Cash and Australian Postal Corporation (Compensation) - [2021] AATA 3323

Cash and Australian Postal Corporation (Compensation) [2021] AATA 3323 (15 September 2021)
Administrative Appeals Tribunal

ADMINISTRATIVE APPEALS TRIBUNAL )

) No: 2016/4590, 2016/6819

GENERAL DIVISION )
Re: Leesa Cash
Applicant

And: Australian Postal Corporation
Respondent
DIRECTION
TRIBUNAL:  Dr I Alexander, Senior Member
DATE OF CORRIGENDUM:            1 October 2021
PLACE:           Sydney

IT IS DIRECTED, in accordance with subsection 43AA(1) of the Administrative Appeals Tribunal Act 1975 (Cth), that the text of the decision in this application is to be altered such that:
1.    both references to “Comcare” in the decision are replaced with “the Respondent”;
2.    the reference to “Comcare” at paragraph 210 of the reasons for decision is replaced with “the Respondent”;
3.    both references to “Comcare” at paragraph 227 of the reasons for decision are replaced with “the Respondent”.

.................................................................[sgd]…………..
Dr I Alexander, Senior Member
Division:GENERAL DIVISION
File Number(s): 2016/4590, 2016/6819
Re:Leesa Cash
APPLICANT

AndAustralian Postal Corporation
RESPONDENT

DECISION
Tribunal:Dr I Alexander, Senior Member
Date:15 September 2021
Place:Sydney

The Tribunal finds that:
· as at 18 July 2016, Comcare was not liable to pay compensation under sections 16 and 19 of the SRC Act for bilateral plantar fasciitis and regional pain syndrome.
· as at 8 September 2016, Comcare was not liable to pay compensation under sections 16 and 19 of the SRC Act for secondary mild adjustment disorder with depressed mood.

The decisions under review are affirmed.
.........................................................[sgd]...............
Dr I Alexander, Senior Member
CATCHWORDS
WORKERS’ COMPENSATION – bilateral plantar fasciitis – regional pain syndrome – whether the effects of the injuries had ceased – secondary mild adjustment disorder with depressed mood – whether the Applicant suffered a psychiatric condition that was contributed to, to a significant degree, by her employment – decisions under review affirmed
LEGISLATION
Safety, Rehabilitation and Compensation Act 1988 (Cth) ss 4, 5A, 5B, 7, 14, 16 ,19
CASES
Military Rehabilitation and Compensation Commission v May [2016] 257 CLR 468
Telstra Corporation Limited v Hannaford [2006] FCAFC 87
Woodhouse v Comcare [2021] FCAFC 95
REASONS FOR DECISION
Dr I Alexander, Senior Member
15 September 2021
BACKGROUND

Ms Cash commenced employment with Australia Post in October 2014 as a casual employee. After 12 months she was employed on a fixed term contract and was then appointed to a permanent position.
On 1 July 2015, about eight months after starting her employment with Australia Post, Ms Cash lodged a claim for compensation.
In a determination, dated 27 August 2015, Australia Post accepted liability under section 14 of the Safety, Rehabilitation and Compensation Act 1988 (Cth) (the SRC Act) for ‘bilateral plantar fasciitis and regional pain syndrome’ with a date of injury deemed to be 10 June 2015.
Following an assessment by Mr T. O’Neill, clinical psychologist, the description of liability for Ms Cash’s claim was extended on 8 January 2016 to ‘bilateral plantar fasciitis and regional pain syndrome and secondary mild adjustment disorder with depressed mood’.
In a reviewable decision, dated 16 August 2016, a Reconsideration Officer affirmed an earlier determination dated 18 July 2021 which determined that Australia Post had no present liability for compensation under sections 16 and 19 of the SRC Act” for the accepted conditions of ‘bilateral plantar fasciitis and regional pain syndrome’ (Application 2016/4590).
In a reviewable decision, dated 21 November 2016, a Reconsideration Officer determined Ms Cash was “not entitled to compensation under sections 16 and 19 of the SRC Act for the psychiatric condition secondary to the foot injury as at 8 September 2016[1] to date and as at the present date” [sic] (Application 2016/6819).
[1] The date of the initial determination that the Respondent was no longer liable to pay compensation in respect of this injury.
In these proceedings, Ms Cash, who was represented by counsel, seeks review of the reviewable decisions.
The Tribunal first heard evidence in this matter on 12 and 13 June 2019 with the parties attending a face-to-face hearing. In the course of the hearing, issues with respect to aspects of the medical evidence arose, and it was agreed to adjourn the hearing to arrange for further evidence.
Due to the interruptions of COVID-19 the matter was unable to be heard until 19 and 20 April 2021. In view of the temporary changes regarding the suspension of face-to-face Tribunal hearings, at that time, all the parties attended the hearing by video conference.
At the request of the parties, in order to all allow the parties to review the evidence and prepare submissions, the matter was again adjourned.
Subsequently, both parties provided written outlines of submissions and on 2 August 2021, by video conference, the hearing was resumed for final oral submissions.
RELEVANT STATUTORY PROVISIONS
Section 14 of the SRC Act provides that Comcare is liable to pay compensation in respect of an ‘injury suffered by an employee if the injury results in death, incapacity for work, or impairment’.
‘Injury’ is defined in subsection 5A(1) of the SRC Act to mean:
(a)       a disease suffered by an employee; or
(b)       an injury (other than a disease) suffered by an employee, that is a physical or mental injury arising out of, or in the course of, the employee’s employment; or
(c)       an aggravation of a physical or mental injury (other than a disease) suffered by an employee (whether or not that injury arose out of, or in the course of, the employee’s employment), that is an aggravation that arose out of, or in the course of, that employment;
but does not include a disease, injury or aggravation suffered as a result of reasonable administrative action taken in a reasonable manner in respect of the employee’s employment. [emphasis added]
‘Disease’ is defined in section 5B of the SRC Act:
(1)       In this Act:
“disease” means:
(a)       an ailment suffered by an employee; or
(b)       an aggravation of such an ailment;
that was contributed to, to a significant degree, by the employee’s employment by the Commonwealth or a licensee. [emphasis added]
(2)       In determining whether an ailment or aggravation was contributed to, to a significant degree, by an employee’s employment by the Commonwealth or a licensee, the following matters may be taken into account:
(a)       the duration of the employment;
(b)       the nature of, and particular tasks involved in, the employment;
(c)       any predisposition of the employee to the ailment or aggravation;
(d)       any activities of the employee not related to the employment;
(e)       any other matters affecting the employee’s health.
This subsection does not limit the matters that may be taken into account.
(3)       In this Act:
“significant degree” means a degree that is substantially more than material.
“Ailment’ is defined in section 4(1) of the SRC Act as ’any physical or mental ailment, disorder, defect or morbid condition (whether of sudden onset or gradual development)’.
Section 7(7) of the SRC Act provides:
A disease suffered by an employee, or an aggravation of such a disease, shall not be taken to be an injury to the employee for the purposes of this Act if the employee has at any time, for purposes connected with his or her employment or proposed employment by the Commonwealth or a licensed corporation, made a wilful and false representation that he or she did not suffer, or had not previously suffered, from that disease.
Section 16(1) of the of the SRC states:
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.
Section 19 of the SRC Act is headed “Compensation for injury resulting in incapacity”. Section 19(1) states ‘This section applies to an employee who is incapacitated for work as a result of an injury other than an employee to whom section 20, 21, 21A or 22 applies’.
ISSUES
The issues in this matter involve three interrelated “ailments”, namely bilateral plantar fasciitis, regional pain syndrome and secondary mild adjustment disorder with depressed mood.
2016/4590
There is no dispute that, in 2015, Ms Cash suffered bilateral plantar fasciitis, and it is agreed that her employment contributed to this condition, to a significant degree. Therefore, this condition was a ‘disease’ for the purposes of section 5B of the SRC Act and Ms Cash was entitled to receive compensation payments under sections 16 and 19 of the SRC Act.
The Respondent contends that, as at 18 July 2016, the bilateral plantar fasciitis had resolved, and Ms Cash was no longer entitled to compensation payments under sections 16 and 19 of the SRC Act.
It is agreed that in 2015, Ms Cash also suffered a ‘pain syndrome’ that is claimed to have been ’triggered‘ by the bilateral plantar fasciitis. The precise nature of this condition has been disputed. Australia Post had accepted liability for regional pain syndrome whereas, Ms Cash contends that the she had suffered a complex regional pain syndrome (CRPS) as diagnosed by her treating physician, Dr Ho in July 2015.
Ms Cash also contends that, as at 18 July 2016, she had not fully recovered from the CRPS and continues to suffer from this condition to the present day, and, therefore, is entitled to continue to receive compensation payments pursuant to sections 16 and 19 of the SRC Act.
2016/6819
At the time of the initial diagnosis of CRPS, Dr Ho also made a diagnosis of Adjustment Disorder with anxiety and depression. Ms Cash contends that this secondary psychiatric condition was caused by her bilateral plantar fasciitis and CRPS and that, as at 8 September 2016, she had not fully recovered and continues to have symptoms to the present day.
There is no dispute that Ms Cash suffers significant mental health issues. The main issue for the Tribunal to determine, is whether Ms Cash did suffer a psychiatric condition that was contributed to, to significant degree, by her employment with Australia Post, that is, whether liability under section 14 of the SRC Act should have been accepted.
