Gerling v AAI Limited t/as GIO
[2022] NSWPICMP 262
•23 June 2022
| DETERMINATION OF REVIEW PANEL | |
| CITATION: | Gerling v AAI Limited t/as GIO [2022] NSWPICMP 262 |
| CLAIMANT: | Jennifer Gerling |
INSURER: | AAI Limited t/as GIO |
| REVIEW Panel: | Principal Member John Harris Medical Assessor John Carter Medical Assessor Michael Rochford |
| DATE OF DECISION: | 23 June 2022 |
| CATCHWORDS: | MOTOR ACCIDENTS – The claimant was involved in a motor accident in 2017; a different Panel had determined in earlier medical disputes (Gerling (No 1)) that the claimant injured her low back resulting in surgery; in Gerling (No 2) a previous Review Panel determined other treatment disputes; the present dispute concerned whether a prolapsed cervix was caused by the motor accident and the assessment of permanent impairment; Held – the Panel accepted that it was not bound by the findings made in previous medical disputes; the claimant was on large amounts of opioids prior to the motor accident which caused constipation; however, the evidence showed a dramatic increase in the consumption of opioid medication following the motor accident; the relationship between the use of the opioid medication and the back condition is evident from the consistent back complaints that led to lumbar surgery and as recounted in Gerling (No 2) and the reduction in use of opioid medication following successful back surgery; the consumption of opioids can cause constipation which causes straining which caused a prolapsed cervix; the Panel accepted that the prolapse occurred in the manner recounted by the claimant which was consistent with the history recorded by the treating specialist; the claimant is required to satisfy the test of causation as discussed in AAI Ltd v Phillips; based on the temporal link, the excessive use of opioid medication and the severe lumbar spine caused by the motor accident the straining led to the prolapse which was caused by the motor accident; the claimant was medically examined by a Medical Assessor on the Panel; the prolapse was found to be greater than assessed by Medical Assessor Korbel and the treating doctor; this is consistent with increased prominence with the course of the medical condition once it has occurred; pursuant to Chapter 11, page 255, paragraph 11.3 of the American Medical Association's Guides to the Evaluation of Permanent Impairment 4th edition (AMA 4) the impairment of the urinary tract is assessed at 12%. |
| DETERMINATIONS MADE: | Medical Assessment – Permanent Impairment WHETHER THE DEGREE OF PERMANENT IMPAIRMENT OF THE INJURED PERSON AS A RESULT OF THE INJURY CAUSED BY THE MOTOR ACCIDENT IS GREATER THAN 10% THE ASSESSMENT MADE BY THE REVIEW PANEL UNDER SECTION 63(4) IS AS FOLLOWS: The Review Panel revokes the certificate of Medical Assessor Korbel dated 27 May 2021 and issues a new certificate that the following injuries caused by the motor accident give rise to a whole person impairment which is GREATER THAN 10%: · Urinary tract. |
REASONS
BACKGROUND
Mr Jennifer Gerling (the claimant) suffered injury in a motor accident on 23 November 2017 when another vehicle failed to stop in time impacting into the rear of her vehicle causing it to shunt into another vehicle (the motor accident).
AAI Limited (the insurer) insured the owner and/or driver of the other motor vehicle for liability to pay to Ms Gerling any damages under the Motor Accidents Compensation 1999 (the MAC Act).
The present dispute between the parties is whether the degree of permanent impairment as a result of the injury caused by the motor accident is greater than 10%. This constitutes a medical dispute within the meaning of the Act.[1]
[1] See ss 57 and 58 of the MAC Act.
Section 44(1)(c) of the MAC Act provides that the Authority may issue guidelines with respect to the assessment of the degree of permanent impairment of an injured person as a result of an injury caused by a motor accident.
The Motor Accident Permanent Impairment Guidelines (the Guidelines) were issued pursuant to s 44(1)(c) for the assessment of permanent impairment. The Guidelines adopt the fourth edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment (AMA 4). Where there is any difference between AMA 4 and the Guidelines, the Guidelines are definitive.[2]
[2] Clause 1.2 of the Guidelines.
