Berry and Comcare (Compensation) - [2019] AATA 4978

Berry and Comcare (Compensation) [2019] AATA 4978 (28 November 2019)
Division:GENERAL DIVISION
File Number: 2017/3061
Re:Brian Berry
APPLICANT

AndComcare
RESPONDENT

DECISION
Tribunal:Member R Maguire
Date:28 November 2019
Place:Brisbane

The decision under review is affirmed.
...............................[Sgd]......................................
Member R Maguire
Catchwords
WORKERS COMPENSATION – coronary artery disease – ischaemic heart disease – aggravation/acceleration of coronary artery disease – passage of time – whether the Respondent remained liable for medical expenses – whether the Respondent remained liable for incapacity payments – decision under review affirmed.
Legislation
Commonwealth Employee’s Rehabilitation and Compensation Act (1988) (Cth)
Safety, Rehabilitation and Compensation Act 1988 (Cth)
Cases
Military Rehabilitation and Compensation Commission v May [2016] HCA 19; (2016) 257 CLR 468
Ogden Industries Pty Ltd v Lucas (1967) 116 CLR 537
Re Colombo and Australian Postal Corporation [2015] AATA 10
REASONS FOR DECISION
Member R Maguire
28 November 2019
INTRODUCTION

This is an application for the review of a decision made on 16 May 2017 to affirm a determination dated 27 March 2017[1] to cease the liability of Comcare under the Safety, Rehabilitation and Compensation Act 1988 (Cth) (“the Act”) as and from 5 April 2017 for a claim for medical expenses under s. 16, and a claim for incapacity payments under s. 21A in respect of the applicants accepted condition of aggravation/acceleration of coronary artery disease (“the compensable condition”) sustained on 1 November 1991 (“the relevant date”).[2] Section 16 is referred to as it stood at the relevant date. Section 21A (which deals with post-retirement entitlements) is as it stood as at the date of the applicant’s retirement, 21 June 2011.
[1] Exhibit 1, T Documents, T21, pages 166 – 168, Determination of no present liability, dated 27 March 2017.
[2] Exhibit 1, T Documents, T24, pages 175 – 178, Reconsideration of Determination, dated 16 May 2017.
As at the relevant date the Act was known as Commonwealth Employee’s Rehabilitation and Compensation Act (1988) (Cth).
The determination of 27 March 2017 was made by a Comcare delegate who found that there was no evidence that the applicant continued to suffer from the compensable condition.[3] The Review Officer who made the decision of 16 May 2017 (“the decision under review”) found that the applicant no longer experienced the effects of the compensable condition.[4]
[3] Exhibit 1, T Documents, T21, page 167, Determination of no present liability, dated 27 March 2017.
[4] Exhibit 1, T Documents, T24, page 176, Reconsideration of Determination, dated 16 May 2017.
The determination of 27 March 2017 had effect as and from 5 April 2017.
ISSUE FOR DETERMINATION
The issue for the Tribunal is whether there is evidence sufficient to support a finding that the applicant continued to suffer the compensable condition beyond 5 April 2017, and if so, whether he continues to suffer it as at the date of this decision.
For the reasons below, the Tribunal finds that the applicant has not continued to suffer the compensable condition beyond 5 April 2017, and the decision under review is therefore affirmed.
THE COMPENSABLE CONDITION
The compensable condition suffered by the applicant was an aggravation/acceleration of coronary artery disease, which is also known as ischaemic heart disease. The compensable condition was not the coronary artery disease/ ischaemic heat disease itself, which although an ailment in common parlance, was not an “ailment” for the purposes of the Act, as it was not accepted as having been contributed to in a material degree by the employee’s employment. It therefore did not fall within subparagraph (a) of the definition of disease set out in paragraph 8 below. The evidence was that the applicant had a pre-disposition to coronary artery disease, and it had developed over many years. However, notwithstanding this, the aggravation of the coronary artery disease was accepted as having been contributed to in a material degree by the employee’s employment, because, as can be seen below, it fell within subparagraph (b) of the definition of “disease”, which in turn fell within the definition of “injury” for the purposes of ss. 16(1)[5], and 21A which provides post-retirement benefits of the Act.
[5] Section 16(1) has been unamended since the relevant date, apart from the omission of reference to “the Commission” which is replaced by “Comcare”.
Evidence of continuing aggravation beyond 5 April 2017 is essential in order to found a finding of an ongoing injury, and thus compensation under either ss. 16, or 21A of the Act. In the absence of demonstrated continuing aggravation, there can be no entitlement under either provision.
LEGISLATIVE FRAMEWORK
As at the relevant date, the Act, was known as the Commonwealth Employee’s Rehabilitation and Compensation Act (1988) and provided (s.4) the following definitions relevant for present purposes:
“disease means:
(a)any ailment suffered by an employee; or
(b)the aggravation of any such ailment;
being an ailment or an aggravation that was contributed to in a material degree by the employee’s employment by the Commonwealth.”
“aggravation includes acceleration or recurrence.”
“ailment means any physical or mental ailment, disorder, defect or morbid condition (whether of sudden onset or gradual development).”
“injury means:
(a)a disease suffered by an employee; or
…”
As was pointed out by the plurality in Military Rehabilitation and Compensation Commission v May [2016] HCA 19; (2016) 257 CLR 468 at [55], the “disease” limb of the definition of “injury” remains an additional basis of liability.
An entitlement to compensation for injury arose via s. 16(1) of the Act which relevantly provided:
“16 Compensation in respect of medical expenses etc.
(1) Where an employee suffers an injury, Comcare is liable to pay, in respect of the cost of medical treatment obtained in relation to the injury (being treatment that it was reasonable for the employee to obtain in the circumstances), compensation of such amount as Comcare determines is appropriate to that medical treatment.”
An entitlement to compensation for incapacity arose via s. 21A which provided as at the date of the applicant’s retirement for compensation for each week of incapacitation after retirement[6]:
[6] The Applicant retired on 21 June 2011: Exhibit 1, T Documents, page 88 Applicant enclosing supporting documentation.
21ACompensation for injuries resulting in incapacity if employee is in receipt of a superannuation pension and a lump sum benefit
(1)Compensation payable to an employee who is incapacitated for work as a result of an injury is determined in accordance with this section if:
(a)the employee is retired from his or her employment (whether the employee retired voluntarily or was compulsorily retired); and
(b)the employee receives:
(i)a pension; and
(ii)a lump sum benefit;
under a superannuation scheme as a result of the employee’s retirement.
(2) Comcare is liable to pay compensation to the employee, in respect of the injury, in accordance with this section for each week after the date of the retirement during which the employee is incapacitated.
The word “aggravation” in the Act has its ordinary meaning, as well as encompassing acceleration or recurrence.
The ordinary meanings of “aggravation” and “acceleration” were considered in Ogden Industries Pty Ltd v Lucas (1967) 116 CLR 537, where Windeyer J said (at 593):
““Aggravation” means, I think, that an existing disease has been made worse, not that it has simply become worse. “Acceleration” I have previously said and ventured to repeat “probably presupposes a progressive disease, one that, running its ordinary course, increases in gravity until a climax, such as death or total invalidism, is reached – its progress to this end result not being ordinarily susceptible of being permanently arrested, but susceptible of being hastened by external stimuli”: Federal Broom Co. Pty Ltd v Semlitch (1964) 110 CLR 626 at 639.”
More recently, in Re Colombo and Australian Postal Corporation [2015] AATA 10, Senior Member Taylor SC cited with approval the following passage:
“In Re Rutledge and Comcare (2011) 130 ALD 94; [2011] AATA 865; at [10] Member Webb summarised the relevant principles. That summary was as follows (I have reformatted the extract, so as to conveniently include the authorities Member Webb cited):
[10] ... An “injury” under the Act includes a “disease”, which is defined to include the aggravation of an ailment that is significantly contributed to by the employee’s employment. The term “aggravation” is defined to include acceleration or recurrence. It is synonymous with exacerbation, in the sense that an ailment
● is made worse: Salisbury v Australian Iron & Steel Ltd [1943] NSWStRp 50; (1943) 44 SR (NSW) 157; Darling Island Stevedoring & Lighterage Co Ltd v Hankinson [1967] HCA 10; (1967) 117 CLR 19; [1967] ALR 545; Asioty v Canberra Abattoir Pty Ltd [1989] HCA 40; (1989) 167 CLR 533; 87 ALR 385.

