Estate of Collins and Comcare

[2007] AATA 1219

Administrative Appeals Tribunal

DECISION AND REASONS FOR DECISION [2007] AATA 1219

ADMINISTRATIVE APPEALS TRIBUNAL      )

)          No N2004/1502

GENERAL ADMINISTRATIVE DIVISION		)
Re		ESTATE OF PAUL COLLINS

Applicant

And COMCARE

Respondent

DECISION

Tribunal Ms N Bell, Senior Member
Dr J Campbell, Member

Date12 April 2007

PlaceSydney

Decision The decision under review is affirmed.

.............................................

Ms N Bell
  Senior Member  

COMPENSATION – Schizophrenia – Panic Disorder - Conditional Medical Registration with the New South Wales Medical Board - Medical Examinations on Visa Applicants – Whether the pre-existing Psychiatric Condition was Aggravated by his Employment – What is the Nature and Usual Course of Schizophrenia and the Effect – Circumstances of the Workplace – The Workplace did not Aggravate his Condition – The Decision Under Review is Affirmed.

REASONS FOR DECISION

Ms N Bell, Senior Member
Dr J Campbell, Member     

1.      Dr Paul Collins died on 17 January 2006, after he had lodged an application for review of Comcare’s decision to deny liability for schizophrenia and bouts of panic disorder.  Following Dr Collins death, his estate took over the application for review.

2.      Dr Collins began employment with Health Services Australia in November 1999, as a medical adviser. Dr Collins worked on Mondays, Wednesdays and Fridays.  Prior to that, he had worked as a medical officer with the Department of Corrective Services, conducting general practice clinics in prisons.

3.      Dr Collins had been under the care of a psychiatrist since 1991 and had been diagnosed with schizophrenia.  By the time Dr Collins commenced work with Health Services Australia, he had a conditional medical registration with the New South Wales Medical Board.  The conditions attached to Dr Collins’ registration were that he work in a supportive environment, inform the Board if he intends to change his employment, receive treatment from a psychiatrist and attend for examination by the Board psychiatrist from time to time.

4.      Dr Collins’ duties with Health Services Australia included conducting medical examinations on visa applicants.  A particular form (Form 26) was required to be completed by examining medical advisers and they were required to refer patients for specialist examination and report where the patient’s presentation was abnormal. 

5.      In March 2001 his employment contract was renewed for a further two years.  In February 2002 Dr Collins was granted full and unconditional registration with the New South Wales Medical Board.

6.      Dr Collins’ immediate supervisors were Dr Eng and Dr Phillips, who shared the position of Senior Medical Adviser.  Dr Robyn Taylor is and was the General Manager of the Surry Hills office where Dr Collins worked.

7.      From early 2003 until August 2003, when Dr Collins ceased to work, his condition became worse.  This culminated in Dr Taylor notifying the Medical Board and telling Dr Collins, on 8 August 2003, that he should cease work for the time being.  Dr Taylor had made an appointment for Dr Collins to see his treating psychiatrist Dr McMurdo and Dr Collins proceeded to that appointment.  Apart from one day at the Health Services Australia Parramatta site, Dr Collins did not return to work.

issues

8.      The issue raised by this application is whether Dr Collins’ pre-existing psychiatric condition was aggravated by his employment, resulting in an incapacity to work from August 2003 until his death in January 2006.

9.      This question requires consideration of a number of factors including the nature and usual course of schizophrenia and the effect, particularly on the course of Dr Collins’ schizophrenia, of external events.  It also requires consideration of the circumstances under which Dr Collins worked at Health Services Australia.

the course of dr collins’ schizophrenia and the effect of external events

10.     Dr Bell, Dr Collins’ widow, said his thought disorder and delusion were controlled by his medication and that he was compliant with his medication regime.  She described an increase in Dr Collins’ anxiety in early 2003 and noted that he talked more about his work.  She also said he had coped reasonably well with his previous work at the Department of Corrective Services, conducting general practitioner clinics at goals.

11.     This evidence contrasted with the picture presented by the clinical notes of Dr Collins’ treating psychiatrist, Dr McMurdo.  Those notes showed no mention of work as a concern until June 2003.  Rather, in February 2003, Dr Collins reported concerns about the Iraq war and difficulties he had with his son.  In correspondence to ComInsure on 6 April 2004 and to State Super on 8 January 2004, Dr McMurdo was equivocal about whether Dr Collins’ concerns were factual or a product of the paranoia associated with his schizophrenia.  He also noted, in his evidence to the Tribunal, that the deterioration in Dr Collins’ condition from February 2003 meant his medication had to be increased.  He allowed that his deterioration may have been related to the dose being too low.

12.     Dr McMurdo also reported chronic anxiety and panic from 1999 and Dr Collins reported to Dr Lewin that these symptoms had emerged as early as 1993.