The present application is a review of a medical assessment pursuant to s 63 of the MAC Act. The medical assessment the subject of this review was conducted by Medical Assessor Edward Korbel dated 27 May 2021.
Medical Assessor Korbel assessed the impairment of the urinary tract at 10%.
The application for referral of a medical assessment to a Review Panel (the Panel) was made by the insurer within 28 days after the parties were issued with the original certificate for the medical assessment for which the review is sought.[3]
[3] Section 63(7) of the MAC Act.
On 18 February 2022, the delegate of the President referred the medical assessment to the Panel as they were satisfied that there was reasonable cause to suspect that the medical assessment was incorrect in a material respect having regard to the particulars set out in the application.[4]
[4] Section 63(2B) of the MAC Act.
Pursuant to s 63(3) of the Act and Schedule 1, clause 14F(2) of the Personal Injury Act 2020 (the PIC Act), the Panel consists of two medical assessors and a member of the Motor Accidents Division of the PIC.
CONDUCT OF THE REVIEW
Part 5 of the PIC Act enables the Personal Injury Commission (the Commission) to make rules with respect to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a merit reviewer or a medical assessor.[5]
[5] Section 41(2) of the PIC Act.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the 2020 Act. A Review Panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application.[6]
[6] Rule 128 of the PIC Rules.
The review is by way of new assessment of all matters with which the medical assessment is concerned.[7]
[7] Section 63(3A) of the Act.
The Panel issued a Direction calling for bundles of documents which were provided by the parties. A subsequent direction was issued in the following terms:
1. The claimant is to file and serve by close of business, 2 May 2022;
(a)a statement whether it accepts or rejects the accuracy of the table provided by the insurer concerning the medication prescribed in the two-year period prior to the motor accident. If this is not accepted, the claimant is directed to prepare a table in response.
(b)A table of opioid medications prescribed to the claimant from the date of the motor accident to 31 October 2020 specifying the quantity and dosage of the medications; and
(c)Response to directions 3 and 4.
2. The insurer is, by close of business 9 May 2022:
(a)respond to claimant’s table (direction 1(b)); and
(b)respond to directions 3 and 4.
3. The parties are to advise whether they accept, if causation is established, that the permanent impairment of the urinary tract is agreed at 10%. Failing such agreement, the claimant may need to undergo a physical examination.
4. The parties are on notice that the Panel will consider the decision in AAI Ltd v Gerling [2022] NSWPICMP 67.[8] Any further submissions addressing this decision and its relevance can be made at the time the parties are required to file further submissions.
5. Following receipt of these submissions, the parties will be advised of the need to examine the claimant by audio-visual link or in person.
6. The Panel notes that the claimant’s medication as at 31 October 2020 is described at page 173 and 176 of her bundle of documents.
[8] Gerling (No 1).
The parties provided succinct and helpful responses to the further directions. The further submissions are set out subsequently in these Reasons.
MEDICAL ASSESSMENT UNDER REVIEW
This review is from the assessment of Medical Assessor Korbel dated 27 May 2021 who determined that Mr Gerling suffered a 10% permanent impairment of the urinary tract. Medical Assessor Korbel stated:
“This lady has had a motor vehicle accident with considerable orthopaedic injuries resulting in prescription of opioid medication and other medications which have caused her to develop chronic constipation. Due to having to force to empty her bladder, she has developed a prolapse. The prolapse is a secondary condition to her medication usage.
This lady has a cystocele following straining when going to the toilet. This is related to her medications which have been prescribed for her orthopaedic condition. These medications have caused chronic constipation.”
OTHER MEDICAL ASSESSMENTS
Medical Assessor Cameron issued a medical assessment dated 10 July 2021 when he determined that Ms Gerling suffered permanent impairment of 2% for various physical injuries, specifically the right shoulder. It does not appear that a combined certificate was issued aggregating the different impairments provided by Medical Assessor Korbel and Medical Assessor Cameron. No review has been filed from that assessment.
Medical Assessor Dixon issued a treatment dispute on 2 June 2021 when he determined that the proposed anterior lumbar spine fusion recommended by Dr Diwan was reasonable and necessary and caused by the motor accident.