● or the experience of it is “increased or intensified by an increase or intensifying of symptoms”: Federal Broom Co Pty Ltd v Semlitch [1964] HCA 34; (1964) 110 CLR 626 at 634–5; [1964] HCA 34; [1964] ALR 1031 at 1036–7 per Kitto J.

● “Neither the absence of change in the underlying condition nor the temporary nature of the symptoms experienced preclude the existence of an aggravation of an ailment for the purposes of the SRC Act”: Mellor v Australian Postal Corporation (2009) 108 ALD 159; [2009] FCA 504 at [26].
In considering the above passage, it must be remembered that Senior Member Taylor SC and Member Webb were dealing with the current legislation which provides a “significantly contributed” test rather than a “materially contributed” test which applies in the present circumstance.
REVIEW OF DECISION RECORD
A synopsis of the decision record of the review officer is as follows.
The applicant’s treating cardiologist, Dr Narendra Kewal, gave a report dated 23 April 2014 that the applicant underwent a coronary artery bypass grafting (“CABG”) in April 1992 and since then has remained well with no angina or dyspnoea and his exercise tolerance is excellent.[7]
[7] Exhibit 1, T Documents, T11, page 37, Report of Dr N Kewal, dated 23 April 2014.
Dr Kewal further stated, in a report dated 11 August 2016, that the applicant had undergone yearly stress tests which have been negative for myocardial ischaemia supporting the clinical impression of a good ongoing surgical result.[8]
[8] Exhibit 1, T Documents, T13, Report of Dr N Kewal, dated 11 August 2016.
Dr Kewal also stated that the applicants bypass grafts are now over 24 years old and the attrition rate of the vein grafts which were utilised in his case increased dramatically with age, particularly after 10 years.
An exercise electrocardiogram performed on 6 April 2014 showed no evidence of myocardial ischaemia 24 years post the applicants CABG.
At Comcare’s request, the applicant attended an independent medical examination on
[9] Exhibit 1, T Documents, T18, Independent Medical Examination Report of Dr K Hossack, dated
7 February 2017 with consultant cardiologist, Dr Kenneth Hossack, who opined that the applicant has a genetic pre-disposition to the development of coronary artery disease.[9]
Dr Hossack further opined that the applicant’s genetic pre-disposition to coronary artery disease was possibly aggravated by work stress and dyslipidaemia. He further reported that the applicant had elevated cholesterol which is a reflection of his body’s inability to metabolise cholesterol adequately and thereby contributing to the development of coronary artery disease.
Dr Hossack also opined that as a result of an adjustment in work tasks, the applicant was no longer exposed to stressful situations and as time progressed, it became more apparent that his elevated cholesterol was a potential contributing factor.
The Comcare delegate acknowledged that Dr Kewal was supportive of the applicant’s ongoing exercise regime and had stated that this was a risk management modality, suggesting that it is required as a preventative measure rather than treating the effect of his aggravation/ acceleration of coronary artery disease sustained in 1991.
The Review Officer concluded that the applicant no longer experiences the effects of his compensable condition, and was not presently entitled to compensation under ss. 16 and 21A of the Act in respect of his accepted aggravation/acceleration of coronary artery disease sustained on 1 November 1991.
The effect of the affirmation of the determination is that from 5 April 2017 to the present date, the applicant is not presently entitled to compensation for medical treatment under s. 16 or incapacity for work under s. 21A of the Act in relation to the accepted condition.
On 24 May 2017, the applicant filed the present application for review, asserting that the reviewable decision was wrong, and that relevant medical information had not been taken into account.[10]
[10] Exhibit 1, T Documents, T2, pages 3 – 8, Application for Review of Decision, dated 24 May 2017.
BACKGROUND
The applicant commenced working with the Australian Taxation Office (ATO) in October 1984 and began auditing duties in July 1985, and was working in that role in 1991 – 1992.
On 20 May 1992, the applicant lodged a claim for compensation for a “heart condition”.[11] The applicant had first noted symptoms on an unspecified date in November 1991 at
[11] Exhibit 2, Supplementary T Documents, ST1, Claim for Compensation, dated 20 May 1992.
5:20 PM, and first received treatment on 26 February 1992.
On 9 June 1992, Dr B McCall, Commonwealth Medical Officer, having examined the applicant on 4 June 1992, reported that the applicant had developed symptoms of ischaemic heart disease in February 1992, and had undergone CABG on 6 April 1992.[12] Dr McCall reported that the applicant currently had no symptoms of ischaemic heart disease but did complain of some shortness of breath and fatigue on exertion, and that this was consistent with his recovery from his operation. Dr McCall considered that the applicant should be granted further sick leave until 26 June 1992 at which time it was likely that he would be fit to return to work on a part-time basis to do light sedentary non-stressful duties. Dr McCall recorded that there was no evidence that the incapacity was due to the wilful action on the part of the applicant for the purposes of obtaining an invalidity benefit. Dr McCall commented that he was awaiting a report from a psychiatrist, Dr B Klug.