If the Tribunal finds that section 14 liability should have been accepted, there is an issue with respect to the operative effect of section 7(7) of the SRC Act, in light of the fact that Ms Cash failed to reveal her pre-existing history of mental health issues in her Australia Post pre-employment medical questionnaire.
If the Tribunal finds that section 14 liability should have been accepted, and that section 7(7) of the SRC Act does not operate to disallow compensation for the psychiatric condition, then the Tribunal must determine whether, as at 8 September 2016 and until present, the Applicant is entitled to compensation under sections 16 and 19 of the SRC Act.
DOCUMENTARY EVIDENCE
Ms Cash’s Statements
In a written statement dated 11 March 2016, Ms Cash stated, inter alia, as follows:
18. As a condition of my employment with Australia Post[2] I was required to were steel cap boots. …
[2] Employment commenced on Monday 27 October 2014.
19. in early November 2014[3] I first saw the GP as I had developed blisters on my feet which had become infected. My general practitioner treated me with antibiotics and I had approximately 7 days off work…
[3] Wednesday 5 November 2014.
24. From when I commenced my employment…my feet were always painful and sore, however symptoms of plantar fasciitis really flared up in March 2015[4]…
[4] There is no reference to foot pain in GP records until June 2015.
25. In May 2015 I underwent a bone scan which indicated that there were several fractures in my feet.[5] …
[5] Bone scan was performed on 26 June 2015 – the “fractures” were misdiagnosed.
27. In June 2015[6] I made a worker’s compensation claim…
[6] 1 July 2015.
28. I made the claim after my feet “seized up” essentially causing my feet to stop working, causing me to fall over.
29. On 16 July 2015 I saw Dr O’Carrigan
30. Dr O’Carrigan referred me to Dr Ho, whom I saw on 24 July 2015…
31. On 27 July 2015 I underwent an MRI which confirmed the diagnosis of plantar fasciitis.
32. On 31 July 2015 I had a cortisone injection into my lumbar spine…approximately 2 weeks after the injection I noticed a big change in my left leg’s sensitivity, for the better, and some pain relief in my left foot. The injection was very beneficial to me.
33. I had an injection of cortisone into the fascia (left foot) about 6 weeks later. That was helpful also.
…
35. Throughout this entire period my left foot has been worse than my right foot, however I have experienced symptoms in both feet .
37. Dr Ho confirmed the diagnosis of chronic regional pain syndrome and I was seeing him every month to 6 weeks.
38. I worked on 1 September, 3 September and 8 September 2015 however between 9 September and 19 October 2015 I did not work at all…
39. I then returned to work 2 days per week…until about the start of February 2016.
40. I then had 6 weeks off and was paid compensation in that period. I then started working again on 9 March, I day per week. …
…
43. My ongoing symptoms…are as follows:
(a) Burning on the soles of both feet, which spreads up the knees.
(b) Swelling in both feet, increasing throughout the day.
(c) Loss of hair and changes to the nature of the hair on both of my feet and legs.
(d) Mottled colour in both feet and legs.
(e) Changes to toenails.
(f) Numbness in both feet.
(g) Constant and chronic pain.
44. My ongoing disabilities… are as follows:
(a) Unable to stand for more than 10 to 15 minutes.
(b) Limited walking to short distance, the distance varying from day to day depending on pain.
(c) poor balance.
In a written statement, dated 14 April 2018, Ms Cash noted similar issues covered in her earlier statement with an expanded description of the circumstances in the workplace and her employment. Other relevant other issues she raised are recorded, inter alia, as follows:
13. I had some post-natal after birth of my first child. I also had post-natal depression after the birth of [child’s name] in 2002 but it wasn’t as bad.
14. … I was admitted to Waratah Psychiatric unit at Campbelltown for depression for about three weeks in 2006. This was a voluntary admission. I have not been readmitted to any psychiatric unit since then.
15. I was treated by a psychiatrist and counselled by my GP for depression. I spent about 12 months in total taking antidepressants when I was pregnant with my fifth child in 2007.
…
18. I commenced working for Australia Post…in about October 2014…as a Christmas casual and continued as a casual for 12 months. I was then put on a fixed term contract for 12 months. At the expiration of the term, I became a permanent employee. …
…
39. By November 2014 I had developed blisters of both feet. I contracted a staph infection. …
…
45. The blisters healed, but I developed numbness and tingling in three toes on the left foot and pain in the heel and then the toes of both feet. The pain was worse in the left foot. The pain then spread in the fascia muscle running from toe to heel
46. I continued working for some months. The pain worsened.
47. On 10 June 2015, I was unable to attend work because of pain and stiffness. When I tried to get out of bed my feet were so stiff they would not support my body and I fell to the ground.[7]
[7] In a consultation note dated 11 June 2015, Dr Ng, Ms Cash’s regular GP, makes no reference to this episode.
48. I contacted Matt Stamar and told him what happened. He asked if my condition was work related. I said yes. He said, you need to come in…
49. My husband drove me in, and helped me into the office, to fill in the incident/accident report.
50. Stamar sent me to Australia Post’s doctor at [location], Dr Lee.
51. Dr Lee sent me for a bone scan. I was told I had 7 broken bones…Dr Lee…sent me to physio who supplied a CAM and I went back to work with the CAM boot on my left foot. .
52. I was assigned to work at the office in [location] … I did this work for two or three weeks. Then I went back to Dr Patrick Lee and told him the CAM boot was not helping. I took the CAM boot off. My foot was swollen and painful and discoloured. Dr Lee advised me that I had complex regional pain syndrome. He referred me to Dr Carrigan [sic]. … He also said I had complex regional pain syndrome. He advised me to obtain an MRI. … It showed that the fascia muscles on both feet were damaged. It was worse on the left side.
…
54. Dr Lee prescribed pain medications. … They did not help.
55. Dr Carrigan referred me to Dr Tim Ho… He gave me steroid infections, and pain medications. They provide some relief, but I could still hardly walk.
56. I saw a podiatrist at about this time. He prescribed a shoe. This was an ASICS gel shoe with inserts provided by the podiatrist.
57. At first, I could only wear these shoes for short periods. I gradually built up tolerance over a period of 12 months.
…
63. On 31 July 2015 I had a cortisone injection. …
64. At about the time of the second infusion November 2016 Australia Post offered me $50,000 dollars to give up my job and go away. I said, “No I want my job. I cannot work anywhere else”.
…
70. I have had five Ketamine infusions in total. I have been told I will need to continue with Ketamine infusions indefinitely.
71. I’m not able to work as I suffer with migraines, memory issues, mind of fog pain from CRPS in both feet and legs and lower back…I haven’t been pain free since the blisters caused by my steel capped boots at Aust Post.
…
73. I am never pain free while walking and I have to take breaks if walking more than 30 minutes The further I walk the more intense the pain is and swelling will start to happen along with muscles spasms.
In a written statement dated 20 August 2018, Ms Cash stated, inter alia, as follows:
…I would like to clarify the sequence of events in relation to my psychiatric injury:
1. I injured my foot as set out in my prior Statement…
2. In around June, about 8 months after my injury, complex regional pain syndrome was diagnosed. Before that, I had seen numerous Doctors and the diagnosis of the continuing pain and its spread had been unclear.
3 The pain increased over time and started to become chronic and experienced every day at a significant level. This played on my mind and made me sad and withdrawn. I sought advice from my GP about this after I realised that something was wrong with me emotionally.
4. The work situation also contributed to my depression…
…
11. As a result of the Supervisor’s actions after my injury, I became isolated and bullied. This added to my depression. I was forced to work on my own at an isolated table and away from other staff. …
In a written statement dated 6 March 2019, Ms Cash stated, inter alia, as follows:
3. I continue to have pain in my feet. The pain extends up the left leg to the left hip.
4. In January 2019, I had a Ketamine infusion. The pain at the moment is less intense than before the Ketamine infusion.
…
6. This was my seventh infusion. I had two infusions last year, in June and November[8]. I am not having as many infusions because I cannot afford them and I need to arrange childcare for admissions into hospital. I am also concerned about side effects of Ketamine.
[8] DHS-Medicare Patient History Report (MPHR) for period 1 May 2014 to 15 April 2019: 7-day Ketamine infusions in June 2017, November 2017, June 2018 and January 2019.
…
9. I would be attending physiotherapy if I could afford it. When I first had physiotherapy I was in too much pain to benefit from it, but now the pain is more controlled, I think I would benefit from physiotherapy.
10. I go swimming every second day. I use my backyard pool in summer. …
…
12. I continue to see Dr Robert Ng every two to three weeks. He provides psychological support. He prescribes Palexia[9] for pain. I take Palexia once or twice a week when pain is bad.
…
19. I do some cooking and food preparation. I can’t stand and this makes cooking and cleaning up difficult. …
…
21. …Occasionally when I am having a good day, I can vacuum.
22. I don’t get out much. ….I feel very anxious.
23. …Occasionally I attend sporting fixtures where [child’s name] is playing. …
24. I can drive short distances. If I drive for long distances, I get cramps in my leg.
[9] DHS – PBS Patient Summary - 1 May 2014 to15 April 2019 (PBS): Tapentadol (Palexia) prescribed by Dr Ng 5 February 2016 (28 tabs no repeats), supplied 9 February 2016. No other prescriptions by Dr Ng recorded. Dr Ho -Tapentadol (28 tabs no repeats) – 24 July 2015, 17 September 2015, 1 December 2015 and 2 May 2017.