Medical Assessor Cameron also issued a treatment dispute dated 10 July 2021 when he determined that extensive treatment and care was not reasonable and necessary and not caused by the motor accident.
Reviews were filed by both parties from these certificates and heard by the one Review Panel.
During the period before the determination of the reviews, Ms Gerling underwent a lumbar spine fusion at L4/5 and L5/S1 which necessitated the redrafting of part of the medical dispute.
The Review Panel determined that the lumbar spine surgery was reasonable and necessary and causatively related to the motor accident: AAI Ltd v Gerling.[9] During the course of those reasons the Review Panel stated:
“149. The motor accident need only be a material contribution between the motor accident and the need for treatment: AAI Limited v Phillips. That means that there can be other non-related causes for the need for treatment included age related degenerative changes.
150. We accept that the claimant was symptomatic in the lower back at times prior to the motor accident. There were periods when the back condition flared up following specific incidents prior to the motor accident. However, Ms Gerling was able to continue work on a part-time basis and was practising for her bronze medallion for surf lifesaving just two weeks prior to the motor accident when she injured her right shoulder.
151. We accept that motor accident caused an aggravation of degenerative changes in the lumbar spine. That aggravation included dermatomal signs in at least at the L5 region as observed by both Medical Assessor Dixon and Dr Kohan in 2021.
152. There is a consistency of complaint by Ms Gerling of continuous low back pain following the motor accident. Those complaints are consistent with the specialist opinion and the various lay statements which discuss Ms Gerling’s ongoing problems.
153. We do not accept the suggestion that the falls detract from the fact that the motor accident aggravated the lumbar spine condition. The claimant’s evidence which we accept indicates that these falls were otherwise due to the deteriorating back condition.
154. The lumbar fusion surgery was explained and recommended by Dr Kohan. Medical Assessor Dixon also supported the fusion although he recommended that Ms Gerling first undergo a discogram.
155. We accept that the claimant’s substantial back pain and observed radicular features were causative of the need for the fusion surgery. In those circumstances based on our finding that the motor accident aggravated the degenerative condition and caused the chronic lumbar spine pain, we find that the motor accident materially contributed to the lumbar surgery.”
[9] [2022] NSWPICMP 67 (Gerling (No 1))
That Review Panel issued a further decision commenting on past need for domestic assistance.[10] In the course of those Reasons that Panel stated:[11]
“43. Ms Gerling suffered from back pain and, to a lesser extent, neck pain, which was causatively related to the motor accident. That the claimant was ‘pain focused’ does not detract from the fact that there was a real need for assistance caused by the motor accident, and which was reasonable and necessary in the circumstances
44. The claimant referred to the histories recorded by treating specialists who noted worsening back pain ultimately resulting in a lumbar fusion. These histories, which we accept as accurate, support the need and causative link between domestic assistance and the motor accident. In addition, the clinical notes of the general practitioner refer to ongoing and debilitating back pain.
45. This conclusion is otherwise consistent with the claimant’s attendance at St George Hospital on three occasions in 2020 for problems either directly or indirectly related to back pain.”
SUBMISSIONS
[10] Gerling v AAI Ltd [2022] NSWPICMP 213 (Gerling (No 2)).
[11] Gerling (No 2) at [43]-[45] footnotes omitted.
Insurer’s submissions
The Insurer filed submissions dated 29 October 2021 seeking a review of the assessment by Medical Assessor Korbel.[12] The insurer submitted that the Medical Assessor ignored pre-motor accident medical evidence and the claimant’s unrelated dependence on analgesic medication, failed to apply the correct on causation and made an erroneous finding resulting in a legally unreasonable decision.
[12] Insurer’s bundle, page 1,167.
The insurer referred to the “analgesic remedies” the claimant was consuming prior to the motor accident and that she was “receiving regular prescriptions of Movicol prior to the accident for constipation”.[13] Reference was made to the records produced by Allianz and the clinical records from Engadine Central Medical Centre. The insurer identified the following medication prescribed to Ms Gerling in the two-year period prior to the motor accident from the clinical notes of Engadine Central Medical Centre.