[12] Exhibit 2, Supplementary T Documents, ST2, Report of Dr B McCall, dated 9 June 1992,
In a further report dated 7 August 1992,[13] Dr McCall recorded that the cardiologists opinion was that “although there has been no causal relationship conclusively demonstrated between stress and the aetiology of coronary artery disease it would not be conducive to his overall well being, and his continued recovery, for him to be placed in the same work situation” as an auditor. The applicant’s prognosis for health was good, provided that these “stress” factors in his workplace were avoided.
[13] Exhibit 2, Supplementary T Documents, ST3, page 6, Report of Dr B McCall, dated 7 August 1992.
Dr McCall further reported that the consultant psychiatrist’s opinion was that the applicant was a Type A personality and that he should not return to his previous stressful duties, but should be employed in a considerably less stressful role, and that he should undergo a program of modification of his Type A behaviour.
In a report dated 12 November 1992, Commonwealth Medical Officer Dr M Hayman who had examined the applicant on 10 November 1992 for the purpose of assessing his fitness for full-time work, reported that the applicant remained “largely symptom free following his coronary artery bypass surgery.”[14] Dr Hayman also reported that the applicant suffered “an occasional non specific sharp mandatory chest pain from time to time and had on occasions felt fatigued after a full day’s work”, but was coping with his current duties. Dr Hayman reported that the applicant was fit to perform his current duties until his review by Dr Kewal, and suggested his hours remained at six per day. The doctor recorded that the applicant was coping well with his six hour working day followed by his one hour exercise prior to his family evening meal together.
[14] Exhibit 2, Supplementary T Documents, ST5, pages 20 – 21, Report of Dr M Hayman, dated 12 November 1992.
On 16 December 1992, Dr B Dragt, Commonwealth Medical Officer reported (PST7) that the applicant had had “excellent results of cardiac bypass-surgery and can now return to a full day’s work of 7 hours and 21 min.”[15]
[15] Exhibit 2, Supplementary T Documents, ST7, pages 24 – 25, Report of Dr B Dragt, dated 16 December 1992.
On 8 December 1992, Dr Kewal, Consultant Cardiologist and the applicant’s treating cardiologist, provided a report to Comcare[16] in which he confirmed that the applicant had undergone a coronary angiography on 5 March 1992, and that this had confirmed the presence of severe coronary artery disease with an 80% left main stenosis. Dr Kewal reported that the applicant underwent CABG on 6 April 1992, with a satisfactory surgical result being obtained, and the patient was now free of symptoms, and a repeat stress test recently had been negative for ischaemia.
[16] Exhibit 1, T Documents, T4, page 10, Report of Dr N Kewal, dated 8 December 1992.
Dr Kewal also stated:
“With regard to Question 3 in your letter, my opinion is that Mr Berry’s employment as a taxation auditor, which placed him under considerable stress, undoubtedly aggravated and probably accelerated his cardiac condition. The relationship between stress and causation of coronary artery disease is unclear as there has been no causal relationship conclusively demonstrated.”
Dr Kewal had previously reported to Dr Enstice, the applicant’s General Practitioner (“GP”) on 3 June 1992[17] that he had reviewed the applicant following his CABG, and “The patient is well with no angina. His exercise tolerance is excellent. … Clinically the patient has had an excellent result from his open heart surgery. I performed a progress stress test which was negative for ischaemia supporting a good surgical result.”
[17] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 3, Report of
Dr Kewal again reported to the GP on 8 December 1992[18] “The patient’s exercise tolerance is excellent and he is completely free of angina. … Clinically the patient is very stable from a cardiac perspective. A repeat stress test was negative for ischaemia, once again supporting a good surgical result.”
[18] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 5, Report of
In a further report dated 18 December 1992 (PST 9) Dr Kewal appeared to resile from the opinion he had expressed in his report of 8 December 1992. In his later report, Dr Kewal stated:[19]
“I would like to confirm that, in my opinion, there was a probable relationship between the stress experienced by Mr. Berry and the aggravation/acceleration of his coronary artery disease. Mr. Berry’s cholesterol levels have been exemplary, and would not have played any significant role in the causation of his problems. The aetiology of his underlying condition is difficult to determine. I am enclosing photocopies for your reference from J. Willis Hurst’s textbook “The Heart”. The section on personality type would, I feel, summarise the current attitude to its role in the aetiology of coronary artery disease.”
[19] Exhibit 2, Supplementary T Documents, ST9, page 33, Report of Dr N Kewal, dated 18 December 1992.

