, however, overwhelmingly indicate that in most cases there was a precipitant to the deceased worker’s episodes, namely non-compliance with his medication regime.
The discharge referral from Prince of Wales Hospital dated 9 August 2016 noted that the deceased worker had not ben taking his medications prior to the admission. A “background medication non-compliance” was noted in Dr Owens’ report following the admission on
4 November 2017. The Queensland Mental Health Services records from 27 February 2018 noted that the deceased worker deteriorated quickly when non-compliant with medication.
Records from Gold Coast Hospital on 5 April 2018 contained a comment from a medical officer observing that relapse was likely in the setting of medication non-compliance. The deceased worker had a long history of medication non-compliance, reporting that he did not feel as though he needed the medication. The applicant had agreed that there was a pattern of relapse from non-compliance with medication.
The applicant was recorded to have observed that the deceased worker was behind on his medication at the time of his readmission on 16 April 2018. In a progress note from
15 June 2918, the applicant was again recorded to have observed that the deceased worker was well and stable while taking medication as prescribed. When the deceased worker ceased medication, he would rapidly deteriorate and usually start to consume alcohol, which caused further decompensation.
At the time of the admission on 23 July 2018, it was noted that the deceased worker had not had his medications for one month. The applicant noted that the deceased worker had not been on any medications when she reported a manic episode to the Murrumbidgee AccessLine on 5 August 2019.
The admission in Young in October 2020 was also noted to have occurred due to non-compliance with medication.
Following this admission, it appears the deceased worker was, for a period, complying with medication and doing well. From December 2020, however, he was noted to have missed his depot injections. The applicant was noted to have observed some depressive symptoms in this context in early January 2021. The Tamworth Hospital records from March 2021, following the Canberra conference, confirm that the deceased worker had not been medicated for three to four months.
Dr Reveley observed that medication made relapse less likely. Forgetting to take medication for one or two days or even up to a week or so was unlikely to cause a problem, but after a month without medication the individual would be at risk of relapse.
Dr Roberts observed the pattern of relapse following medication non-compliance in the clinical material and commented that non-compliance with treatment would be accepted by the overwhelming body of psychiatric opinion to represent the most reliable predictor of relapse. Dr Roberts gave the opinion that cause of the deceased worker’s psychiatric deterioration was non-compliance with treatment on a background of a deteriorating bipolar disorder.
Dr Canaris was cognisant of the deceased worker’s non-compliance with medication at the time of the Canberra conference. Dr Canaris also agreed that historically the deceased worker’s comorbid alcohol use disorder seemed to have been a consequence of manic and hypomanic episodes and predominantly restricted to periods when his bipolar disorder was poorly controlled. Dr Canaris commented that the deceased worker would have been more vulnerable to relapse at the time of the Canberra conference because he had stopped taking psychotropic medication.
Nonetheless, Dr Canaris expressed the opinion that the level of drinking during and after the Regions Rising conference would have placed the deceased worker at significant risk of a relapse of mood disorder even if he had been medicated.
This opinion from Dr Canaris appears to have been informed by his understanding from the applicant’s evidence that BSO was a “hard drinking colleague” and the first respondent had a “culture of drinking in the workplace”. For the reasons given above I am not satisfied that the applicant’s impressions of BSO and the workplace culture were reliable.
I do accept that BSO’ own drinking, particularly on the first night in Canberra, his willingness to drink with the deceased worker, his funding of some of the deceased worker’s drinks, the circumstances of the deceased worker’s employment relationship with BSO, the more unstructured environment of the conference and being away from his family and usual routines were contributing factors to the aggravation. I accept that these factors may have encouraged and, to an extent, facilitated the deceased worker’s excessive drinking during the conference.
I am not, however, satisfied that these factors, even collectively, were the main contributing factor to the aggravation. The deceased worker’s extended period of non-compliance with his medication prior to the conference was, in my view, a far more significant contributing factor to the aggravation. I accept that the period of time that had elapsed since his last episode and the apparently deteriorating nature of his condition over time were also significant contributing factors to the aggravation.
As noted above, there is no evidence that drinking alcohol, exposure to alcohol or exposure to others drinking it had, in the past, triggered the deceased worker’s symptoms.
For all of these reasons, I prefer the ultimate opinion of Dr Roberts over that expressed by Dr Canaris.
It is necessary to consider the effect of the other relevant events in the workplace identified by the applicant as potentially causative of an aggravation of the deceased worker’s condition.
I have addressed already the applicant’s claims regarding a culture of drinking and the availability of alcohol in the first respondent’s workplace. I am not satisfied that the applicant’s perception of the workplace was reliable but, even if it was, the fact that there was no aggravation of the deceased worker’s condition in that environment prior to the conference, and the evidence that he in fact was doing very well, are not consistent with the work environment itself being causative of an aggravation.
Following the Canberra conference, I accept that the deceased worker’s performance at work declined. I accept that he found managing his new assistant frustrating and stressful. I accept that he appears to have had some difficulty managing his workload. I accept that he was invited to a meeting to discuss alleged breaches of the first respondent’s code of conduct and was not immediately advised by the first respondent of the particulars of those allegations. I accept that his employment relationship with the first respondent ceased in those circumstances and that his role was readvertised. I accept that all of these events may have been stressful.
There is, however, no medical evidence that these events individually or collectively were causative of any new or further aggravation of the deceased worker’s psychological condition. Although I accept that the deceased worker saw his general practitioner and a medical certificate was issued around the time of the letter advising the deceased worker of a meeting to discuss the allegations against him, no doctor, including either of the experts has expressed an opinion that these workplace events were the main contributing factor to an aggravation of the deceased worker’s condition.
I am not satisfied on the applicant’s lay evidence alone that there was any further aggravation of the deceased worker’s disease caused by the workplace events after the Canberra conference.
I am satisfied on the evidence that the deceased worker’s condition was already florid by the time of his return from Canberra. The subsequent workplace events are consistent with a manifestation of symptoms that were already in place. Although the deceased worker resumed treatment, there is no evidence that it was successful in stabilizing the aggravation that commenced in Canberra. The applicant’s own evidence and the first respondent’s witness evidence suggests that the aggravation that commenced in Canberra continued until the time of the deceased worker’s death. As Dr Canaris observed, the resumption of very heavy drinking at the Canberra conference would have made the management of the deceased worker’s condition much more challenging.
I am not satisfied that the workplace events after the Canberra conference were in themselves the main contributing factor to an aggravation of the deceased worker’s condition. Nor am I satisfied that they formed part of a series of events which included the Canberra conference that was the main contributing factor to an aggravation of the condition.
The applicant has not discharged her onus of establishing on the balance of probabilities that employment with the respondent was the main contributing factor to an aggravation of the deceased worker’s pre-existing disease. The requirements of s 4(b)(ii) of the 1987 Act are not met.
There is no suggestion on the evidence of an injury which would satisfy s 4(a) or s 4(b)(i) of the 1987 Act.
As it has not been established that the deceased worker sustained a compensable “injury”, I am not satisfied that his death resulted from injury for the purposes of s 25(1) of the 1987 Act.
In view of these findings, it is not necessary to consider further the other issues arising in the proceedings pertaining to dependence, apportionment etc.
There will be an award for the first respondent.

[2024] NSWPIC 70

20 February 2024