[13] Insurer’s bundle, page 1,169.
In addition, the insurer noted that the claimant had an unrelated partial left knee replacement in 2021.
The insurer submitted that the Medical Assessor failed to apply the correct test of causation in accordance with clauses 1.6 and 1.7 of the Guidelines. Reference was also made to the decision of AAI Ltd v Phillips, albeit a case on medical treatment, that the motor accident made “a material contribution to the need for surgery” and it should have been considered whether the proposed surgery “would not have arisen but for the occurrence of one or more of the accidents being considered”.
In applying the correct test on causation, the following matters were relevant:
- whether the opioid consumption would have continued “but for the accident occurring”;
- whether there was any causal relationship between any medications and the motor accident, and
- whether the urological injury would not have arisen but for the motor accident.
The insurer referred to the determination of Medical Assessor Cameron who found against causation for all 12 treatment and care disputes including seven different analgesics. The insurer noted that Medical Assessor Korbel’s decision on causation was inconsistent with that provided by Medical Assessor Cameron. That inconsistency resulted in the legally unreasonableness of the determination issue by Medical Assessor Korbel.
The insurer did not dispute the accuracy of the claimant’s table concerning post-accident medication. It reiterated its earlier submissions of the claimant’s “chronic dependence” on pain-relief medications noted a pre-accident consultation on 21 June 2016 regarding education and the need to monitor overdose.[14] It also referred to Dr Teh’s note dated 2 February 2018 when Targin was first prescribed and the comment that the claimant was “keen for stronger analgesia”.[15] The insurer submitted:[16]
“[T]hat the claimant’s chronic use of pain-relief medications pre-dated the subject accident and continued as she sought to try other stronger medications due to ongoing pre-existing pain.”
[14] Insurer’s bundle, page 225.
[15] Claimant’s bundle, page 390.
[16] Insurer’s further submissions, paragraph 5.
The insurer did not accept the assessment of 10% permanent impairment of the urinary tract and suggested that there should be a deduction for pre-existing impairment.
Claimant’s submissions
The claimant filed submissions dated 3 December 2021 opposing the application for review of the determination made by Medical Assessor Korbel.[17] It submitted that the prolapse injury to the urinary tract arose from chronic constipation.
[17] Claimant’s bundle, page 1,153.
This issue was determined in favour of the claimant in the determination made by Medical Assessor Cameron. No review on this determination was sought. The determination of causation for the urinary tract/prolapse “follows naturally from causation for the digestive system/chronic constipation found by [Medical] Assessor Cameron”.
The insurer provided no submissions on the impairment dispute and did not serve any evidence relevant to the urinary tract assessment.[18] There was no failure by the Medical Assessor because no argument was articulated by the insurer.
[18] Claimant’s bundle, page 1,158.
The Medical Assessor conducted his own assessment and reached an opinion different to that now posited by the insurer. There was “no evidence” of “chronic dependence” of opioids. The evidence provided by the insurer does not establish dependence on opioids and there are only five references in the clinical records and notes to the claimant receiving Movicol from her general practitioner.
The claimant noted that there was no evidence of a pre-existing prolapse. She also referred to the increase in the nature and extent of the medication after the motor accident which included new medications including Targin, Lyrica, Tramadol, Cymbalta, Duloxetine, Coloxyl with Senna, Temazepam and Diazepam.[19]
[19] Claimant’s bundle, page 1,162.
The motor accident caused considerable injuries which resulted in resulted in a requirement for opioid medication. The claimant’s case was clear because there were no pre-existing bladder problems, no prior prolapse and the accident caused the need for medication usage.
In its further submissions the claimant summarised the medication in the three years period following the motor accident as follows:
- Endone was prescribed on 78 occasions compared with seven times in the two years before the motor accident;
- Panadeine Forte was prescribed on 72 occasions compared with 28 in the two years before the motor accident;
- Targin was prescribed on 65 occasions, having not been prescribed in the two years before the motor accident, and
- Tramadol was prescribed on four occasions having not been prescribed in the two years before the motor accident.