The passage to which Dr Kewal referred, was marked with asterisks, and was as follows:[20]
“*Personality Type*
Individuals with certain personality characteristics appear predisposed to develop atherosclerosis. In the type A individual with time urgency (trying to accomplish more and more in less and less time) who is aggressive, ambitious, competitive, impatient, and frequently frustrated, coronary risk is increased. This is seen both in men and women and among women occurs equally in housewives and in women working outside the home. The association is more pronounced among white-collar than blue-collar workers. The mechanism remains obscure, but possible atherogenic features include high circulating catecholamine levels that may predispose to hypertension, abnormalities and platelet function, mobilization of fatty acids, and hyperlipemia. Type A personality appears to enhance other risk factors and is a more powerful predictor in persons with other risk characteristics. Friedman and Rosenman offer suggestions for modification of type A behaviour. Recently, a high hostility score on the Minnesota Multiphase Personality Inventory (MMPI) has also emerged as strongly related to coronary arteriosclerosis. Nevertheless, a National Heart, Lung, and Blood Institute Review Panel concluded that more objectively quantifiable and replicable techniques were needed to measure coronary prone behaviour and that specificity and physiologic mechanisms underlying the presumed relationship were not yet established.”
[20] Exhibit 2, Supplementary T Documents, ST9, pages 34 – 35, Extract of textbook “The Heart”.
On 29 November 1993, Dr Kewal reported to the GP[21] that “The patient is well with no angina. His exercise tolerance is excellent. … Clinically, therefore, the patient is progressing very well from a cardiac perspective.”
[21] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 7, Report of
On 17 November 1994, Dr Kewal again reported to the GP[22] saying “He is feeling extremely well and pursues a regular exercise programme including walking and swimming. He participated in a half marathon which he completed quite satisfactorily. There has been no recurrence of angina although he did experience some atypical chest discomfort which he finally worked out was related to some hot chips he had eaten.”
[22] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 9, Report of
On 7 February 1995, Comcare wrote to Dr Kewal specifically asking:[23]
“In your opinion, are his employment duties at Australian Taxation Office a significant factor by way of aggravation of this condition. Please explain your answer.
Is he still suffering from the effects of stress associated with his job at the time of his claim for compensation (01/11/91), or is his condition now naturally progressing, irrespective of his employment duties?
If not for the work circumstances of 01/11/91 which gave rise to his compensation claim, would Mr Berry strill [sic] require the treatment he is currently undergoing, including medication?
[23] Exhibit 2, Supplementary T-Documents, ST10, page 39, Correspondence from Comcare to Dr N Kewal, dated 7 February 1995.
Dr Kewal responded in a letter dated 25 May 1995 in which he advised:[24]
“With regard to the questions related to whether his current employment duties at the Australian Taxation Office are a significant factor in aggravation of his condition and whether he is still suffering from the effects of stress associated with his job at the time of his claim for compensation, I regret to say that I am unable to respond to these questions as I am not familiar with the exact nature of his current employment duties and I would suggest that further effects of stress related to his job would be best evaluated by a clinical psychologist.”
[24] Exhibit 2, Supplementary T-Documents, ST11, page 40, Correspondence of Dr Kewal, dated 25 May 1995.
On 29 November 1995,[25] Dr Kewal reported to the GP “He continues to do extremely well following his CABG by Dr. Greg Stafford on 16/4/92. His exercise tolerance is excellent. … Clinical examination was normal. … A maximum stress test was performed and this was once again negative for ischaemia with the patient completing an excellent workload.”
[25] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 11, Report of
Dr Kewal again reported to the GP on 23 April 1997[26] “He continues to do very well…. His angina is fully controlled. His exercise tolerance is excellent and he participates in regular competitive swimming. … The patient underwent a maximum stress test and once again had an excellent result completing 14 minutes of the Accelerated Bruce Protocol without any symptoms of angina or ST segment changes on the ECG. This reflects his commitment to regular exercise and a good diet.”
[26] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 13, Report of
By letter dated 5 June 1997,[27] Comcare again wrote to Dr Kewal requesting an up-to-date medical report responding specifically to the following points:
[27] Exhibit 2, Supplementary T-Documents, ST12, pages 41 – 43, Correspondence from Comcare to
·what is the exact nature and cause of the current cardiac condition?
·what was the history of the development of that condition, as related to you by Mr Berry?
·was there a history of treatment with heart medication prior to onset in 1992 – if so what was the medication used and over what period?
·what was the basis of the indicated exertional angina and its contribution to the development, or cause of the need for treatment and surgery in 1992?
·does the employment with ATO continue to materially aggravate the underlying cardiac condition, and how is this so? What specific factors of the ATO employment because aggravation?
·you refer to Mr Berry’s father passing away due to a ruptured aortic aneurysm. Does this mean there is a family history that may pre-dispose
Mr Berry to the identified CAD?
·you refer to Mr Berry’s personality type as an aetiological developmental factor. If this is the case, would the CAD condition have developed, or been aggravated regardless of type of employment undertaken by Mr Berry?
·given that ATO have taken action to redeploy Mr Berry to a less stressful area, would you have expected any aggravation to have ceased by now – if not when would you reasonably expected it to cease?
·as Mr Berry is presently only under pharmaceutical management for his condition – would this be for the management of the effects of any work aggravation, or for the ongoing maintenance of the pre-existing CAD condition?
·what is the prognosis for the current cardiac condition?
On 10 June 1997, Dr Kewal replied[28] saying that he had written extensively about the applicant’s condition to Comcare, his opinions had not changed, and he referred Comcare back to his previous correspondence for the information they were requesting, and said that he was not prepared to comment further on Comcare’s queries as they were going over the same ground again.
[28] Exhibit 2, Supplementary T-Documents, ST13, page 44, Correspondence of Dr N Kewal, dated 10 June 1997.
On 15 March 1999, Dr Kewal again reported to the GP:[29]
“He continues to do very well following his CABG by Greg Stafford on 6^th April 1992. The patient’s exercise tolerance is excellent. … The patient underwent a maximum stress test which was negative for myocardial ischaemia with him completing 15 minutes and 30 seconds of the Bruce Protocol with no chest pain or ST segment changes on the ECG. On the strength of this and his clinical presentation I reassured him that all was well from a cardiac perspective with no evidence of ischaemia with exercise. … I have suggested that he come back in 2 years for another stress test.”
[29] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 15, Report of
Dr Kewal next reported to the GP on 14 May 2003:[30] He continues to do very well following his CABG by Greg Stafford on 6/4/92. The patient has not had any angina and his exercise tolerance remains excellent. … The patient is doing extremely well following his open heart surgery 11 years ago. His risk factor management is excellent.”
[30] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 18, Report of