13.     In answer to a question about whether a deterioration of Dr Collins’ condition preceded his complaints about his work, Dr McMurdo said it was a difficult question and noted that Dr Collins had managed to work previously, in spite of marked psychotic symptoms.  He described a number of paranoid delusions suffered by Dr Collins and the depression and anxiety that had fluctuated over the four years he had treated him but said the notable change was that he started, in June 2003, to complain about something in his real life situation, that he was overloaded at work, and that was accompanied by a marked deterioration.

14.     We also note the report of the Medical Board in 1994 and Dr Collins’ evidence to the Board that he had difficulty coping with his work at the prisons.   Evidence was also given at that hearing by Dr Sara of the Prisons Medical Service who said staff at one prison had to “cover” for Dr Collins, that he had little rapport with patients and that on a number of occasions he was found just staring into space.

15.     Dr Lewin, psychiatrist, was of the opinion that external events have none but a transitory impact on the course of schizophrenia.  He considered that Dr Collins’ complaints about work were a product of his condition and that, if there was any temporary exacerbation because of work, it would resolve soon after he ceased.  He described schizophrenia as a condition that follows a fluctuating course with or without treatment and regardless of external stimuli.

16.     We also note Dr Eng’s evidence that initially Dr Collins’ symptoms would come and go but by late June 2003 they occurred every day.  She said she had observed accelerated speech, sweating and repeated checking of files (signs of anxiety) from January 2003 onwards.  She said that until June 2003 he was able to perform his duties even though he had regular panic attacks and time out.  She said that until June the panic attacks were short lived and relieved by a discussion with either her or Dr Philips.  She said, if he had a concern about work, he would generally raise either his need to check and re-check or his concern about recording blood pressure results when he asked to “have a chat” with her.  She said he did not raise any other work related matter but often simply felt anxious with no particular trigger.  She considered that, by July 2003, he was having difficulty performing his duties even though he was allocated only the simplest cases.

17.     We are satisfied that Dr Collins’ schizophrenia had been sufficiently disabling for him to have required conditional registration as a medical practitioner; that it affected his ability to properly perform his functions at the Department of Corrective Services; and that  his condition fluctuated over the course of his employment with Health Services Australia.  We also find that, from February 2003, Dr Collins’ condition began to deteriorate, with him focussing on the Iraq war, and that, by June 2003, he began to regard some aspects of his employment as the focus of his problems.

18.     We find the evidence of Dr Lewin more persuasive, compared to Dr McMurdo’s more equivocal view, as to the nature and course of schizophrenia and we accept his expert opinion that, while schizophrenia may be temporarily exacerbated by an external event or stimulus, the exacerbation will cease when the event or stimulus ceases.  We accept that the severity of schizophrenia fluctuates, independently of external stimuli.

19.     We note that the question of whether Dr Collins was compliant with his medication regime was agitated by the parties to a limited extent.  However, the evidence in that respect was inconclusive and neither party relied on it in final submissions.

the circumstances of dr collins’ employment

20.     Counsel for the estate of Dr Collins noted two particular aspects of Dr Collins’ employment circumstances as contributing to his incapacity or aggravating his pre existing condition.  The first was Dr Collins’ and his supervisors’ approach to the form required to be completed in the course of his duties.  The second was events during the period 1 to 8 August, culminating in Dr Collins’ departure.

21.     By way of background, we accept the evidence of Drs Taylor, Philips and Eng that, generally, Dr Collins was provided with a work environment in which his psychiatric condition was substantially accommodated.  This was particularly so after Dr Collins commenced to be supervised by Drs Philips and Eng from approximately January 2003.  We accept their evidence that they each spent considerable time with Dr Collins talking to him about his work and listening to his concerns about various matters, generally not related to work, that were troubling him.

22.     In addition we find no evidence of Dr Collins’ workload having increased in early 2003, although we accept that, at this time of year, the total workload of the office increased with an influx of student visa applicants.  However, we accept Dr Taylor’s evidence that additional doctors were taken on to deal with this increase.  We also accept the evidence of Drs Eng and Philips that Dr Collins’ workload was restricted to uncomplicated matters and specifically excluded families and young women.

23.     As to the first aspect of employment raised by Counsel for the estate, Form 26 is a form used by medical advisers to report on examinations of visa applicants.  According to a statement made by Dr Collins, he had been instructed to “normalise” blood pressure measurements on the form so that clients with readings outside the stated normal range would not experience any delay in the processing of their visa applications.  He described this as being in conflict with established best medical practice and an instruction that caused him extreme anxiety.

24.     The response of Dr Taylor to this allegation was that Dr Collins had insisted on reporting trivial and insignificant conditions on the forms.  These included tinea and heightened blood pressure of five or less mms or heightened blood pressure in an individual who was young and anxious.  She said he had been instructed to annotate the form appropriately in these circumstances but never to record incorrect readings.  She explained the consequences for the Department and the individual when trivial conditions were referred back for a second opinion or referred to a specialist.  She said this had been explained to Dr Collins on a number of occasions but he remained rigid in his approach.  This evidence was supported by the evidence of Dr Philips and Dr Eng.  Those doctors suggested it was Dr Collins’ obsessive and paranoid tendencies (a feature of his schizophrenia) that gave rise to his concentration on trivial details and the rigidity with which he approached examinations.