The claimant accepted that this Panel should consider the decision in Gerling (No 1) which, she submitted “is consistent with Assessor Korbel finding the claimant had a motor vehicle accident with considerable orthopaedic injuries resulting in prescription of opioid medication. and other medications”.[20]
[20] Claimant’s further submissions, [3.3].
EVIDENCE
The evidence is summarised in Gerling (No 1) and is adopted in these reasons.[21] We otherwise refer to the following evidence.
[21] Gerling (No 1) at [39]-[77].
The insurer provided a table of the claimant’s pre-motor accident use of medication. We adopt that table subject to the correction made by the claimant in her submissions.[22] The pre-accident medication use for the two year period prior to the motor accident is attached at Schedule 1 to these Reasons.
[22] The claimant in her further submissions accepted the accuracy of the table subject to the duplication of entries for the attendances on 6 December 2016, 15 December 2016 and 19 December 2016.
We also adopt the claimant’s submissions on the extent of her post motor accident opioid medication.[23] The insurer did not dispute the accuracy of the table.[24] The document of post motor accident opioid medication is attached as Schedule 2 to these Reasons.
[23] Claimant’s further submissions, Schedule 2 and summarised at [38] herein.
[24] Insurer’s further submissions, paragraph 5.
In a referral to Dr Gan dated 31 October 2020 Dr Cezar Darwiche noted a recent lump in the vagina when straining.[25] Current medications were described as:
- Duloxetine 60 mg, one per day;
- Lyrica 150 mg, one per day;
- Panadeine Forte 500 mg; 30 mg tablet, 1-2 three times per day;
- Endone 5 mg tablet PRNBD, and
- Targin 5/2.5 mg BD.
[25] Claimant’s bundle, page 178.
“PRNBD” means as required twice per day.
Dr Darwiche provided a similar referral to Associate Professor Karantanis on 7 November 2020.[26]
[26] Claimant’s bundle, page 176.
Associate Professor Emmanuel Karantanis provided a report dated 11 November 2020. The doctor then noted severe back pain following the motor accident with regular opioid usage and resultant constipation.[27] He described a straining to void resulting in a protruding cystocoele and the cervix coming to the introitus.
[27] Claimant’s bundle, page 173.
The examination undertaken by Medical Assessor Korbel confirmed the findings noted by Associate Professor Karantanis.[28]
[28] Insurer’s bundle, page 1,182.
RE-EXAMINATION
Ms Gerling was examined by Medical Assessor Rochford on 16 June 2022. The examination report is as follows.
“After identification Ms Gerling agreed to the interview regarding her claim for Cystocele prolapse occurring as a result of motor vehicle accident that occurred on 23 November 2017.
1. Was any prolapse in evidence before the accident?
No prolapse was evident before the accident
2. How long after accident did prolapse appear?
The prolapse first appeared sometime in October 2020
3. What changes were made to analgesic intake as result of accident?
Before accident Ms Gerling was prescribed Panadeine Forte and Endone. This was for treatment of knee pain following a Right Knee replacement in December 2012.
Following the accident Ms Gerling required stronger analgesics because of severe low back pain. Besides Panadeine Forte and Endone she was prescribed Targin, Tramadol, and Lyrica.
Constipation became an early problem, treated with various medication s including – Movicol, Coloxyl, Benefibre plus others.
Constipation resulting in episodes of severe abdominal pain and episodes of faecal incontinence. She was admitted to hospital by treating gastro-enerologist, Dr Gan, on one occasion in 2020.
Ms Gerling underwent Anterior Interbody Spinal Fusion of lower lumbar vertebrae (AISLF) in November 2021 by Dr Kohan assisted by vascular surgeon Dr Limerick.
Following this operation there was a decreased requirement for analgesic. Targin was discontinued.
PRESENT MEDICATION
Ms Gerling still required Panadeine Forte and Endone for continuing pain on a regular basis. Also continues on, Duloxetine, Movicol and Coloxyl.
4. PROLAPSE HISTORY
Bowel constipation became a problem following the accident when her analgesic treatment was increased to include opioid medication.