In a written statement, dated 3 February 2020, Ms Cash provided details of her airplane travel as follows:
October 2016: Thailand - 10 days - Holiday/relaxation (minimal activity)
October 2018: Cairns – 10 days - Holiday /relaxation for my birthday
November 2019: Barcelona – 15 days - Accompanying my daughter … watched my daughter playing games and undertook basic sightseeing
Prior to each of the above trips, I consulted with my GP and medication was taken on all trips…my specialist was also consulted prior to each trip[10] …I have spent more time in hospital…having ketamine infusions than time away.
[10] This claim is not consistent with the documentary evidence.
Surveillance reports
During several periods of surveillance in February 2017, April 2017, April 2019, December 2019 and January 2020, Ms Cash was observed to regularly drive a silver-coloured Toyota Camry sedan (Car 1), which was fitted with an automatic transmission.
During the same period Ms Cash’s partner was observed to regularly drive a silver coloured Toyota Corolla sedan (Car 2).
Surveillance field notes from December 2019 are reported, inter alia, as follows:
Friday 27 December 2019
6:30 am: Surveillance commenced…in the vicinity of the given address at [Ms Cash’s home address]. …[Car 1] was observed parked and unattended in the driveway with [car 2] parked kerbside. …
11.58 am: [Car 2] departed…with the driver not identified at this time.
The vehicle parked at the loading dock of [Market Place]…at 11.59am … An unknown male alighted from the driver’s seat carrying an empty shopping bag…
12.15 pm: [Car 2] returned to [home address]. The unknown male person carried some grocery bags into the residence. …
Saturday 28 December 2019
7.00 am: Observations continued…
7.52 am: [Car 2] departed with the unknown male person believed to be Claimant’s partner ex-husband/partner as driver and sole occupant. …
8.05 am: He returned to the residence.
8.30 am: [Car 1] departed with a female matching the Claimant’s description as driver, her partner as front passenger, and possibly children in the rear passenger seat. [Mobile surveillance commenced]
8.40 am: [Car 1] travelled along the [highway] in a southerly direction with the Claimant as driver…
9.21am: It continued to travel along [road]…
9.45 am: The Claimant drove her vehicle along [road]…entering [National Park].
9.50 am: The Claimant parked her vehicle in the secluded [Picnic Area].
10.01 am: …we identified the Claimant returning to her vehicle carrying a large bag over her right shoulder and a handbag over her left shoulder. Her partner also carried some picnic type items and the Claimant placed the items into the boot and re-entered the driver’s seat. Two children entered the rear passenger seat and the vehicle departed again. …
10.09 am: After turning left onto [road]…the Claimant travelled about 1 kilometre before pulling over and conducting a U-turn. …
10.33 am: We canvassed [National Park] and its various campground picnic areas.
12 00 pm: With no further sighting of the Claimant or her vehicle, we ceased observations.
Pre- Employment Medical – Australia Post
A Pre-Employment Medical Questionnaire, signed and dated by Ms Cash and Dr Papatheodorakis on 8 September 2012, recorded the following:
Do you have or have you ever experienced the following? Please answer all question by writing YES or NO in the box.
…
38 Depression? NO
…
40 Anxiety, nervous illness or breakdown which have discussed with a doctor or counsellor? NO
DOCUMENTARY MEDICAL EVIDENCE
Waratah House Campbelltown Hospital
On 3 February 2006 Ms Cash was admitted to the Waratah House Mental Health Unit for treatment of Major Depression. She was discharged on 21 February 2006 on antidepressant medication.[11]
[11] Effexor (venlafaxine) - SNRI antidepressant.
Campbelltown Medical Dental Centre
Clinical practice records confirm that between January 2011 and February 2013, Ms Cash was being treated for depression with antidepressant medication.
Dr Kneebone – Consultant Psychiatrist
On 24 October 2012 Dr Chakma, Ms Cash’s treating GP at that time, referred Ms Cash to Dr Kneebone for advice and help in the continuing management of her “anxiety and depression”.
In a letter to Dr Chakma dated 24 October 2012, Dr Kneebone noted that Ms Cash “was commenced on antidepressant medication 5 years ago, currently Dothiepin 50 mg daily, following a severe depressive episode requiring hospital treatment.”
Dr Kneebone summarised his “clinical impression” as follows:
Leesa is a 40 year old woman presenting with a longstanding history of distractibility, lack of sensitivity, inflexible adherence to self imposed rules, restlessness and shortness of temper, beginning in childhood which has given rise to impairments in her interpersonal and social functioning.
Her clinical picture has been complicated by anxiety and a probable major depressive disorder.
Her history and clinical picture are felt to be consistent with DSN-IV diagnosis of attention deficit hyperactivity disorder[12] occurring in the context of autistic spectrum disorder with multiple comorbidities including anxiety and a major depressive disorder.
[12] ADHD.
Dr Kneebone recommended further psycho-education with an educational consultant specialising in ADHD and a trial of Ritalin.[13]
Eagle Vale Medical Centre - Extracts from clinical practice notes[14]
[13] Ritalin (methylphenidate) is a nervous system stimulant often used in treating ADHD.
[14] These extracts have been significantly edited in the interest of privacy.
The following extracts are from the clinical practice notes of Dr Robert Ng, except where otherwise indicated:
15 April 2013: on antidepressants for 7yrs. had ‘breakdown’ and was in waratah house for 3 wks … on dothep 25mg at night[15]… teary and anxiety. seeing a counsellor. increase dothep for now…
[15] Tricyclic antidepressant.
2 August 2013 (Dr Mikhail): DEPRESSION ON DOTHEP 25…
3 October 2013 (Dr Mikhail): GOING TO THAILAND…
20 November 2013: went off dothep 50 mg a day and weened off 3 mths ago.
> teary. Depressed…suicidal thoughts thought about overdose…
start on dothep. review in wk and go to counsellor again…
25 November 2013: started dothep. needs a care plan…
5 December 2013: long chat again…Reason for contact: Depression
3 February 2014: struggling with depression. on dothep again a wk ago. 25mg now. was taking 75mg.prefers not to increase. … was on efexor but stopped working. was on lexapro > no good. then dothep > worked with anxiety, depression and fibromyalgia. Reason for contact: Depression [emphasis added] ……
12 February 2014: still struggling. suicidal thoughts. was on 75mg dothep but too tired. has to go to court to give evidence against ex husband…
10 March 2014: will take two wks off…‘break down’…some pressures at work… stressful with job, stressful kids , relationship problem…
17 March 2014: - .fibromyalgia[16] is playing up. fatigued and pain … in a pain pit. not happy…wants to be left alone…some suicidal thoughts…seroquel[17] 25mg nocter and stop dothep and start efexor 37.5>75mg[18]…Reason for contact: Depression [emphasis added]
[16] For definition of fibromyalgia see report of Dr Johnstone at para 93 below.
[17] Seroquel (quetiapine) is an atypical antipsychotic medication used for the treatment of schizophrenia, bipolar disorder and major depressive disorder and is often used as a sleep aid due its sedating effect.
[18] Efexor (venlafaxine) – SNRI antidepressant.
21 March 2014: seroquel 25mg slept…noise in head gone. hasn’t started on efexor. still not ready to go back to work again. [emphasis added]
11 April 2014: back to work. overall ok…improving…ok without antidepressant. continue on seroquel for now.
12 May 2014: had meeting today…why she shouldn’t be sack…
13 May 2014: she was sacked today because she did not meet the marist brother mission > solicitor will take it up for unfair dismissal…
18 June 2014: doesn’t want seroquel > too tired. did not try efexor…overwhelmed with grief and pain… [emphasis added]
24 June 2014: started efexor. feeling better…walking daily…appetite still low. only one teary episode. concentration still poor [emphasis added]
21 August 2014: ….feeling depressed since st gregs put her off. no job > insecurities and hopelessness. started family counselling…?antidepressant... side effects. lexapro > wt. dothep > dopey. efexor xr > muscle tight and sore
prolonged consult re depression ? cyclothymia and cbt. …
Prescription added: sertraline…50 mg mane[19]…
[19] Sertraline - SSRI antidepressant: PBS Patient Summary (1/5/2014-15/4/2019) - prescription not dispensed.
17 October 2014: casual at australia post first shift on 27/10
5 November 2014: steel capped shoes. broke skin and now cellulitic
7 November 2014: ‘melt down today’…she feels like she doesn’t have power over her own life …she goes well for a few mths and then not so well. pain and she is not worthy…pain is intense [emphasis added]
2 December 2014: hates the people and the job…supervisors talk down to you.
23 December 2014 – Reason for contact: Anxiety
struggling. depression…likes the job doesn’t like people…
Prescriptions….SEROQUEL TABLET 25mg ½ nocte [emphasis added]
17 January 2015: has self medicated with alcohol … drank shots – almost ½ bottle of rum. did it twice. now when stressed she numbs pain with alcohol…
Reason for contact: anxiety and depression…
SERTRALINE…ceased. … SEROQUEL…ceased.
Prescriptions…EFEXOR-XR SR CAPSULE 37.5 mg 1 daily[20] [emphasis added]
[20] There is no record of prescriptions being dispensed.
24 January-2015: [significant family issues noted but not disclosed for privacy reasons]…seroquel 25mg too strong > so stopped. hasn’t started efexor > start.[21] [emphasis added]
[21] There is no record of prescriptions being dispensed.
4 February 2015: [family issues noted but not reproduced for privacy reasons]
EFEXOR…ceased…Prescription…VALIUM TABLET 2 mg 1 t.i.d p.r.n[22]
[22] There is no record of prescriptions being dispensed.
21 February 2015: 12 mths fixed contract and now supervisor…
5 March 2015: not coping. people’s expectations are unrealistic…
9 March 2015: [family issues noted but not disclosed for privacy reasons]
11 April 2015: VALIUM TABLET 2 mg ceased. …dizzy spells…when she is stressed or tired it is worse
15 April 2015: not coping…has had a headache all day. tender over upper neck
2 June 2015: [significant family issues noted but not reproduced for privacy reasons]