On 31 May 2006, Dr Kewal reported to the GP:[31] “He remains very well with no angina following his CABG by Greg Stafford on 6/4/92. The patient’s exercise tolerance is excellent. … The patient had a maximum stress test which was negative for myocardial ischaemia. He completed 16 minutes and 47 seconds of the Bruce Protocol without any angina or ECG changes of myocardial ischaemia. … Clinically, therefore, this patient is doing very well 14 years post CABG.”
[31] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 20, Report of
On 6 June 2007, Dr Kewal reported to the GP:[32] “The patient is well with no angina or dyspnoea. His exercise tolerance is excellent. … Clinically this patient is progressing very well from a cardiac perspective. His risk factor management is excellent.”
[32] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 20, Report of
The applicant was subsequently referred to Ms Sue-Ellen Noort, a Physiotherapist with Arc Rehabilitation Services, who provided a report dated 20 March 2008[33] which recommended that the applicant continue with his current management regime, and that he might benefit from participating in counselling sessions to assist with enhancing his stress management skills. It also recommended that the applicant would benefit from being provided with work duties which minimised his exposure to stress.
[33] Exhibit 2, Supplementary T-Documents, ST14, pages 45 - 48, Report of Ms S-E Noort, dated 20 March 2008.
On 2 April 2008, the applicant underwent an exercise ECG[34] which showed that the resting ECG was normal, and that during exercise there were no significant ECG changes of myocardial ischaemia. The conclusion was that there was no evidence of myocardial ischaemia 16 years post CABG.
[34] Exhibit 1, T Documents, T5, page 11, Exercise ECG Result, dated 2 April 2008.
Dr Kewal provided a further report dated 2 April 2008[35] in which he stated that: “The applicant’s angina is well-controlled and his exercise tolerance is excellent. He did have an episode of left sided chest pains about a month ago following a very stressful interview at work. This has not recurred.” The doctor went on to say:
“The patient mentioned to me that his work situation has changed quite dramatically and that he is now being asked to undertake tasks in areas that led to considerable stress 16 years ago when he was doing similar sort of work. This particularly concerned me as it does put him at risk of future cardiac events given that these were similar situations to what led to his premature coronary artery disease in the first place. One also needs to keep in mind his bypass grafts are now 16 years old and the rate of attrition of these grafts increases quite dramatically beyond 10 years. I have, therefore, emphasised to him that it is more important today to control his risk factors and in this case particularly stress which is a known risk factor for coronary artery disease.”
[35] Exhibit 2, Supplementary T-Documents, ST16, pages 54, Report of Dr N Kewal, dated 2 April 2008.
Dr Kewal also reported:
“The patient underwent a progress stress test using the standard Bruce Protocol. He exercised for 15 minutes and achieved his maximum predicted heart rate without any angina or ECG changes of ischaemia. A copy of the report is enclosed.
I have advised him to continue with his current management. I would also recommend in the strongest possible terms that his supervisors at work pay due consideration to the circumstances in which he is placed and to ensure that the risks for coronary artery disease and graft disease are minimised in his current work environment.”
On 7 April 2008, the applicant was reviewed by Dr David Douglas, a Consultant Occupational Physician, who provided a report dated 15 April 2008.[36] Dr Douglas recorded that the applicant felt “very much better” after the surgery on 6 April 1992. The applicant had worked very hard at the fitness exercises prescribed and competed in the Gold Coast 10 km walk in 1993, and in 1994 was able to run and complete the Gold Coast half marathon. In order to increase his upper body strength, the applicant started swimming more seriously in around 1995, increasing this to up to 4km per day, but had reduced that and was currently swimming about 2km on most days. The applicant also reported that he was currently walking on for days per week from 4 to 6km over undulating terrain in his local suburb. The applicant told Dr Douglas that ever since the coronary artery bypass surgery he had had no further heart symptoms (emphasis added).
[36] Exhibit 1, T Documents, T6, Independent Medical Report of Dr D Douglas, dated 15 April 2008.
The applicant did however tell Dr Douglas that he was well but feels anxious about his future at the ATO. The applicant reported no limitation on any physical activity, and was planning a backpacking holiday for two months in Europe in July/August 2008. Dr Douglas recorded that the applicant was “noted to be a very fit and healthy looking man of stated age.”
Dr Douglas considered that the applicant was fit for duty and had been since late 1992, and considered that the applicant should not return to audit and compliance type duties similar to that which led to his increased stress levels prior to his or coronary artery disease in 1992. Dr Douglas said the applicant would never be fit to return to field audit type duties, and that the applicant could safely undertake the type of work he had been doing the past many years i.e. internal finance review work, and was fit for full-time duties. Dr Douglas did not consider that any further rehabilitation assessment of services was indicated, and no further specialist assessment was required. In his opinion the applicant was well motivated to continue work with the ATO, provided he was not placed in highly stressful situations as he would have been if he were to return to a field auditing role. Dr Douglas considered there were no barriers to prevent a return to preinjury or suitable duties.
The applicant was seen by Dr Michael G. Darke on 11 June 2008, and Dr Darke subsequently provided a report dated 26 June 2008.[37] Dr Darke reported that the cause of death of the applicant’s father had been previously misreported and he died as a result of bacterial endocarditis and not a ruptured aneurysm.
[37] Exhibit 1, T Documents, T7, pages 21 – 25, Independent Medical Report of Dr M Darke, dated 26 June 2008.
Dr Darke recorded that the applicant had made an excellent recovery from his surgery, and was currently active, mobile, undertaking regular exercise, as well as a rehabilitation program. Dr Darke recorded that the applicant acknowledged being a Type A personality, and that some cardiologists accept that Type A personality might exacerbate blood pressure and/or the symptoms of chest discomfort. He further stated that Type A profile is probably not an actual cause of atherosclerotic disease anywhere in the body, particularly the heart.
Dr Darke opined that:
“It is highly unlikely that his employment with the ATO caused the underlying pathology of endothelial plaque formation with calcium and soft cholesterol plaque. Significant anxiety and stress, particularly when occurring in a person who is of a time urgent nature, may very well be provocative for the presence of symptoms of ischaemic coronary disease.”
Dr Darke said that the applicant had made a good recovery from surgery, was physically active, and was maintaining an excellent body weight, and maintaining an excellent lipid profile also recorded that he had been relatively free of further symptoms, and there appeared to be no clinical evidence of progression of the applicant’s condition, and no objective evidence of disease progression.
Dr Darke considered that the applicant was clearly able to work although the type of work needed to be evaluated.
Dr Darke provided a supplementary report dated 20 October 2008, in which he stated:[38]
“Whilst Mr Berry is a precise gentleman with some traits suggestive of a Type A personality, there is no evidence that any stress or his current presentation plays a part in his coronary artery disease which is regularly evaluated by