Her main complaint throughout 2020 was severe constipation, abdominal pain and episodes of faecal incontinence. She was hospitalised in mid-2020 for this problem.
Her GP investigated this pain by Ultrasound and X-Rays.
Ms Gerling brought Films and reports to this interview.
20 June 2020 Ultrasound Pelvis -Transabdominal and Transvaginal probes
Conclusion – No pelvic pathology identified.
2 September 2022 CT Abdomen and Pelvis for investigation of Left Iliac pain and possible diverticulitis.
Reported anteverted – ovaries appear normal.
No mention of any prolapse.
Ms Gerling first noticed prolapse on straining in October 2020. She saw her GP Dr Darwish Cezar. He confirmed her observation and referred her to Dr Emmanuel Karantanis (Gynaecologist) and for review by Dr Gan (Gastro-enterologist).
Dr Karantanis in November 2020 noted on examination a cystocele protruding and cervix coming to introitus. He diagnosed a stage II prolapse He referred her for Pelvic Floor Physiotherapy
Following the spinal surgery (AISLF) by Dr Kohan in November 2021 Ms Gerling noted a decrease in the protrusion of the prolapse. Dr Limerick the vascular surgeon who assisted Dr Kohan attributed this to the disturbance of the position of abdominal contents as required to perform the spinal fusion.
Ms Gerling stated that for many weeks following the operation she was unable to strain because of the pain in the lower abdominal incision made to gain access trans-abdominally to the lumbar vertebrae.
The prolapse recurred after two months and the protrusion was more obvious Ms Gerling was referred by her GP back to Dr Karantanas in February 2022 because of the increase in the severity of the prolapse and the onset of urinary incontinence.
EXAMINATION
This examination carried out in presence of a chaperone.
The cystocele prolapse observed at vaginal introitus with Ms Gerling in supine position. On cough or straining the prolapse protruded through introitus of vagina.
It is noted that Ms Gerling was fully cooperative throughout this assessment.
Her presentation was straight forward.
ASSESSMENT
It is noted that Cystocele is more prominent than noted at earlier assessments by Assessor Korbel and examination by Dr Karantanis.
Assessment under AMA 4 Chapter 11 page 255 Para 11.3.
I would assess her as being in Class 1 with a 12% whole person impairment.”
FINDINGS
The review is a new assessment of all matters with which the medical assessment is concerned. We note the merit of the claimant’s submission that the insurer failed to articulate an argument before the Medical Assessor. However, the Delegate has allowed the appeal to proceed, and the Panel is now required to conduct a new assessment. Our duty is to consider any substantially articulated argument which, unfortunately was not made to Medical Assessor Korbel.
The Panel, comprised of two specialist medical practitioners, is not required to choose between competing medical opinions and is required to form its own opinion: Insurance Australia Group Ltd v Keen[29] and Insurance Australia Ltd v Marsh.[30]
[29] [2021] NSWCA 287 at [40], [41] and [45].
[30] [2022] NSWCA 31 at [11], [21] and [64].
We note that we are not bound by findings made by other Panels on other medical disputes as they are only conclusive as to the medical assessment before it: Owen v Motor Accidents Authority[31]; Allianz Australia Insurance Ltd v Girgis[32]; Brown v Lewis[33] and Pham v Shui[34]. Accordingly, whilst we are not bound by the findings in Gerling (No 1) and Gerling (No 2), we have considered the reasons in those decisions as part of our function.
[31] [2012] NSWSC 650.
[32] [2011] NSWSC 1424
[33] [2006] NSWCA 587.
[34] [2006] NSWCA 373.
The expert medical opinion on the Review Panel accepts that opioids can cause constipation which causes straining which cause a prolapse cervix. This conclusion is supported by the opinion expressed by Professor Karantaris and Medical Assessor Korbel, and the history provided by Ms Gerling to these doctors.
The claimant was on large amounts of opioids prior to the motor accident which caused constipation.
In the motor accident the claimant sustained injuries to the cervical and lumbar spine. She suffered from pre-existing bilateral knee conditions and a right shoulder condition suffered shortly before the motor accident.