29 June 2015: pain started in oct when she started working for aust post. saw me with blisters on 5/11/14 and 11/11. in feb and march worse but most intense pain about 3-4 weeks ago
15 July 2015: …rt ankle sore. also sore ankles and knees and back. pain meds – palexia[23] up to 4 tablets a day and prednisone…also has had pan forte
[23] Palexia (tapentadol) - oral opioid analgesic.
16 July 2015: …left plantar fasciitis…Dr Tim Ho, pain specialist…
22 July 2015: she went back to work on Tuesday…pain medication makes her feel drowsy, foggy, so cannot drive. so she doesn’t take anything if she has to drive. so she is in extreme pain. takes her 35-40 minutes.
27 July 2015: saw pain specialist. he believes that she has crs [sic] from plantar fasciitis
28 July 2015: letter dr O’Carrigan…thinks she is at risk of developing a complex regional pain syndrome because of the global nature of the pain, the hypersensitivity and the burning nature
29 July 2015: not coping with pain > dr Ho > increase palexia tds
3 August 2015: Dr Ho, took her off neurontin because of side effects. given efexor but side effects so she stopped
14 August 2015: given endep 10[24] - but very tired. has helped with pain…saw Dr Ho last Friday > took efexor xr ; increased palexia 100mg tds and creams
[24] Endep (amitriptyline) – tricyclic antidepressant.
17 August 2015: exacerbation over the weekend…current meds: palexia 100mg tds. endep 10 nocte. she stopped temporarily because too sedating
18 August 2015: cream that Dr Ho gave > ketamine / amitriptyline/ lignocaine…
19 August 2015: burning sensation has lessened…endep still knocking her out…not helped with foot pain. the creams are giving some relief
25 August 2015: Dr O’Carrigan > mri > plantar fasciitis. underlying pathology is plantar fasciitis but pain profile is crp.
28 August 2015: Dr Magill calls it regional pain syndrome but Dr ho doesn’t know of such diagnosis. Dr Ho wants her to go back on endep, she stopped because she was too tired > she is needs [sic] to keep taking this.
4 September 2015: had injections in her feet today.
9 September 2015: had big session with physio today – pain is worse.
10 September 2015: she could hardly walk after physio.
14 September 2015 - Note from Dr Ho. increase work hours in 2 weeks to 3 days a wk…duloxetine 30mg mane [25] instead of endep. psychologist and physio.
[25] Duloxetine – SNRI antidepressant medication – no PBS record of supply.
18 September 2015: Dr Ho, thinks she has an adjustment disorder with anxiety and depression related to pressure of increasing hours and pain. he suggests that she see a psychiatrist for mental capacity assessment and management of anxiety and depression.
28 September 2015: she is still in pain…burning has got worse
28 October 2015: went to work yesterday. bad day. she almost left early but she stayed the whole day. was aching, burning and painful.
6 November 2015: this wk she struggled with pain and discomfort. she is doing everything. cannot walk fast or long
28 November 2015: saw Dr Ho yesterday > burning sensation moved up to back of her lt thigh…appointment on 11/12 - if worse see him before and will do an infusion in hosp
7 December 2015: saw podiatrist…he noted there was an infection between rt 4/5 toes …looks like tinea…canesten cream…uses also antifungal powder
19 December 2015: had a bad day yesterday. went to work…had a lot of pain. started epilim[26]… [notes describe issues at work]
[26] Epilim (sodium valproate) - anticonvulsant medication.
21 December 2015: Reason for contact: Tinea…in shoes and compression socks…tinea between rt 4/5^th toes not healing…sore and swollen
5 February 2016: Dr Ho moved to Parramatta. he sent her to a colleague in parramatta -psychologist
21 March 2016: going ok at [work location]. this coming week to do two full days from 19/3>29/3. Then…every 3 weeks increase by ½ day
8 April 2016: flare up of pain yesterday for no obvious reason
16 April 2016: air con in [work location] is too cold so this is flaring her pain up
11 May 2016: (Dr Kathirgamanaarthan): left leg pain. Complex regional pain syndrome. Examination: not red, not swollen, not hot, not tender. [emphasis added]
18 May 2016: Dr Ho > now palexia 100 mg tds prn and topical agents prn > doing well as she has been able to wean off her regular meds > more efficient in managing pain flares
21 May 2016: pain is worse lt foot and leg. flare up Monday 16/5…rang Dr Ho…he is going to organise a ketamine infusion in hosp…saw a dr from w/c…dr David Maxwell, orthopaedic surgeon
3 June 2016: no better this wk. still waiting on approval for ketamine
7 June 2016: showed me pictures of her feet with the colour changes. early signs of paronychia, edge of lt big toe ripped off… Reason for contact: early paronychia[27]…Prescription…EES tablet 400mg 2 b.d.[28]
[27] Paronychia - inflammation of skin around toenail. In note there is no description of clinical signs consistent with CRPS.
[28] Antibiotic.
21 June 2016: letter from australia post, she doesn’t have complex regional pain syndrome
22 June 2016: she is very upset tha [sic] Australia Post has not accepted her diagnosis of complex regional pain syndrome
25 June 2016: very depressed…
6 July 2016: spoke with Dr Ho. he is wanting to do ketamine infusion. she still has crps
12 August 2016 (receptionist): call from auspost…case closed…no present liability as of 17/7/16
13 August 2016: Dr Ho – she did not turn up fo her appointment
27 September 2016 (Dr Kathirgamanaarthan): For immunization. Otherwise feeling well [emphasis added]
27 September 2016 (Registered Nurse): Reason for contact: Travel vaccination [emphasis added]
8 May 2017 (Dr Mikhail): CHRONIC PAIN SYNDROME
17 October 2017 (Dr Kathirgamanaarthan): NEEDS CC. Chronic pain syndrome… Musculoskeletal: Not red, not swollen, not hot, tender, restricted ROM [emphasis added]
30 January 2018: due to see Dr Ho…will write a referral
11 April 2018 (Dr Kathirgamanaarthan): NEEDS CC - REGIONAL COMPLEX PAIN SYNDROME…Musculoskeletal: Not red, not swollen, not hot, tender, restricted ROM [emphasis added]
23 May 2018: 4wk venesections every mth for 6 mths. Reason for contact: haemochromatosis and venesection
30 May 2018 (Dr Tran): ketamine infusion for CRPS every 3 - 6 months…uses ketamine cream PRN. Palexia 100mg SR PRN
19 June 2018: she was in cold because was [sic] watching her kids run on the weekend.> pain in both feet. going to get another ketamine infusion and also the radiofrequency
13 July 2018: mentioned that she had her ketamine infusion
11 January 2019: finished ketamine infusion. muscles cramping and spasms. a lot of pain and so got more medications, used palexia 50 mg sr and magnesium 1000mg daily. Dr Ho will do magnesium infusion with next ketamine infusion. was given a lower dose than her previous dose of ketamine so pain relief not as good.
16 January 2019: muscle spasms back of knee and back of thigh
26 April 2019: migraines gets them for a week
9 May 2019: some burning in her feet
28 August 2019: bad fatigue. crps pain in left > right foot and whole left leg into the left hip
5 September 2019: wants another pain specialist
29 October 2019: impaired glucose tolerance > diabex but going to spain > start when she returns
16 November 2019 (Dr Tran): sore throat since coming back from spain. fevers and chills. coughing with green phlegm
22 November 2019: urti for 12-13 days. sore throat and ears…Reason for contact: Sinusitis
25 November 2019 (Dr Wang): URTI. Sore throat for the past 2 weeks. Coughing intermittently…feeling very fatigued…Travelling within Barcelona for 2.5 weeks and symptoms started there. Had slight left calf cramping on 30 hour flight but subsequently resolved
17 February 2020 (Dr Tran): noted CPRS – no longer seeing any specialist. awaiting final decision by court
19 February 2020 (Dr Phan): “Depressed and no energy”…feeling anxious, unable to calm herself down… Has previously seen psychologist years ago… Recently getting hot sweats…not employed due to CPRS…Financial stress…
Dr O’Carrigan - Orthopaedic Surgeon
In a letter to Dr Ng dated 16 July 2015, Dr O’Carrigan stated, inter alia, as follows:
Thanks for asking me to see Leesa who is a…Australia Post worker…she has been there for the last 8 months and since then she has started to develop problems with bilateral lower limb pain. …she has had progressive problems with pain in the shins, Achilles’ and a burning sensation around the arch and the foot. …
On examination… She is tender along the tibia and she is tender at the medial calcaneal tuberosity and over the plantar fascia. She is tender elsewhere in the foot. The plantar fascia seems to be the most painful area.
Bone scan shows a hot spot in the calcaneal tuberosity consistent with plantar fasciitis…
Leesa needs bilateral ankle MRI to confirm the diagnosis…I think she is really at risk of developing a complex regional pain syndrome because of the global nature of pain, the hypersensitivity and the burning nature
…I have asked her to see a Pain Management Specialist, Dr Ho[29]…
[emphasis added]
[29] In his record of examination, Dr O’Carrigan does not describe the characteristic signs of CRPS
In a letter dated 18 February 2016, Dr O’Carrigan noted, inter alia, as follows:
….she is still getting burning and dysaesthesia. … She is getting bilateral knee pain…as well as bilateral ankle pain. She feels that is secondary to an abnormal gait which is secondary to the CRPS.
On examination, she has a slow but steady gait…
In a letter to Bryden Lawyers dated 23 June 2019, Dr O’Carrigan stated, inter alia, as follows:
Thank you for your letter dated 9^th of April 2019 and your request for comments following review of Dr Maxwell’s exhaustive report.
I would agree with Dr Maxwell’s assessment that Leesa doe not fulfil the strict criteria for the diagnosis of Complex Regional Pain syndrome as detailed in Guides to the Evaluation of Permanent Impairment 5^th edition.
My clinical findings were similar to his in terms of her extreme hypersensitivity and disproportionate pain relative to the demonstrable pathology which was largely limited to plantar fasciitis. I also agree that there are major psychological factors that are shaping the clinical presentation and it was for this reason that I did not perform any invasive procedures and referred Leesa to a pain management specialist and podiatrist.
I disagree with his conclusion that the nature and conditions of her employment with Australia Post were not a major contributing factor to her developing plantar fasciitis…
MRI