Dr Narendra Kewal.”
[38] Exhibit 1, T Documents, T8, pages 26 – 27, Supplementary Independent Medical Report of Dr M Darke, dated 20 October 2008.
Dr Darke also opined that emotional stress itself, is probably not a cause of coronary artery disease, but may aggravate symptoms. Dr Darke considered stress did not contribute to the applicant’s then current medical condition. In response to the question: “Do the effects of any aggravation or acceleration continue to materially contribute to the condition or have any effects of that aggravation resolved?” Dr Darke replied: “Not to my knowledge.”
In response to the question “Is the current treatment required for the coronary artery disease or is the need for the treatment due to the aggravation?” Dr Darke replied:
“This man has had reconstructive coronary artery surgery and whilst this has had an excellent result, it is not a cure and long-term follow-up by his Cardiologist, regular adherence to physical examinations, and regular assessment of his lipid profile, blood pressure and ability to work, is something that will require medical surveillance in some form or other for the rest of his life.
It is not due to any aggravation of his anxiety state, it is just the normal process for his medical condition. It is very much to his advantage to stay under the care of Dr Narendra Kewal.”
Dr Darke considered that the applicant was “perfectly able to return to work” and that the type of work would be dependent upon an occupational psychologist’s assessment.
On 15 April 2009, Dr Kewal reported to the GP:[39] “He continues to do extremely well following CABG by Greg Stafford in April, 1992. The patient’s exercise tolerance is excellent and he participates in regular gym work and swimming. … The patient underwent a progress stress test which was once again negative for myocardial ischaemia. … I reassured him that all was well from a cardiac perspective.”
[39] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 25, Report of
On 14 April 2010, Dr Kewal reported to the GP that the applicant had been free of angina since undergoing surgery in April 1992.[40] Dr Kewal reported:
“The patient underwent a maximum stress test which was negative for ischaemia. He completed 15 minutes of the Bruce Protocol and achieved a heart rate of 155/min without any chest pain or ECG changes of ischaemia. … The patient is stable from a cardiac point of view. However, I would once again point out that his bypass grafts are 18 years old and one needs to be extremely careful about risk factor control to prevent graft disease. This includes his work environment which precipitates a lot of stress for him.”
[40] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 27, Report of
On 19 April 2010, the applicant was reassessed by Dr Douglas who provided a report dated 21 April 2010[41] in which he said that the applicant had reached the point where even minor stressors at work would result in exacerbations of his coronary artery disease, and he therefore believed that the applicant had reached the point where he should retire from work on medical grounds.
[41] Exhibit 1, T Documents, T9, pages 28 – 33, Independent Medical Report of Dr Douglas, dated 21 April 2010.