We have reviewed the reasoning in Gerling (No 1) and Gerling (No 2) and independently agree with the findings. Our acceptance of these decisions is consistent with the complaints made by Ms Gerling of extensive back pain following the motor accident which includes:
- in a letter dated 12 March 2018 the claimant’s general practitioner, in is referral to Dr Diwan, noted worsening back pain;[35]
- on 4 April 2018 Dr Diwan recommended bilateral facet joint injections;[36]
- in a letter dated 11 July 2018 Dr Diwan recommended home assistance and that the claimant was unfit to return to her pre-injury duties;[37]
- Dr Kohan provided a second opinion. In a report dated 12 September 2018 Dr Kohan noted low back injections did not relieve symptoms and suggested further treatment;[38]
- in a report dated 1 November 2018, Dr Kohan noted that the recent injection did not relieve pain and that Ms Gerling proceed with pain management review;[39]
- the pain management review with ACTIVATE Pain management program commenced in March 2019.[40] Ms Gerling attended again on 9 January 2020 feeling she had regressed and reporting that she was struggling after trying to reduce medications;[41]
- in May 2020 the claimant was referred by Dr Boon to St George Hospital with concerns of cauda equina syndrome with pain in the S1 dermatome;[42]
- in June 2020 Ms Gerling attended St George Hospital complaining of bladder dysfunction on a past history of back injury;[43]
- on 30 June 2020 Dr Kohan noted progressive disc degeneration and advised surgery, and[44]
- Ms Gerling attended St George Hospital on 30 September 2020 with acute low back pain when she was admitted for titration of her analgesia.[45]
[35] Claimant’s bundle, page 273.
[36] Claimant’s bundle, pages 1,127-1,129.
[37] Claimant’s bundle, pages 245-247.
[38] Claimant’s bundle, pages 240-241.
[39] Claimant’s bundle, page 238.
[40] Claimant’s bundle, page 276.
[41] Claimant’s bundle, page 275.
[42] Claimant’s bundle, page 327.
[43] Claimant’s bundle, page 325.
[44] Claimant’s bundle, page 235.
[45] Claimant’s bundle, page 320.
The parties were invited to make further submissions on the findings in Gerling (No 1). The claimant endorsed the approach. The insurer noted it when confirming that “causation remains in issue as per point 3 above given the pre-accident condition of the claimant in the context of analgesia usage”.[46]
[46] Insurer’s further submissions, paragraph 4.
As we earlier stated, we are not bound by the findings in Gerling (No 1) and Gerling (No 2). However, they provide persuasive opinions that Ms Gerling suffered an ongoing back and neck injury which resulted in lumbar spine surgery. Ms Gerling consumed far greater medication following the motor accident, which increased both in quantum, dosage and type due to her pain reaction particularly to the lumbar injury.
The history provided by Ms Gerling to Professor Karantaris and Medical Assessor Korbel, as well as to the Medical Assessor on the Panel, is that she was straining at the time of causing the prolapse. We accept this history. It is consistent with the temporal connection of excessive consumption of medication and extensive back pain.
The insurer placed reliance on the findings of Medical Assessor Cameron rebutting causation. As we have indicated, we accept independently that the back injury resulted in severe pain and ultimately led to surgery. We otherwise prefer the findings articulated in Gerling (No 1) and Gerling (No 2).
The schedules attached to these reasons show the dramatic increase in the consumption of opioid medication following the motor accident. Endone was occasionally used prior to the motor accident. That medication was then regularly used and, in due course, led to the use of even stronger opioid medication (Targin). The relationship between the use of the medication and the back condition is evident from the consistent back complaints that led to lumbar surgery and as recounted in Gerling (No 1) and Gerling (No 2) and the reduction in use of opioid medication following successful back surgery.