An MRI of both ankles performed on 27 July 2015 is reported as showing ‘mild to moderate plantar fasciitis’ in the right foot and ‘moderate plantar fasciitis’ in the left foot.
Dr Ho – Pain and Rehabilitation Specialist
Extracts from Dr Ho’s Letters to Dr O’Carrigan are, inter alia, as follows:
7 August 2015:[30] CRPS type one of the left foot triggered by plantar fasciitis. A recent MR showed plantar fascia tear… Adjustment disorder with anxiety and depression. … Examination showed improved temperature and range of motion of the foot, especially eversion and lateral deviation of the foot.
21 August 2015: I am pleased that Leesa’s secondary hyperalgesia and dysaesthesia /allodynia has improved significantly. The foot range of movement is improving. … Leesa has expressed interest in a return to work. I have given her a pain action plan for her to be able to stay at work with pain exacerbations…
4 September 2015: Chronic sensitised mixed nociceptive and neuropathic left foot pain secondary to: 1. Plantar fasciitis and plantar tear on the left leg; 2. Superimposing CRPS; 3. Adjustment disorder with anxiety and depression. … Clinically, Leesa is still making significant improvement with reduction of nociceptive zone and dysaesthetic sensation. She is finding benefit from her current medication[31]and there are no side effects. We performed a plantar fascia block today: … I have suggested she continue with work next week. … I have advised her that she needs a physiotherapy follow up for aggressive therapy.
11 September 2015: Bilateral plantar fasciitis… Resolving CRPS of the left foot. Adjustment disorder with anxiety and depression. … Leesa continued to show clinical improvement of the left heel pain. … There is a significant reduction of the left heel pain. She reports aggravation of her left foot pain and dysesthesia after physiotherapy… She is just starting to cope with her current workload. [emphasis added]
18 September 2015: Leesa was not in a good way today. In the last week, worsened and this coincides with the rehabilitation program of increase of work hour. Her depressed mood and anxiety became constant… The proposed increase in work hour impose significant psychological stress which is causing psychological decompensation. I have suggest [sic] that she see a psychiatrist for mental capacity assessment net and management of anxiety and depression first before she return to work
30 October 2015: Leesa’s bilateral foot exacerbation has taken time to settle down… Clinically the left foot vasomotor and sudomotor sign has significantly improved since I saw her. The allodynia and dysaesthesia sensation of bilateral foot continues to be the main problem and may take more time to improve. The right foot exacerbation is likely due to central sensitisation due to overuse. [emphasis added]
11 December 2015: Chronic mixed bilateral foot pain secondary to: 1. CRPS of the left foot; 2. Bilateral foot plantar fasciitis; 3. Adjustment disorder with maladaptive coping, anxiety and depression. … Overall the background pain control is reasonable at least for four days a week. She is still getting breakthrough pain significantly on the other three days. … I have given her a script for PRN Endone on days for severe pain. She may use Epilim 100 mg BD[32]… If this is still resistance we may consider Ketamine infusion in hospital for seven days. … Overall, however, I think Leesa is making progress… Her gait is significantly better than before. I have suggested that she work on the same hours for now which is two days per week.
[30] The first two consultations with Dr Ho were on 24 July 2015 and 31 July 2015. No documentation in respect of these consultations has been provided to the Tribunal.
[31] Palexia (tapentadol) 100mg tds; Endep (amitriptyline) 25 mg nocte; Lignocaine/Capsaicin cream, Lidocaine/Ketamine/Endep 5% cream.
[32] Department of Human Services, PBS patient summary (24 June 2014-15 April 2019): there is no record of Epilim being supplied.
In a letter to Australia Post, dated 25 January 2016, Dr Ho noted that psychological treatment had been approved and he recommended the pain psychologist at the Sydney Pain Management Centre for 8 psychology sessions over 8 weeks.
In a letter to Dr Ng, dated 5 May 2016, Dr Ho noted that Ms Cash:
is doing very well in the programme. She was able to wean off most of the regular medication. She is using Palexia as required on bad days which happen about twice per week. She is more efficient in managing pain flares. Her centralised symptoms have reduced….
In a letter to Turner Freeman Lawyers, dated 29 January 2016, Dr Ho noted that between 24 July 2015 and 15 January 2016 he had examined Ms Cash on 15 occasions and stated, inter alia, as follows:
My initial diagnosis was chronic mixed nociceptive and sensitised neuropathic and sensitised neuropathic left foot pain and nociceptive right foot pain secondary to:
1. CRPS of the left foot triggered by plantar fasciitis and plantar fascia tear ….fulfils Budapest Criteria of CRPS with signs and symptoms of all of allodynia, sudomotor, vasomotor, motor and trophic changes.
2. Plantar fasciitis of the right foot.
3. Adjustment disorder with anxiety, depression and maladaptive coping. This is worsened by transference of her conflict with her insurer and an object relationship of being mistreated by her insurer. [sic]
…
Mrs Cash has engaged in the treatment program well. I have incorporated medical psychology and physiotherapy strategies in my sessions to increase pain coping and self-management. Mrs Cash requires significant psychological counselling as Mrs Cash’s treatment progresses. …
Despite the barriers, we have achieved the following goal:
1.    Reduce pain severity by 30%...significant reduction superficial allodynia… significant reduction of sudomotor, vasomotor and motor signs
2.    Normalisation of gait. … [emphasis added]
3.    Independent with home exercise program. Independent with aerobic exercise program with swimming.
4.    increase emotional regulation with CBT strategies. Increase stress tolerance and mental flexibility…
5.    Able to self-monitor and pace return to work progress…
…
As a result of her impairment Mrs Cash has…:
1.    Reduced physical capacity. Walking tolerance of 10 minutes.
2.    Restriction of capacity for work… Her current work capacity is 12 hours a week at the last consult. I would expect this to increase with the improvement of her CRPS and adjustment disorder…
Mrs Cash is currently medically stable. She needs ongoing pain management and pain psychology sessions. … Her overall prognosis is good given her progress and goal attainment so far in the pain management program. …
In a report, dated 6 July 2019, Dr Ho noted that he was Ms Cash’s treating doctor from 24 July 2015, with 15 consultations up to 15 January 2016 and subsequent consultations on 19 March 2018, 20 June 2018 and 2 January 2019, and that his clinical review of her was more than 6 months ago.[33]
[33] MPHR: Consultations on 2 & 3 March 2017, 19 March 2018; 7-day ketamine infusions in June 2017, November 2017, June 2018, January 2019.
Dr Ho stated, inter alia, as follows:
Mrs Cash first saw me in late July 2015, and during our initial assessment, she reported that she had always been well and had no history of chronic pain prior to her injury[34]…she was coping well with her work prior to her injury. [emphasis added]
[34] This is not consistent with general practice records.
…
Mrs Cash had developed chronic soft tissue injury and infection in her bilateral feet… It was reported that her pain became persistent… She had an MRI scan which showed bilateral plantar fasciitis. … The pain severity and distribution, however, were out of proportion to plantar fasciitis. At my initial assessment, Mrs Cash required two axillary crutches for mobilisation due to severe pain.
With regards to Mrs Cash’s condition, I opined a diagnosis of:
Chronic mixed nociceptive and sensitised neuropathic left foot pain and nociceptive right foot pain, secondary to: [emphasis added]
a. CRPS of the left foot triggered by plantar fasciitis and plantar fascia tear; At the time of my examination, Ms Cash’s condition fulfilled the Budapest Criteria of CRPS, with all the signs and symptoms of allodynia[35], sudomotor[36], vasomotorr[37], motor changes and trophic changes. …
[35] Pain hypersensitivity.
[36] Sweating.
[37] Warmth and/or colour change.
b. Plantar fasciitis of the right foot; and
c. Adjustment disorder with anxiety depression and maladaptive coping…
…we had tried multiple treatment modalities over the course of our treatment…
The various treatments improved Mrs Cash’s condition and the improvement was demonstrated through the reduction of symptoms in allodynia, as well as changes in vasomotor, sudomotor and improved active range of motion (motor changes). Mrs Cash’s medication requirements were also significantly reduced over time. These improved results are consistent with the natural history of CRPS with treatment…
With improvement through the treatments, Mrs Cash was able to progress functionally and was able to walk without aids. She was able to return to attending family and social/ recreational activities over time. …
Mrs Cash has been compliant with her treatments and has made significant progress…
In my opinion, Mrs Cash’s diagnoses and ongoing impairments related to the index event are:
1   Chronic neuropathic left lower limb pain, secondary to CRPS…
2.    Chronic nociplastic right lower limb pain, secondary to central sensitisation…
3.    Adjustment disorder…
I have noted that Mrs Cash has no previous history of chronic pain prior to the index event[38]. Therefore I opine that the above diagnoses are triggered by her workplace injury…
[emphasis added]
[38] This is not consistent with general practice records.
In response to Dr McGill’s report of 10 August 2015 in which he reported his examination findings of “no abnormal colour, temperature or sweating, hair growth, nail and skin texture and no swelling”, Dr Ho noted that these clinical findings did not fulfil the Budapest Criteria of CRPS.
However, Dr Ho asserted that when he saw Ms Cash in and around July 2015 she had “all the signs of allodynia, sudomotor, vasomotor, and motor changes” at the time of the initial consultation.[39] Dr Ho also stated that he had performed a “paravertebral block” in July 2015 and that there was “noted significant improvement” in Ms Cash’s symptoms, and suggested that Dr McGill’s findings was “likely due to the response to the nerve block, medications and physical therapy.”
[39] 24 July 2015.
In a letter to Dr Huynh, dated 5 August 2019, Dr Ho stated that “Leesa is having a current flare of her CRPS left lower limb. I have organised for a ketamine infusion”. I note that there is no description of any clinical signs of CRPS.
In a report, dated 9 March 2021, Dr Ho stated that on 11 February 2021 Ms Cash attended for an “independent medical and diagnostic” assessment and that she reported that, prior to her injury, there was a “history of depression which was controlled and stable” and that otherwise there was “no history of chronic pain, no pre-existing health problems, no other psychiatric history.”[40]
[40] This is not consistent with general practice records.
To assist in the assessment Dr Ho was provided with a report from Dr Johnstone, surveillance reports and films, and a statement of Ms Cash dated 3 February 2020.
Dr Ho noted that his last review of Ms Cash was in 2019.[41] He recorded a history which was essentially the same as in his previous report, but did add, inter alia, as follows:
Ms Cash reported that she continues to engage in pain self-management …such as water- based exercise, home exercise program, walking program, emotional regulation and reactivation. She reported she is doing her best in engaging in family and social activities, as well as participate in Activities of Daily Living (ADLs) tasks.
…
Current Pain Medications: Palexia SR 100mg daily; Tilray Cannabis Oil – on trial. Other Medications: Valium 5mg – daily…
[41] 2 January 2019.
Dr Ho noted current complaints and self-reported disability, inter alia, as follows:
Ms Cash described her current pain as constant fluctuating pain over her left lower limb, left upper limb and left face/head. The primary pain was reported to be over her left foot and the pain was described as burning. … There was reported associated intermittent swelling, colour change and reduced range of motion. The pain was also reported to be worst with usual activities. Ms Cash also reported spontaneous nocturnal pain.
...Ms Cash informed that she currently lives with her daughter in a house with a garden and there are 15 steps of stairs within her property. She advised that she has withdrawn from many social and recreational activities and stays at home mostly due to her pain.
On examination Dr Ho observed that Ms Cash was able to sit through the interview and mobilise independently without aid. He noted that the temperature of the skin was equal in both feet (36˚C), that the “circumference of the calf at 5 cm above the medial malleolus is 23 cm on the right, and 22 cm[42] on the left, suggesting muscle wasting” and that there was “reduced active range of motion in all directions in the left ankle”. Common sensory testing showed superficial allodynia of the left lower limb, mechanical allodynia over the left lower limb, and dysaesthesia[43] over the left lower limb and left upper limb. Power in the left foot was noted as “reduced at 4/5, as limited by pain, but there was no sign of significant upper motor neuron or lower motor neuron” [sic].
[42] It appears that Dr Ho measured the ankle circumference and not the calf circumference - c.f. Dr Maxwell: right ankle 26.5cm, left ankle 26.6cm.
[43] Abnormal sensation e.g. painful burning.
In recording his opinion Dr Ho emphasised that Ms Cash had no “premorbid history of chronic pain” and stated, inter alia, as follows:
My diagnoses for Ms Cash’s chronic pain syndrome are:
1. Chronic neuropathic left lower limb pain secondary to CRPS Type 1 triggered by her workplace injury…:
a. Currently…Ms Cash still fulfills the Budapest clinical criteria for CRPS but not Workcover criteria.
b. Chronic neuroplastic upper limb and left facial pain, secondary to central sensitisation.
…
Cortical augmentation with significant adjustment disorder, catastrophisation and reduced self-efficacy
I have noted the video surveillance and I opine that the surveillance does not contradict her self-reported disability… I further opine that the surveillance does not suggest Ms Cash is not suffering from pain or pain related disability.
Mr Boudville – Sports Podiatrist
In a report, dated 18 September 2015, Mr Boudville stated, inter alia, as follows:
She commenced working for Australia Post in October 2014 as a casual employee. … Her initial problems related to blisters and infections on her feet from the wearing of safety footwear in November 2014. … She continued to complain of foot pain… Due to the progressing nature of the pain in the first half of 2015 she was eventually referred for a bone scan which confirmed multiple stress reactions/fractures and raised the suspicion of complex regional pain syndrome (June 2015). …
At the time of presentation at Foot Focus she complains of bilateral foot pain with the left being worse. The pain is of an intense nature and renders it difficult to stand and walk, even for short periods. She finds it difficult to wear socks, footwear or even touch her feet and lower leg region. She is hypersensitive to any type of pressure. Trying to ascertain the specific area of pain was impossible. …
Leesa stands with an awkward posture. She appears in pain, and is consciously maintaining a semi-flexed left knee without any weight-bearing on the left heel. … There appeared to be some mild swelling in her ankles.
I was not able to fully examine her feet …
Leesa continues to focus on the diagnosis of her foot condition and not on treatment or any improvement that may come as a result. She is extremely negative in that she sees everyone as a hindrance to her recovery rather than an ally in wanting her to get better.
In a letter dated 25 June 2016, Mr Boudville stated he had reviewed Ms Cash for the final time and noted that her treatment “seems to have stagnated and shows no further improvement since the previous review [in March 2016]”, but that she continued “to wear the Asics shoes and fluctuates from wearing the orthotics to at times not”. He also noted that at the time of consultation “her foot and leg showed normal colour and even temperature to touch” and that there was “continued hypersensitivity over her left heel and along the plantar fascia”.
Mr Boudville indicated that Ms Cash “requires no further podiatric intervention” and was advised to “continue with the orthotics and footwear”.
Dr McGill – Consultant Rheumatologist
In a report dated 10 August 2015, Dr McGill stated, inter alia, as follows:
I asked her to recap on her symptoms over the last week…
She experiences a burning sensation in both feet radiating up to just below the knees. It is worse on the left. ... She also experiences a sensation she likened to “jabbing knives up through my heels”. Both arches are “just so painful” and her ankles are very sore and very sensitive. She reported that her knees are “not happy” and that her hips are “sore”. Both shins are “really painful”.
…
… She initially walked very slowly with a limp favouring the left lower limb.
The lower limbs looked symmetrical. There was no abnormal colour, temperature or sweating. Hair growth, nail shape and skin texture were normal bilaterally. There was no oedema. She reported hyperaesthesia (increased sensitivity to light touch) in the left lower limb distal to the knee. Hyperaesthesia involved the entirety of the left lower limb… Touching the inferior surface of the foot was reported to be painful regardless of whether very light touch or pressure was applied. …
Sensation was intact in both limbs. The lower limb reflexes were normal and symmetrical… She declined to attempt assessment of muscle power in the left foot and ankle but her function during the entirety of the examination and when she was walking did not suggest any true muscle weakness. …
…
I think the appropriate diagnostic label for her symptoms is regional pain syndrome. She does not have complex regional pain syndrome at this stage but the region of tenderness to light touch extended beyond the bounds of what could be reasonably attributed to plantar fasciitis or any other specific physical disorder.
…
I think it is probable that her bilateral fasciitis was aggravated by prolonged standing in boots... I think her plantar fasciitis played a substantial role in the development of her regional pain syndrome. The vast majority of people with plantar fasciitis do not develop regional pain syndrome and psychological factors are often important in those people who do. …
The nature of regional pain is that people experience and report symptoms in excess of what would be expected based on the objective physical findings. …
…
With respect to her plantar fasciitis one would expect the problem to settle sufficiently over the next six months… Managing her regional pain syndrome will be influence by resolving conflicts in the workplace and her perception of having been bullied.
She is physically fit to resume her normal hours performing predominantly seated duties. A small amount of walking around the office is within her capacity and is likely to be beneficial…
[emphasis added]
In a supplementary report, dated 2 September 2015, Dr McGill referred to his earlier report and stated, inter alia as follows:
…[Ms Cash] commenced work with Australia Post in October 2014, soon after developed blisters on the posterior aspect of her heels, the blisters healed but she reported that she continued to experience pain in her feet. She felt “terribly bullied” by her new shift manager unrelated to her feet symptoms. She ceased work three weeks before I saw her that is in mid-July. Bone scan and MRI supported the diagnosis of plantar fasciitis but when I saw her she reported tenderness well outside the range that could be attributed to plantar fasciitis.
Although I thought that it was probable that plantar fasciitis (aggravated by work) had played a substantial role in the development of her regional pain syndrome, psychological factors are usually important in people who present in this manner.
Because of the importance on non-physical factors in this type of presentation, prediction of when people will feel capable of returning to normal or near work duties id much more difficult and less accurate than in a situation where pure physical disease is responsible… I would anticipate that she would be able to wear safety shoes immediately and that she would be able to return to some operational duties…within six months…