25.     We accept as correct the view of Dr Collins’ supervisors that his approach to the form was unnecessarily rigid with potentially costly results.  We accept it as reasonable that he was counselled against this approach.  While any conflict perceived by Dr Collins as arising out of this divergence of approach may have distressed him, we do not consider that it caused or contributed to his ultimate incapacity.  The cause of his behaviour, his distress, and his ultimate incapacity was his schizophrenia.

26.     As to the second relevant aspect of Dr Collins’ employment, Dr Philip’s evidence was that on 1 August 2003, following his inability on the previous afternoon to see clients, she had a meeting with Dr Collins in which he expressed distrust of her and of Dr Eng.  She said his manner made her feel threatened and uncomfortable.  Up until that time, she considered, Dr Collins had readily sought her counsel and he viewed her as a source of support.  After this meeting, however, she considered her relationship with Dr Collins had become untenable.  At a later meeting on that day, Dr Philips told Dr Collins that Dr Taylor wished to meet with him to discuss his work performance.  That meeting eventually took place on 8 August.

27.     Dr Eng had a similarly difficult meeting with Dr Collins at about that time and reached the same conclusion about her relationship with him.  She said his manner with her was threatening and it was clear to her that he no longer trusted her and that the situation was untenable.

28.     Dr Eng also said that by the end of June she had taken the step of discussing Dr Collins’ performance with Dr Taylor and of contacting Dr Collins’ psychiatrist.  She said that, in August 2003, Dr Taylor asked her to prepare some notes on Dr Collins for submission to the Medical Board.

29.     Dr Taylor’s evidence was that she did plan to hold a meeting with Dr Collins but it was delayed because she also wished to refer the matter back to the Medical Board and it had been in the process of moving to a new site during the relevant week.  She said she wished to obtain some guidance from the Medical Board and to alert it to Dr Collins’ current condition.  She had asked Dr Eng to speak with Dr McMurdo to arrange an appointment following her planned meeting with Dr Collins, to ensure he had any support and assistance he needed.

30.     Dr Collins, in his statement, was very critical of the way in which he was driven by Dr Taylor and another officer of Health Services Australia to Dr McMurdo’s premises for his appointment.  He claimed it was done with a sense of urgency and in a manner that was patronising and excessive.

31.     We accept that, by this time, some action had to be taken in relation to Dr Collins – if only to protect the safety of his supervisors.  We accept the evidence of Drs Eng and Philips that they had each felt physically unsafe in Dr Collins’ presence.  While the delay in holding the meeting with Dr Taylor is regrettable, and it may have been appropriate to advise Dr Collins of the approach made to the Medical Board, we consider that at this point Dr Collins’ condition had deteriorated to such an extent as to incapacitate him for work.  The meeting with Dr Taylor was an inevitable result of that incapacity and neither the cause of it nor a contributor to it.   Similarly, making an appointment for Dr Collins to see his psychiatrist and driving him there could only have assisted him and was not an exacerbating factor.

cobnclusion

32.     Dr Collins’ illness had been diagnosed in 1991 and was on a course of deterioration, not unusual in schizophrenia, as early as February 2003.  By June/July 2003 his condition had deteriorated to the extent that he was becoming less able to perform his work and more dependent on the support and accommodations of his two supervisors.  By the afternoon of 30 July he was unable to see clients and on 1 August his relationship with his supervisors broke down into one of distrust. On that day he threatened one supervisor and later the other.  This behaviour prompted a meeting with the General Manager in which she suggested he absent himself from work for a while and he was assisted to an appointment that had been made for him with his psychiatrist.

33.     We consider that Dr Collins’ workplace and the actions of his supervisors and of management played no part in the deterioration of his condition.  On the contrary, Drs Philips and Eng, in particular, went to some lengths to provide support to Dr Collins and they accommodated his limitations and difficulties, consulting appropriately with Dr Taylor.  Dr Collins’ deteriorating condition was a consequence of his underlying schizophrenic disorder with episodic symptomatology.  That episodic symptomatology was integral to the condition and not caused by, contributed to or aggravated by his work. 

decision

34.     The decision under review is affirmed.

I certify that the 34 preceding paragraphs are a true copy of the reasons for the decision herein of Ms N Bell, Senior Member and Dr J Campbell, Member

Signed:         .................[Sanjiv Shah].....................
  Associate

Dates of Hearing  11 and 12 September 2006
  20 and 21 February 2007

Date of Decision  12 April 2007
Counsel for the Applicant         Mr M Gollan
Solicitor for the Applicant          WG McNally Jones Staff

Counsel for the Respondent     Mr B Kelly
Solicitor for the Respondent     Sparke Helmore Lawyers