Dr Kewal provided a further report dated 2 July 2010[42] which noted that since his bypass operation, the applicant had been free of angina pectoris and his exercise tolerance was satisfactory. Dr Kewal had at this time perused the report by Dr Douglas, and fully concurred with Dr Douglas’s report that the patient had permanent invalidity related to his coronary artery disease. Dr Kewal said that he would “not recommend that the patient be returned back to work either in a full-time or part-time capacity.”
[42] Exhibit 2, Supplementary T-Documents, ST17, page 55, Report of Dr N Kewal, dated 2 July 2010.
The applicant was seen by Dr D.A. Pritchard, Cardiologist, on 14 December 2010.
Dr Pritchard subsequently provided a report[43] dated 20 December 2010.
Dr Pritchard reported “no clinical evidence of recurrent myocardial ischaemia”. He then went on to say:
“However, he now has features of mild, somewhat liable hypertension and an inappropriate resting tachycardia, both of which are almost certainly the result of a chronic anxiety state which has been confirmed by psychiatrist,

Dr. Nicholas Jetnikoff. There seems no doubt that the workplace and particularly confrontational issues therein have constituted major stressors over the years, contributing in a major way to significant anxiety and introspection regarding his cardiac condition. Anxieties regarding potential graft failure in the future are ongoing and maintain background aggravation.”
[43] Exhibit 1, T Documents, T10, Independent Medical Report of Dr D Pritchard, dated 20 December 2010.
Dr Pritchard reported:
“There does not appear to be any invalidity purely on a cardiac basis related to ischaemic heart disease at this point but I believe his health would continue to deteriorate with an increased risk of acute cardiac events were he to try to resume his former employment in any role.”
Dr Pritchard agreed with Drs Kewal, Douglas and Darke recommendation for retirement on medical grounds, on the basis of total incapacity for work which, in his opinion was permanent.
On 20 April 2011, Dr Kewal again reported to the GP:[44] “He remains well with no angina following CABG by Dr Greg Stafford in April, 1992 when he was 39 years old. He has done well from the operation with no recurrence of angina. … The patient underwent a maximum stress test which was once again negative for ischaemia at a high workload. … Clinically this patient is progressing very well from a cardiac point of view.”
[44] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 29, Report of
Subsequently on 21 June 2011 the applicant was retired from the ATO on invalidity grounds.[45]
[45] Exhibit 1, T Documents, T20, page 88 Applicant’s statement enclosing supporting documentation.
On 2 May 2012, Dr Kewal again reviewed the applicant and reported to the GP:[46] “He has had a good result from the operation and has been free of angina since. … Clinically this patient is very stable from a cardiac point of view. He has had a very good result from his open heart surgery 20 years ago.”
[46] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 31, Report of
On 1 May 2013, Dr Kewal again reviewed the applicant and reported to the GP:[47] “He continues to do very well with no angina or dyspnoea following CABG with Dr Greg Stafford in April, 1992 at the age of 39 years. His exercise tolerance is excellent. … The patient had a further stress test which was once again negative for myocardial ischaemia at a very high workload. His performance today was in fact better than what he did 12 months ago. … I reassure [sic] the patient that all was well from a cardiac perspective. He has had an excellent result from his open heart surgery 21 years ago.”
[47] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 33, Report of
Dr Kewal reviewed the applicant on 23 April 2014 and reported[48] to the GP: “He remains well with no angina or dyspnoea and his exercise tolerance is excellent. The patient underwent a maximum stress test which was negative for myocardial ischaemia at a very high workload. He completed 15 minutes of the Bruce Protocol and achieved his predicted maximum heart rate without any symptoms or significant ECG changes. … Clinically this patient is progressing very well from a cardiac point of view. His risk factor management is excellent.”
[48] Exhibit 1, T Documents, T11, page 37, Report of Dr N Kewal, dated 23 April 2014; Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 35, Report of Dr N Kewal, dated
Dr Kewal reviewed the applicant again on 20 May 2015 and reported to the GP:[49] “He continues to do very well with no angina or dyspnoea following CABG by
[49] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 37, Report of
Dr Greg Stafford in April, 1992 when the patient was 39 years old. He exercises regularly and can maintain a heavy workload without any problems. … Clinically this patient is very stable from a cardiac point of view. He has had an excellent result from his open heart surgery 23 years ago.”
Dr Kewal reviewed the applicant again on 6 April 2016 and reported to the GP:[50] “He remains very well with no angina or dyspnoea following CABG by Dr Greg Stafford in April, 1992. … His risk factor management is very satisfactory and he keeps himself quite active with regular exercise. … The patient underwent a progress maximum stress test which was once again negative for ischaemia at a high workload. … Clinically this patient remains very stable from a cardiac perspective. He is doing very well following his open heart surgery 24 years ago.”
[50] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 39, Report of
Dr Kewal provided a further report dated 11 August 2016[51] in which he recorded that the applicant had undergone yearly stress tests which had been negative for myocardial ischaemia supporting the clinical impression of good ongoing surgical result.
[51] Exhibit 1, T Documents, T 13, pages 39 – 40, Report of Dr N Kewal, dated 11 August 2016.
Dr Kewal also recorded:
“The focus of Mr Berry’s management is now towards minimising his risk factors to prevent occlusive disease developing in his bypass grafts. His bypass grafts are now over 24 years old and the attrition rate of the vein grafts which were utilised in his case increases dramatically with age, particularly after 10 years.
…
I do not believe that aggravation of Mr Berry’s coronary artery ceased after his coronary bypass grafting in 1992. The surgery does not do anything regarding risk factor management.
Mr Berry is now at a higher risk of bypass graft disease given the duration since the operation and it is even more important that he continue with his current exercise programme involving the gym, swimming and walking.”
Doctor Enstice, General Practitioner, stated in a report[52] dated 2 September 2016 that the applicant had diligently followed a structured exercise programme which had been successful to date and should be continued indefinitely.
[52] Exhibit 1, T Documents, T14, page 41, Report of Dr M Enstice, dated 2 September 2016.
On 7 February 2017, the applicant was reviewed by Dr Hossack, Consultant Cardiologist, who subsequently provided a report dated 10 February 2017.[53] Dr Hossack recorded that the applicant indicated that since surgery he had had no angina symptoms, and denied exertional shortage of breath since surgery. Examination revealed no evidence of heart failure. The resting electrocardiogram was normal.
[53] Exhibit 1, T Documents, T18, pages 62 - 67, Independent Medical Report of Dr K Hossack, dated 10 February 2017.
Dr Hossack expressed the opinion that the applicant had a genetic predisposition to coronary artery disease that was possibly aggravated by work stress and dyslipidaemia. Dr Hossack also opined that if the applicant developed further problems with coronary artery disease, or developed symptoms with graft degeneration, this was due to the natural progression of the underlying disease and was in no way related to the alleged stress at work in 1991. He also said that there was a very strong association between age and the progression of coronary artery disease.
Regarding other health issues, Dr Hossack stated:
“I am of the opinion that Mr Berry has a pre-morbid anxious personality. Unfortunately this makes it difficult for him to deal with stressful situations. Despite cognitive behaviour therapy he still continues to react badly to perceived stress.”
Dr Hossack also considered that as a result of an adjustment in work tasks Mr Berry was no longer exposed to a stressful situation, and reported:
“As time progressed it became more apparent that an elevated cholesterol was a potential contributing factor to coronary artery disease. Because