In a report dated 6 April 2017, Dr Mc Gill stated that Ms Cash had confirmed the information she had provided previously and noted current medication as follows:
She received an intravenous Ketamine infusion from 2 to 9 March 2017. She has Tapentadol 100mg slow release available but has not needed it since the infusion. She also has Ketamine compounded cream available but has not needed it since the infusion. In the weeks prior to the infusion she used oral Tapentadol between one and three tablets per week[44] and intermittently applied the cream.
[44] PBS Tapentadol supplied on 9 February 2016 (28 tabs no repeats), supplied on 2 May 2017 (28 tabs no repeats) – no record of any prescriptions supplied up to April 2019.
Current symptoms are recorded, inter alia, as follows:
She feels “depressed, suicidal, anxious, fatigued, confused, frustrated.” She has “just pain 24/7”. The pain is felt predominantly in both feet, both calves and in the thighs, more on the left. She has a burning sensation over the lateral thighs, more on the left.
She reported that her nails (toenails more than fingernails) are not growing well and that the hair doesn’t grow well in the left leg and foot.
She needs to keep her feet warm and keep the rest of her body cool.
On examination Dr McGill recorded, inter alia, as follows:
She walked in her running shoes and indicated that she could not tolerate an attempt to walk in her socks or bare feet. She removed her shoes and socks for the supine examination. Colour of the feet, legs and thighs was normal and symmetrical. There was no swelling of either foot or leg. There were no lower limb hairs on either side except over the dorsum of the great toes……… Her toenails looked normal and symmetrical. There was no visible asymmetry of the lower limbs although circumference of the left calf was 38 cm compared with 39 cm on the right, both measured 25 cm proximal to the medial malleolus.
She reported that light touch felt unpleasant in the left lower limb from the mid shin distally. There was no such problem in the right limb. In the assessment of muscle power she alleged profound weakness of great toe dorsiflexion bilaterally such that I could easily overcome her power on both sides using one finger with minimal force. There was no visible indication that her weakness was related to pain and although she indicated that she had pain, predominantly in the left lower limb, she did not think the pain was the explanation of the weakness. For great toe plantar flexion, ankle dorsiflexion and ankle plantar flexion she provided the same alleged profound weakness. ...
The right knee and right ankle reflexes were normal. She declined to have the left side tested. She responded accurately to cotton wool light touch above the knees. Below the knees she missed occasionally bilaterally but not in any consistent pattern.
[emphasis added]
After reviewing the Eagle Valley Medical Centre records and various other medical reports Dr McGill summarised, inter alia, as follows:
This 44 year old lady had experienced severe prolonged psychological problems associated with pain prior to her commencement with Australia Post… She did not acknowledge any of that past history when I saw her on 10 August 2015…
She has been considered by her treating pain specialist, Dr Ho to have complex regional pain syndrome.
She today reported unpleasant sensitivity to light touch in the left leg and foot and to a minor extent over the anterior distal left thigh. She also reported minor unpleasant sensitivity to touch of the right distal leg and foot. She alleged profound weakness of great toe dorsiflexion and plantar flexion and ankle dorsiflexion and plantar flexion, not explicable on the basis of pain and not consistent with any organic pathology. She provided a photo showing increased redness of the left foot but colour, temperature, sweating, skin and nail appearances today were symmetrical when comparing the two lower limbs…
…I think that she did develop plantar fasciitis and that her standing at work played a role in the development of her plantar fasciitis.
In comparison to the non-physical factors, I think her plantar fasciitis has been of little importance with respect to her ongoing pain problems.
I do not think the superficial foot ulceration caused by wearing steel cap boots, played any role in the symptoms she experienced and reported from mid-2015 onwards.
Plantar fasciitis usually causes troublesome symptoms over several months and the symptoms then resolve. At the outside, I think plantar fasciitis may have influenced her symptoms until February 2016.
In that she reports pain in a region, she has a regional pain syndrome. With respect to whether she has complex regional pain syndrome, it depends on the diagnostic criteria required. The reported sensitivity to light touch and colour asymmetry would fit for that condition but she did not have oedema, significant skin or nail change, or sweating, colour or temperature asymmetry today.
I think her problems prior to commencing with Australia Post were predominantly in the psychological sphere and that remains the case. I think the physical component of her work is not relevant to her symptoms.
…
Noting the severe psychological problems that were documented by Dr Ng over a long period before she commenced with Australia Post, I think there is a high likelihood that she will continue to experience symptoms as a result of her psychological makeup and the family and environmental stressors that she has been exposed to in the past and which remain.
[emphasis added]
Dr Beer - Orthopaedic Surgeon
In a report dated 15 December 2015, Dr Beer noted Ms Cash’s present complaints, inter alia, as follows:
…severe burning in the soles of her feet…around the ankle, up the shin…on both sides, the left worse that the right; …swelling in the lower limbs, the left more so than the right; …some pitting oedema; …numbness on the left, more so than the right, her hair has been falling out…of the lower legs and colour changes in the feet.
On examination, Dr Beer noted mid-calf measurements of “38.5 cms right and 37 cms left” and “bald patches due to skin loss [sic]” on each lower leg. He also noted some reduced range of movement of the left ankle when compared to the right, hyperalgesia in the lower legs and ankles, some mild “cyanotic mottling of the foot”, some coldness in skin temperature of the forefoot but “no obvious pitting oedema”, ”some joint stiffness” in both ankles, some “striation of the nails”[45], and “hair growth fine and patches where the hair has fallen out ….in both lower limbs”.
[45] In his report dated 19 May 2016, Dr Maxwell stated that “striation of the nails is not a sign” of CPRS.
Mr O’Neill – Clinical Psychologist
In a report, dated 16 December 2015, Mr O’Neill noted Ms Cash’s psychological /psychiatric history, inter alia, as follows,
Ms Cash denied behavioural or emotional disturbance in her childhood or early adult years. She said she may have had some post-natal depression after the birth of her first child. … She denied ever seeing a psychiatrist, psychologist or counsellor in the past for any mental health issues. …
…She denied any problems with previous jobs…
Ms Cash told me she believes she has been bullied at Australia Post ever since commencing as a Christmas casual in November 2014. She said this worsened in the process of her submitting her Workers Compensation Claim.
[emphasis added]
In his conclusion Mr O’Neill stated, inter alia, as follows:
She has been diagnosed with bilateral plantar fasciitis and complex regional pain syndrome. She is receiving pain specialist advice and medication for this, which she believes is helping and is engaging in her own rehabilitation involving self-pacing, pain management and a hydrotherapy program that is self-initiated. …
…She also had a range of industrial grievances about her working conditions…and was very upset with how she believed her manager…dealt with her attempts to submit the workers compensation claim. … She was also upset that Dr McGill advised that she was fit to work the two months she had off work…
From a psychological point of view, it is my opinion that Ms Cash suffers from a mild adjustment disorder with depressed mood secondary to her physical condition. … It is also significantly fuelled however by her difficulties not only coming to terms with her pain and restrictions, its impact on her personal and family life, but also her perception that her manager at work has been disruptive in the claim process and she now feels unsupported by her colleagues and peers. …
I have no evidence of a pre-existing or underlying psychological condition… There were also some personality qualities, suggesting that she is interpersonally sensitive, and may be seen by others to be tough minded, sceptical and hostile.
I would expect Ms Cash’s condition to resolve over the next couple of months…
At this stage given Ms Cash’s reports of her relationship with Dr Ho, and the psychological nature of the intervention and her awareness of pain management approaches, I am not of the opinion that an external referral to a clinical psychologist with expertise in pain management is reasonably necessary.
[emphasis added]
Dr Maxwell – Orthopaedic Surgeon
In a report, dated 19 May 2016, Dr Maxwell noted that Ms Cash is being treated by Dr Ho, a pain specialist who has been treating her for “complex regional pain syndrome” and has suggested that she would benefit from a Ketamine infusion.
Dr Maxwell noted present symptoms, inter alia, as follows:
She states it [the pain in her left foot] is getting worse with overuse. Her pain becomes worse when she is under emotional stress.
She states she is starting to experience Regional Pain Syndrome radiating up to her left thigh. …
She experiences burning in the front of her left shin. She states the toes of her left foot have become stiff. The outside three toes are in ”agony”. …
She states she experiences similar symptoms in the right foot but the pain is not as bad. She said she cannot walk barefooted and always has to have shoes on because of hypersensitivity of her feet
On examination Dr Maxwell noted, inter alia , as follows:
She was a somewhat vague historian and seemed somewhat angry.
She walked with a fairly unusual gait limping on her left leg mainly walking on the toes of her left foot with a slightly short stance phase on the left leg.
Her right thigh measured 50.8cm, 10cm above the patella and her left 50cm.
Her right calf measured 38.3cm, her left 37.8cm.
Her right ankle 26.5cm and her left 26.6 cm.
Examination of her right foot and lower leg:
…There was no oedema. She complained of purple discolouration of the soles of both feet. There was no excessive sweating of the right foot. The growth of nails was normal. She reported hypersensitivity and a sensation of dysesthesia in the whole of her lower leg….
Examination of her left foot and ankle:
There was no swelling. … She complained of extreme sensitivity on light palpation but there was no significant discolouration. There was no atrophy of the muscles of her left foot. … I was unable to palpate the sole of the left foot to detect whether she had any tenderness…
…She was reluctant to actively flex and extend the left or right ankle so that I could measure the range of motion. She was also reluctant to move the toes of her left foot which she said was too painful.
Overall, these signs were not compatible with Complex Regional Pain Syndrome Type 1.
[emphasis added]
Having reviewed the various documents provided, including the Eagle Vale Medical Centre practice records, Dr Maxwell addressed various specific questions, inter alia, as follows:
…psychological conditions do affect one’s perception of pain. Certainly there is an extremely strong psychological component in individuals who experience pain over and above what one would expect given the underlying pathology.
…The term Regional Pain syndrome is a psychiatric description of pain and it describes pain out of proportion to the underlying pathology. …there are no particular abnormal signs…
…20% of asymptomatic individuals on MRI scanning of the plantar fascia show increased signal intensity in the plantar fascia which was previously felt to be suggestive of plantar fasciitis. …
It would appear that it is likely she did at one stage have symptoms and signs suggestive of plantar fasciitis particularly of the left heel.
.I have treated many patients over many years with plantar fasciitis and the majority of them cannot relate the onset…to any particular activity particularly increased standing or walking. …
I consider it is probable that she did develop some plantar fasciitis but I am not convinced this was a result of her employment with Australia Post…
…I do not consider her symptoms are as a direct result of her employment with Australia Post. I consider her symptom complex has been magnified by her underlying constitutional psychological state.
…
In my experience plantar fasciitis is a constitutional condition which usually comes on spontaneously and appears to have no relationship to excessive standing or walking.
Professor P Siddal – Professor in Pain Medicine
In a letter dated 10 May 2017 Professor Siddal stated inter alia as follows:
I saw Leesa Cash in the Pain Clinic… As you know, she reports pain primarily in the left foot but also involving the rest of the left leg as well as the right leg and left arm.
The pain is constant, dull, aching, cramping and sharp and feels like walking on gravel. She has had treatment with first line neuropathic pain medications ……she has been under the care of Dr Timothy Ho who has tried various approaches including three monthly hospital admissions for ketamine infusion which she finds result in significant reduction in her pain. As well as the pain, she reports changes in colour, temperature and sweating with the left foot going red at times and the right being purplish. …she also repots reduction in hair growth, increased sweating and nail changes.
…
She trained in nursing and worked as an AIN before working at Australia Post. She now spends much of the day lying or sitting although tries to exercise in the pool. Walking tolerance is 10-15 minutes maximum. … She describes some mood changes with irritability and depression and has been suicidal in the past but not currently. She is not keen on taking antidepressants. …
On examination, she walks unaided. There were sensory changes in both legs in a stocking distribution that were more pronounced on the left side. These include sensitivity to light touch with brush over the left foot and extending to just below the knee as well as over the right foot. … There was some slight decrease in power with flexion and dorsiflexion of the left foot… There was reduced circumference of the left calf by 1 cm. … On examination today there was no apparent difference in colour or temperature between the feet or both hands and both feet were pink and warm. There was no obvious oedema.
[emphasis added]
Dr Champion – Consultant Psychiatrist
In a report, dated 23 May 2017, Dr Champion stated, inter alia, as follows:
When I attempted to explain to Ms Cash that we had been asked to meet today for a psychiatric assessment, she interrupted me forcefully saying “we are here today so Australia Post can rip me off”.
…
Ms Cash told me that she suffered with Chronic Regional Pain Syndrome which had caused her continuing pain and disability and led to depression. She said she had had that condition for two years and it had been “caused by having to wear steel capped boots at work”.
…
More recently, she has been told, apparently by Dr Ho, whom she continued to consult, that there was no treatment for Chronic Regional Pain Syndrome but she was determined that she would get better.
Currently she was receiving Ketamine Infusions over a period of days whist hospitalised every three months. “It keeps me walking”, she also used Ketamine Cream. The Ketamine Infusions she said were of considerable help but progressively lessened in their ability to reduce her pain. She was however “still able to walk a little bit” and could only stand for 15-20 minutes. The pain had spread progressively and now also affected her lower limbs in areas not initially affected.
….
Because of her problems with the painful feet, the bullying, and having her compensation ceased, she had developed an “Adjustment disorder”, she said, which consisted of mostly depression. …
Ms Cash told me that she had an assessment from…Mr Thomas O’Neill for Australia Post who diagnosed her with Adjustment Disorder. In her view this proved Mr O’Neill to be “an honest man”. …
…
She considered treatment received by Dr Ho had been very helpful having achieved some improvement in her “very bad pain”. …she told me that she constantly suffered from “brain fog” and was fatigued all the time. This caused her to miss out on her children’s events. Her mood was sad most of the time and when this became “bad” she would be suicidal. … Apparently she was taking an antidepressant…but was not being treated by a psychologist or psychiatrist.
…
She continued taking the antidepressant medication and believed it was helpful. … Ms Cash told me, on enquiry, at this point of the examination that she had never previously been under the care of a Psychiatrist or Psychologist and had not had any significant difficulties with anxiety, depression or other forms of psychiatric disorder.
…
Ms Cash presented as a casually groomed woman… There was a level of resistance to the examination from the outset…with Ms Cash referring on several occasions to her belief that Australia Post was hiring medical experts whose brief was to dispute her claim. … The history she provided was chronologically disorganised with reference to matters….with little detail provided concerning the matter. This applied throughout her history and was particularly applicable to her responses when questioned about her previous need for antidepressant medication. There was no indication of depression or anxiety or emotional distress apart from anger and no signs of psychosis. …
Comment: On the basis of the presentation Ms Cash impressed as having a quite emotionally labile personality structure and at examination appeared to find it difficult to provide a detailed chronological description of the events about which she complained. There was however no indication in the presentation of anxiety, depression or other forms of diagnosable Psychiatric Disorder. On the basis of the emotional lability demonstrated the possibility of underlying Personality Disorder…would need to be considered.
[emphasis added]
Dr Champion commented that that the history provided by Ms Cash “was given in a disorganised fashion with varying emotion” and that “her affect appeared labile, at times she seemed to be amused, at other times angry.”
Dr Champion proceeded to review the provided documents[46] in some detail and commented, inter alia, as follows;
I have reviewed Mr O’Neill’s report in some detail. It should be pointed out that Mr O’Neill does not seem to have had the benefit of the opportunity to review all of the general practitioner’s records as they relate to psychiatric/psychological disorder. Mr O’Neill’s conclusions may have been different had he considered Ms Cash’s history of the need for many years of treatment with antidepressants and with the general practitioner’s regular commentary upon emotional distress and psychological dysfunction and, in particular, Dr Kneebone’s 2012 report…
…
A history of the need for long term antidepressant medication…indicates an individual prone to suffering with episodes of recurrent or chronic Psychiatric Disorder. Often the background to this pattern is unstable personality function (Personality Disorder).
…It would appear that Ms Cash is fully aware that she is providing inconsistent histories and providing a false picture or her early developmental years. …
The report from Dr Kneebone outlines clearly the history of difficulties in psychological/psychiatric functioning and negative early experiences effecting Ms Cash during her developmental and later years. These factors are likely to have been the basis for complaints of poor mental state and elaboration of physical injuries during the period she was employed by Australia Post. The type of mental health problems experienced by Ms Cash are constitutionally based and are likely to continue to produce difficulties for her in stable psychological functioning on an ongoing basis. It is clear that Ms Cash has learned, possibly since being assessed by Dr Kneebone, that the frank and full history she provided to him may not assist when she is attempting to claim that her psychological dysfunctions is the result of injury and external pressures affecting an otherwise stable individual.
[46] I note the documents reviewed by Dr Champion included extracts from the GP practice records obtained under summons and Mr O’Neill’s report of 16 December 2015.

Dr Ho has provided no other clinical records where he documents his clinical examination findings.
In his report of 10 August 2015, Dr McGill recorded a physical examination which revealed no objective clinical signs to support the diagnosis of CRPS. This appears to be inconsistent with Dr Ho’s correspondence.
In his report of 15 December 2015 Dr Beer, on examination, noted a reduced mid-calf measurement of 1.5 cm on the right when compared to the left and also some reduced range of movement of the left ankle, “some mottling and mild cyanotic mottling of the foot, some coldness in skin temperature…no obvious pitting oedema”.
On 11 May 2016, GP consultation noted “left leg pain. Complex regional pain syndrome. Examination: not red, not swollen, not hot, not tender.”
In his report of 19 May 2016 Dr Maxwell, on examination, noted a difference of 0.5 cm in the mid- calf measurements but no objective signs of CRPS.
In his report 10 May 2017. Professor Siddall noted a 1cm difference in calf measurements but no apparent objective signs of CRPS.
On 17 October 2017, GP consultation noted ”Chronic pain syndrome…Musculoskeletal: Not red, not swollen not hot, tender, restricted range of movement.”
On 11 April 2018, GP consultation noted “REGIONAL COMPLEX PAIN SYNDROME…Musculoskeletal: Not red, not swollen not hot, tender, restricted range of movement.”
In his report of 27 July 2018, Dr Bentivoglio noted 1.5 cm difference in calf measurements and some reduced range of movement in the left ankle, but no objective signs of CRPS. He commented that CRPS appears to have “burnt out, although she still has residual symptoms.”
In his report of 6 July 2019, Dr Ho stated that at the first consultation in July 2015 Ms Cash had “all the signs and symptoms of allodynia, sudomotor, vasomotor, motor changes” and suggested that Dr McGill’s findings in August 2015 were due to “the nerve block, medications and physical therapy”.
In her report of 14 April 2020, Dr Johnstone noted a 1 cm difference in calf measurements, some “minor erythema discolouration of the left foot” and “impaired dorsiflexion of the left foot” but no evidence of signs “which characterise acute complex regional pain syndrome or ongoing sympathetic features”. Dr Johnstone commented that the CRPS suffered by Ms Cash “appears to have functionally resolved apart from reduced muscle mass”.
In his report of 9 March 2021, Dr Ho, on examination, noted equal temperature on both feet, reduced active range of motion in the left ankle and reduced power in the left foot because of pain. He also noted a 1 cm difference in the “circumference of the calf” which suggested some wasting, inexplicably based on measurements of the circumference of the ankle.
The weight of the medical evidence in my view is that, since August 2015, with repeated examinations, there is no convincing evidence of persisting objective signs of CRPS. The only objective sign that CRPS has persisted is a difference between right and left calf measurements ranging from 0.5 to 1.5 cm. The accuracy and relevance of these measurements is, in my view, unclear.
Ms Cash’s claim is largely based on her own self-report of symptoms and claimed functional incapacity.
In her written and oral evidence, Ms Cash provides a self-reported narrative with a relentless focus on the characteristic clinical symptoms and signs of CRPS as the cause of her continuing difficulties.
The difficulty with Ms Cash’s self-reported narrative is that there is evidence of exaggeration and misrepresentation as well as inconsistencies with contemporaneous documentary and surveillance evidence.
The medical evidence in this matter is also problematic in that the issue of “chronic pain” is quite complex and some of the assessments and opinions have been significantly devalued because they have been based on incomplete and inaccurate information provided by Ms Cash.
In her oral evidence Ms Cash’s response to questions was somewhat defensive with frequent denial and failure of recollection, particularly with respect to her past history of mental health issues and treatment for depression. When asked, she was unable provide a satisfactory explanation for the fact that, when undergoing psychological assessment, she had provided an incomplete and inaccurate history of her past mental health issues.
When asked about her pre-employment medical assessment form and failure to disclose her prior mental health history, Ms Cash conceded that she had made a conscious decision to lie to ensure that she would be employed.
Ms Cash’s evidence with respect to the severity of her symptoms and limited capacity to participate in normal activities during overseas and interstate travel was also somewhat inconsistent with contemporaneous documentary evidence and generally unconvincing.
I note that the only consultation prior to her trip to Thailand in October 2016 was on the 27 September 2016 for travel vaccination with recorded comment “otherwise feeling well”.
A GP consultation dated 25 November 2019 was recorded as:
URTI. Sore throat for the past 2 weeks. Coughing intermittently feeling very fatigued…Travelling within Barcelona for 2.5 weeks and symptoms started there. Had slight left calf cramping on 30 hour flight but subsequently resolved.
When shown some images from the surveillance evidence which clearly showed that she been driving, Ms Cash vehemently denied that was she was in fact driving.
Overall, I found Ms Cash’s evidence somewhat self-serving and not always reliable.
Dr Ho’s evidence
Dr Ho claims to have been Ms Cash’s treating doctor since July 2015. However, since January 2015, the consultations were limited to, except for two consultations in March 2017 and one consultation in in March 2018, several admissions for ketamine infusions that were “backup for severe pain flare”.
For reasons that are unclear, Dr Ho was unable to provide any clinical practice records. Most of the documentary evidence that has been provided in the form of correspondence with limited and repetitive clinical information with no evidence of any physical examination or assessment of functional capacity.
At the hearing, Dr Ho conceded that between January 2016 and 2019 he did not have much experience in the assessment of Ms Cash’s clinical progress or functional capacity. In fact, he really only saw her when she presented for a ketamine infusion “because she couldn’t cope with her chronic pain”. It appears that the only regular treatment that Ms Cash had during this time was seven-day infusions of “ketamine”, a form of treatment that is also used for treatment of treatment-resistant depression. Ketamine is also a well-known “party drug” with the potential for abuse and addiction.
Dr Ho agreed that there was improvement in the CRPS but confirmed his opinion that Ms Cash still fulfilled the “Budapest clinical criteria” on the basis that she still had allodynia and “muscle wasting” with a “2 cm difference of the calf circumference’’. When asked to explain why in his last report he had in fact recorded a 1 cm difference in circumference in the right and left ankle Dr Ho became confused and did not provide a satisfactory answer.
In his report of 6 July 2019, Dr Ho noted that during his initial assessment in July 2015, Ms Cash had reported “that she had always been well and had no history of chronic pain prior to her injury”. It appears from the evidence Dr Ho has proceeded on a management path with no understanding of Ms Cash’s complex psychosocial and medical history which in fact included “fibromyalgia”.
Dr Johnston’s evidence
In her report of 14 April 2020, it was clear that Johnstone had some difficulty in reconciling Ms Cash’s self- reported clinical presentation of “a widespread pain distribution” with her own physical examination and the video surveillance evidence.
Dr Johnstone noted that Ms Cash had “residual reduced muscle bulk in the left leg” and “mild discolouration” consistent with a previous CRPS diagnosis. However, she stated that on examination of the left foot “there was no evidence of oedema (swelling) or significant erythema (redness) which characterise acute complex regional pain syndrome or ongoing sympathetic features”.
Dr Johnstone stated that “the surveillance evidence does not support the ongoing presence of a severe debilitating condition CRPS. There is no evidence that neuropathic pain and nociplastic pain conditions persist”.
In respect to a question as to current diagnosis, Dr Johnstone stated:
Ms Cash has a recent history of significant pain disorder CRPS. This appears to have functionally resolved apart from reduced muscle mass. The amount of pain that she is experiencing from this disorder is not able to be objectively quantified.
Dr Johnstone noted that “Ms Cash does show evidence of exaggeration of her symptoms that make formulation of her pain condition extremely difficult”. She also noted that Ms Cash had completed questionnaires in respect to pain and depression and that the scores suggested “that she was severely disabled both physically and psychologically”, which was inconsistent with “an individual who is able to go away on holiday, travel overseas and to make a day trip to a national park”.
Dr Johnstone suggested that Ms Cash had provided her with “an opaque picture of her actual disabilities”.
In her evidence at the hearing Dr Johnstone stated Ms Cash “did have a complex regional pain syndrome and the symptoms have now waned” and that now she has “a long-term regional pain or chronic primary limb pain”.
Dr Johnstone addressed the Budapest diagnostic criteria for CRPS in some detail and concluded that the CRPS had “burned out” and she now had “chronic primary limb pain….an ongoing, less intense pain condition”.
Dr Johnstone expressed some ambivalence about the surveillance evidence but conceded that she could not explain the big discrepancy between the person she saw in her rooms and the person she saw in the surveillance video.
‘When asked about Ms Cash’s presentation of with widespread left sided pain, Dr Johnstone said that it was “highly unusual presentation” which she could not explain.
Conclusion
On consideration of the available evidence, I am satisfied that in 2015 Ms Cash did suffer CRPS in the left lower limb that was triggered by her plantar fasciitis.
Ms Cash, with the support of Dr Ho, submits that that she currently continues to suffer from CPRS and is entitled to payments pursuant to sections 16 and 19 of the SRC Act.
Dr Johnstone suggested a current diagnosis of “chronic primary limb pain”. This diagnosis covers the unusual presentation of Ms Cash’s claimed symptoms but does not provide much assistance in determining the cause of her symptoms.
I accept that Ms Cash continues to suffer an “ailment”, the precise nature of which, on my reading of the evidence, is uncertain.
The question that now arises is whether her current “ailment” and CRPS can be considered to be the same “ailment”.
The relevance of this question is addressed in the decision of the Full Federal Court in Woodhouse v Comcare [2021] FCAFC 95 where the court heard an appeal form a decision of the Tribunal that the applicant was not presently entitled to compensation pursuant to sections 16 and 19 of the SRC Act.
The Full Court dismissed the appeal and his honour, Derrington J, relevantly stated:
[51] Comcare’s submissions should be accepted. On the construction by the parties and adopted by the Tribunal below, the factual inquiry focused upon whether the ailment continued to be contributed to, in a material degree, by the employee’s employment. In that analysis, it was irrelevant that it was characterised as being the same or a different ailment as that from which she suffered following the incident. Conversely, if her employment, had ceased to contribute in a material degree to an ailment, it did not matter that it was the same ailment as that from which she suffered earlier. By contrast, on the construction for which the applicant now contends, it is only necessary to consider whether the ailment from which she now suffers is the same as her earlier ailment, the contraction of which was contributed in a material degree by her employment. Whether her employment continues to contribute to the applicant’s ailments is irrelevant. … [Counsel for applicant] accepted that, on that construction, had the Tribunal found that the applicant’s current ailments were not the same as the Compensable Injuries, they would not be compensable under the SRC Act.
…
[84] Some understandable uncertainty and ambiguity crept into the submissions in this case which can be traced to the use of the word “continuing” in describing the causal relationship between the employment and the injury in respect of which compensation is sought. It must be kept in mind that s14 operates to impose liability on Comcare where and for a long as certain conditions exist. However, s 14 only provides the core or central touchstone of liability and other sections regulate the extent and manner in which such compensation is provided. An important element of s 14 is the condition that compensation is payable only where it results in death, incapacity or impairment. Whilst death is permanent, the other two sequelae may be temporary with the result that s 14 will only render Comcare liable to where the causative requirement continues to have effect. Similarly, s 14 only renders Comcare liable where that which causes or has caused death, incapacity or impairment is an “injury” as defined by s 4(1); ie in this case, an ailment that has been contributed to by the employee’s employment and is therefore a “disease”. If the cause of the incapacity ceases to be an “injury” as defined, the constituent elements for Comcare’s liability also ceases. It follows that it is the continuing existence of the necessary statement of affairs which defines the duration of Comcare’s liability. …
[85] Logically, the causes of a disease or ailment tend to cease once the condition is suffered and the employee ceases employment or the causative factors are remedied. However, having been caused by the contribution of the employee’s employment, the condition itself often continues and compensation is payable to the extent to which it results in death, incapacity or impairment. It does not follow that, in order for Comcare to remain liable, the employee’s employment needs to remain a constant and continuing contributor to the ongoing injury. …what is required is that the contribution requirement remain in place in the sense that the disease or ailment continues to have the characteristic of having been contributed to in a material degree by the relevant employment. … it is preferable to say that the causal nexus between the employee’s employment and suffering of the disease continues unbroken. …
…
[90] … Comcare has no liability under s 14 in relation to an ailment, the continued existence of which can longer be said to have the necessary causal connection to the employee’s employment. The mere fact that the ailment suffered may once have had the necessary causal connection to the employee’s employment is irrelevant. Even where the ailment continues unabated, if it ceases to have the characteristic of being one which was relevantly contributed to by the employee’s employment, Comcare’s liability ceases.
[emphasis added]
It follows, that in this matter, it is not necessary to decide whether the CRPS and Ms Cash’s current claimed symptoms are the same “ailment”.
The relevant issue is whether Ms Cash’s current “ailment” continues to have “the characteristic” of having been contributed to, to a significant degree by her employment.
The difficulty for Ms Cash is that the available evidence points to a conclusion that the CRPS had resolved at some point during 2016 with no subsequent clear evidence of the presence of the required objective clinical signs.
In Military Rehabilitation and Compensation Commission v May (2016) 257 CLR 468 (“May”), the High Court noted the Full Court’s conclusion that “the inquiry demanded by the statutory definition of "injury" was "whether the person has experienced a physiological change or disturbance of the normal physiological state (physical or mental) that can be said to be an alteration from the functioning of a healthy body or mind"”. The High Court further noted in May, however, that this conclusion should be rejected to the extent that it suggests that symptoms subjectively experienced by an individual, without “accompanying physiological or psychiatric change”, are sufficient to engage section 14 of the SRC Act.
I accept that Ms Cash continues to suffer “pain” and some functional incapacity, however, the available evidence which, in my view, is somewhat incomplete, inconsistent and at times unreliable, does not provide a satisfactory explanation for the persistence and claimed severity of her pain or the claimed severity of her functional incapacity.
The evidence is largely based on Ms Cash’s self-reported symptoms and her own description of incapacity with little contemporaneous documentary corroboration.
In particular, I am not persuaded that there is sufficient reliable evidence to support a conclusion that, as at 18 July 2016 and since that date, Ms Cash’s symptoms have been accompanied by “physiological change” that can be causally connected to her employment with Australia Post.
In conclusion, I am satisfied that by 18 July 2016, Ms Cash‘s ongoing “pain” condition had ceased to have the have the characteristic of being an “ailment” that was contributed to, a significant degree by her employment with Australia Post.
Therefore, as at 18 July 2016, Comcare’s was no longer liable to pay compensation under sections 16 and 19 of the SRC Act in respect of regional pain syndrome.
Mental health condition - Secondary mild adjustment disorder with depressed mood
The documentary evidence before the Tribunal clearly reveals that Ms Cash has experienced a longstanding and complex psychosocial history with significant family and interpersonal difficulties, frequent episodes of anxiety and depression, intermittent treatment with antidepressant medication with poor compliance, and a hospital admission for major depression.
In the period leading up to Ms Cash’s employment with Australia Post, between February 2014 and October 2015, the GP consultations appear to have been focussed on psychosocial issues with entries recorded, inter alia, as follows:
Struggling with depression, on dothep…was on efexor but stopped working…then dothep > worked with anxiety, depression and fibromyalgia (3 February 2014)
still struggling. suicidal thoughts (12 February 2014)
thinks she lives with an aggressive partner, thinks this is damaging to relationship with children (12 February 2014)
Reason for contact: Depression…’break down’…some pressures at work (10 March 2014)
depression, fibromyalgia is playing up. fatigued and pain, looks back her life because of her decisions she made [sic]. she shouldn’t have…got married again…some suicidal thoughts but has child, some flashbacks of being made advantage of (17 March 2014)
been stepped down with full pay…at meeting, no sackable offence… (9 May 2014)
was sacked today…unfair dismissal (13 May 2014)
overwhelmed with grief and pain…appetite low…suicidal moments , (18 June 2014)
started efexor. feeling better (24 June 2014)
feeling depressed, no job…insecurities and hopelessness…prolonged consult re depression (21 August 2014)
[emphasis added]
In his letter of 7 August 2015, Dr Ho lists “adjustment disorder with anxiety and depression” as an issue. Dr Ho provided no clinical details or rationale for this presumed diagnosis, and in my view his opinion is of questionable value.
In his report dated 16 December 2015, Mr O’Neill expressed the opinion that Ms Cash suffered a “mild adjustment disorder with depressed mood secondary to her physical condition” that would be expected “to resolve over the next couple of months”.
I note that Ms Cash did not provide Mr O’Neill with a complete and accurate personal and mental health history and, therefore, his expressed opinion must be given significantly less weight.