Mr Berry was ageing this was an additional factor that contributed to the progression of coronary artery disease.”
Regarding the question whether the applicant’s employment contributed to his condition, the doctor commented:
“It would be my opinion that work related stress is no longer a contributor to the progression of coronary artery disease. Any effect of work related stress on progression of coronary artery disease has long since ceased.”
Dr Hossack recorded that whilst the medical literature supported physical activity following coronary artery bypass surgery there was no medical literature which indicated that that must be a specific gymnasium program and/or a swimming program. In his opinion the gymnasium program/swimming and yearly exercise tests were not necessary medical treatment. An annual exercise test did not prevent progression of coronary artery disease.
Dr Hossack did not recommend any further medical treatment, and considered that the aggravation/acceleration of coronary artery disease had ceased.
Following receipt of Dr Hossack’s report, on 14 February 2017, Comcare sent the applicant a notice of an intention to determine the applicant had no present entitlement to compensation for his accepted condition.[54] Comcare invited the applicant to submit further medical evidence supporting his claims for compensation by 17 March 2017.
[54] Exhibit 1, T Documents, T19, pages 68 – 70, Notice of Comcare’s intention to determine no present liability, dated 14 February 2017.
The applicant provided a response dated 10 March 2017.[55]
[55] Exhibit 1, T Documents, T20, pages 71 - 165, Applicant’s response and evidence to Comcare, dated
By a determination dated 27 March 2017, it was determined that the applicant did not continue to suffer the effects of the accepted “aggravation/acceleration of coronary artery disease” and as such the applicant had no present entitlement to compensation under section 16 or 21A of the Act.[56]
[56] Exhibit 1, T Documents, T21, pages 166 - 168, Determination of no present liability – ‘aggravation/acceleration of coronary artery disease’, dated 27 March 2017.
Dr Kewal again reviewed the applicant on 12 April 2017 and reported to the GP:[57] “He continues to do well with no symptoms of angina or dyspnoea. His exercise tolerance is quite satisfactory. The patient had a maximum stress test performed which was very well done with him completing 13½ minutes of the Bruce Protocol without any symptoms or ST segment changes of myocardial ischaemia. I discussed the findings with him and reassured him that all was well from a cardiac perspective. He has had an excellent result from his coronary artery bypass grafting 25 years ago.”
[57] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 41, Report of
By email dated 19 April 2017, the applicant requested reconsideration of the determination made on 27 March 2017.[58]
[58] Exhibit 1, T Documents, T22, pages 169 – 173, Applicant’s request to Comcare for reconsideration, dated 19 April 2017.
On 16 May 2017, Comcare issued a reviewable decision affirming the determination of
[59] Exhibit 1, T Documents, T24, pages 175 - 178, Reconsideration of determination, dated 16 May 2017.
27 March 2017.[59]
On 24 May 2017, the applicant made the current application to this Tribunal.[60]
[60] Exhibit 1, T Documents, T2, pages 3 – 8, Application for Review of Decision, date 24 May 2017.
Dr Kewal again reviewed the applicant on 17 July 2017 and reported to the GP:[61] “He has done well with no recurrence of angina or dyspnoea. His exercise tolerance is quite satisfactory. … BP was 185/84 (sitting) and probably reflected a degree of the “white coat syndrome” as well as the stress he is having discussing some of the legal issues that have arisen with Comcare recently. … Clinically this patient remains stable from a cardiac point of view. His risk factor management is satisfactory.”
[61] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 42, Report of
Professor Michael O’Rourke, cardiologist provided a report on the papers to Comcare dated 4 November 2017.[62] The Professor considered the applicant suffered coronary atherosclerotic disease causing ischaemic heart disease (IHD) causing symptoms in November 1991, and that symptoms had been relieved by successful coronary artery bypass surgery in April 1992. The doctor considered the applicant had been free from symptoms of IHD from the time of surgery to the time of the report.
[62] Exhibit 6, Briefing Letter and Report of Professor M O’Rourke, dated 11 October 2017 and 4 November 2017 respectively.
Professor O’Rourke opined that the applicant’s “[e]mployment with the ATO does not appear to have contributed to the onset, aggravation, acceleration or exacerbation of underlying pre-existing or constitutional conditions to any significant degree.” Professor O’Rourke stated the applicant’s coronary lesions had “almost certainly” been developing all his life up to time of symptoms onset, and that “it is more likely than not that work issues had no role in the development of coronary plaque.” Professor O’Rourke further stated “It is in my view very unlikely that employment has contributed in any way to his coronary artery disease and IHD.” He also stated “I believe that the applicant’s condition would be the same today regardless of any aspect or incident of his employment”.
This hearing took place on 9 May 2018, before a Senior Member who has since become incapacitated and unable to deliver a decision.
On 31 May 2019, the matter was re-constituted to the present member for the purpose of making a decision based upon the transcript of the hearing, and the various exhibits before the Tribunal at that time. Owing to the passage of time since the hearing, the parties were invited to make any further submissions they might wish to make by 21 June 2019, and both parties declined to do so.
The applicant later sent an email to the Tribunal on 23 July 2019 advising of the death of his mother at the age of 91.
CONSIDERATION
The applicant in this case suffers from coronary artery disease, and acknowledges that this probably commenced when he was in his late teens, built up over many years, and did not manifest itself until he was 39 years of age, by which time he was an employee of the ATO working in a high stress environment. The applicant suffered symptoms in 1991, and was diagnosed with ischaemic heart disease in February 1992, resulting in his undergoing a Coronary Artery Bypass Graft on 6 April 1992.
Subsequent to his surgery, the applicant has lost considerable weight, and adhered to an admirable dietary and exercise programme. He has closely monitored his health under regular specialist supervision, and has achieved a commendable level of physical fitness, and has not suffered any symptoms of angina or myocardial ischaemia since his surgery during the 27 years which have passed since his surgery.
Comcare only ever accepted liability in respect of the aggravation (as that term is used in the Act) of the applicant’s coronary artery disease. The applicant’s coronary artery disease, once diagnosed, was always going to require management, even if the admitted episode of aggravation had never occurred. Comcare never accepted liability for the coronary artery disease as such, and therefore could not be liable for its ongoing management. Comcare’s liability was limited to the aggravation /acceleration of that condition. If the aggravation ceased, so too did Comcare’s liability.
There is no evidence before the Tribunal so as to admit of a finding that the applicant’s compensable condition has recurred, worsened, accelerated, exacerbated or intensified during the period since his post-operative recovery. There is, therefore, no evidence before this Tribunal so as to admit of a finding that the applicant has suffered any episode which might be described as an aggravation of his condition since completing post-operative recovery. In all the circumstances, it appears that the applicant’s recovery has been as good as could be hoped for, and he and his medical advisors should be proud of that. Dr Kewal put it in a nutshell when he said: “Clinically this patient remains very stable from a cardiac perspective.”[63]
[63] Exhibit 9, Bundle of medical tests and reports relating to the Applicant’s stress tests, page 39, Report of
In the absence of any episode of aggravation since the applicant’s post-operative recovery, it is unnecessary to consider whether the applicant’s employment contributed to it in a material degree.
The Tribunal is satisfied, and finds as a fact, that the aggravation of the applicant’s compensable condition ceased following his post-operative recovery. It follows that the applicant has had no compensable condition on or after 5 April 2017.
DECISION
Accordingly, the decision under review is affirmed.

I certify that the preceding 112 (one hundred and twelve) paragraphs are a true copy of the reasons for the decision herein of Member R Maguire

......................[Sgd]..............................
Associate
Dated: 28 November 2019

Date of Hearing: 9 May 2018

Applicant: In person

Counsel for the Respondent: Ms K Slack

Solicitors for the Respondent: Sparke Helmore

10 February 2017.

Dr N Kewal, dated 3 June 1992.

Dr N Kewal, dated 8 December 1992.

Dr N Kewal, dated 29 November 1993.

Dr N Kewal, dated 17 November 1994.

Dr N Kewal, dated 29 November 1995.

Dr N Kewal, dated 23 April 1997.

Dr N Kewal, dated 5 June 1997.

Dr N Kewal, dated 15 March 1999.

Dr N Kewal, dated 14 May 2003.

Dr N Kewal, dated 31 May 2006.

Dr N Kewal, dated 6 June 2007.

Dr N Kewal, dated 15 April 2009.

Dr N Kewal, dated 14 April 2010.

Dr N Kewal, dated 20 April 2011.

Dr N Kewal, dated 2 May 2012.

Dr N Kewal, dated 1 May 2013.

23 April 2014.

Dr N Kewal, dated 20 May 2015.

Dr N Kewal, dated 6 April 2016.

23 March 2017.

Dr N Kewal, dated 12 April 2017.

Dr N Kewal, dated 17 July 2017.

Dr N Kewal, dated 6 April 2016.

Date of Hearing:	9 May 2018
Applicant:	In person
Counsel for the Respondent:	Ms K Slack
Solicitors for the Respondent:	Sparke Helmore