In his report of 23 May 2017, Dr Champion provided a psychiatric assessment which included a more comprehensive consideration of Ms Cash’s personal and mental health history as recorded in the relevant GP records.
Dr Champion noted that his review of GP records, with reference to the period from February 2014 to June 2015, “suggests the presence of ongoing interpersonal difficulties with labile emotional responses including episodes of depression which had apparently required antidepressant medication against a back ground of episodes of frank severe depression”.
Dr Champion expressed his diagnosis of Ms Cash’s psychiatric condition as “Pre-existing unstable mental function, manifesting as episodes of anger and anxiety/depressive symptoms, on the basis of perceived unfair treatment in both domestic and workplace situations.”
In conclusion, Dr Champion described that the cause of Ms Cash’s “psychiatric condition” as “constitutional unstable emotional and interpersonal functioning most likely due to a combination of genetic input and adverse nurture in her formative years leading to personality disorder/dysfunction”.
In his report of 11 July 2018 Dr Clark, on the basis of a somewhat incomplete and inaccurate history, concluded that Ms Cash “has a Major Depressive Disorder”. I found this report to be unhelpful and of limited value.
I note that from January 2015, apart from the medico-legal psychiatric assessments, there is no documentary evidence of any formal psychiatric treatment.
Relevantly, at this point I note that in Telstra Corporation Limited v Hannaford [2006] FCAFC 87 the Full Federal Court concluded at [57]:
the AAT is empowered to make subsequent findings of fact in relation to the circumstances the subject of the decision-making under ss 16 and 19 of the SRC Act …where the determination of the first instance decision maker…made under the auspices of s14 of the SRC Act remains in operation in the sense that it has not been the subject of any inconsistent outcome in the context of subsequent review by the AAT.
I accept that, following the diagnosis of bilateral plantar fasciitis, Ms Cash may have suffered intermittent mental health symptoms, however, on the available evidence I am not satisfied she suffered secondary mild adjustment disorder with depressed mood, or any other psychiatric condition, that was contributed to, to a significant degree by her employment with Australia Post.
In reaching my decision I have preferred the opinions expressed by Dr Champion, who in my view provided a more comprehensive and persuasive assessment.
It follows that, as at 8 September 2016, Ms Cash was not entitled receive compensation payments pursuant to sections 16 and 19 of the SRC Act in respect of secondary mild adjustment disorder with depressed mood.
As I have found that Ms Cash did not suffer any psychiatric condition that was contributed to, to a significant degree, by her employment, it is not necessary to consider whether, by reason of her failure to reveal her pre-existing history of mental health issues in her pre-employment medical questionnaire, section 7(7) of the SRC Act operates to disallow compensation for the psychiatric condition.
DECISION
For reasons the set out above, the Tribunal finds that:
· as at 18 July 2016, Comcare was not liable to pay compensation under sections 16 and 19 of the SRC Act for bilateral plantar fasciitis and regional pain syndrome;
· as at 8 September 2016, Comcare was not liable to pay compensation under sections 16 and 19 of the SRC Act for secondary mild adjustment disorder with depressed mood.
The decisions under review are affirmed.

I certify that the preceding 228 (two hundred and twenty-eight) paragraphs are a true copy of the reasons for the decision herein of Dr I Alexander, Senior Member

...............................[sgd].........................................
Associate
Dated: 15 September 2021

Date(s) of hearing:
12 & 13 June 2019
19 & 20 April 2021
2 August 2021

Counsel for the Applicant:
Michele Fraser (June 2019)
Brendan Jones (April 2021, August 2021)

Solicitors for the Applicant: Robert Bryden Lawyers

Counsel for the Respondent: Matthew Gollan

Solicitors for the Respondent: Sparke Helmore Lawyers

ADMINISTRATIVE APPEALS TRIBUNAL	)
)	No: 2016/4590, 2016/6819
GENERAL DIVISION	)

Date(s) of hearing:	12 & 13 June 2019 19 & 20 April 2021 2 August 2021
Counsel for the Applicant:	Michele Fraser (June 2019) Brendan Jones (April 2021, August 2021)
Solicitors for the Applicant:	Robert Bryden Lawyers
Counsel for the Respondent:	Matthew Gollan
Solicitors for the Respondent:	Sparke Helmore Lawyers