Left knee surgery was undertaken in early 2021. The clinical history is that the claimant had extensive bilateral knee problems prior to the motor accident. That condition does not explain the extensive increase in opioid medication following the motor accident nor that the medication usage significantly dropped after the lumbar spine surgery
We otherwise reject the insurers submission at [30] herein which did not appear to be made based on any medical opinion. It is inconsistent with our conclusion that the increase in the consumption of more and stronger opioid medication was attributable to the severe pain caused by the back injury. The submission is otherwise inconsistent with the substantial reduction in pain relief medication following what was apparently successful back surgery.[47]
[47] The reduction in pain relief medication following back surgery is discussed in the earlier decisions.
We accept the insurer’s submission that the claimant was consuming medication to reduce or avoid constipation prior to the motor accident and is a matter which is weighed against the claimant.
The claimant is required to satisfy the test of causation as discussed in AAI Ltd v Phillips.[48] We are satisfied, based on the temporal link, the excessive use of opioid medication and the severe lumbar spine caused by the motor accident, that the straining led to the prolapse which was caused by the motor accident. On the balance of probabilities, given the extensive increase in pain relief medication due to back pain and to a much lesser extent, neck pain, we consider that the prolapse is causally connected to the motor accident.
[48] [2018] NSWSC 1710.
Assessment
Medical Assessor Korbel assessed the claimant at 10% impairment based on Chapter 11, page 255, paragraph 11.3 of AMA 4. The claimant accepted the figure. The insurer did not accept the assessment but made no submissions on the appropriate assessment if causation was otherwise established.[49]
[49] Insurer’s further submissions, paragraph 5.
Medical Assessor Korbel carried out a pelvic examination and confirmed Professor Karantaris’ findings which involved a “quite marked cystocele” and cervix which descended to the introitus (stage 2 prolapse). The Medical Assessor rated the impairment as Class 1 which ranges between 0 and 15% and assessed the impairment at 10%.
Given the absence of agreement, the Panel was required to conduct a new examination.
We adopt the precise and recent examination findings made by Medical Assessor Rochford. His clinical examination noted that the “Cystocele is more prominent than noted at earlier assessments by Assessor Korbel and the examination by Dr Karantanis”. That increased prominence is consistent with the course of the medical condition once it has occurred.
Ms Gerling falls within Class 1 of paragraph 11.3 of AMA 4 because the condition requires intermittent treatment such as pelvic exercises between episodes of malfunctioning. The severity of the prolapse is relevant to our determination that Ms Gerling falls within the upper end of the range of Class 1. Accordingly, exercising a discretion within the range, we accept that the appropriate assessment is 12%.
The history provided by Ms Gerling and the clinical notes show that there is no pre-existing condition. The insurer asserted that there was “pre-existing impairment as required under clause 1.31 of the Guidelines”[50] but did not specify the objective evidence establishing the impairment.
[50] Insurer’s further submissions, paragraph 5.
Whilst there was pre-existing use of medication and likely some constipation, there was no objective evidence of impairment of the urinary tract condition pre-existing the motor accident. The clinical examination of the Medical Assessor was specifically directed to this issue as it had been raised by the insurer. There is no evidence to support the insurer’s submission that there was a pre-existing impairment.
There is otherwise no basis to find that there is any contribution to the impairment from any subsequent injury.
We are satisfied that the impairment is permanent because it is unlikely to change substantially with or without treatment and is not likely to remit despite medical treatment.
Conclusion
We note that Medical Assessor Cameron provided an assessment of 2% impairment due to the shoulder injury. No review has been made against that decision. Despite the inconsistency between that certificate and the reasons on injury for a different medical dispute in Gerling (No 1), the certificate stands for the purposes of assessment of permanent impairment.
The certificate issued by Medical Assessor Korbel is revoked. A replacement certificate is issued at the commencement of these Reasons. Whether combined or on its own, Ms Gerling exceeds 10% impairment as a result of the injury caused by the motor accident.
SCHEDULE 1
Pre-motor accident opioid medication
15 October 2015 complained of flare up of knee osteoarthritis in which the claimant uses Panadeine forte (an opioid based analgesic) intermittently – she was prescribed Panadol Osteo (665mg 1 tablet twice a day).
4 December 2015 Noted degenerative musculoskeletal disease (bilateral knee pain) – was prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day).
28 January 2016 Ear pain – prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day).
15 March 2016 Right sided back and hip pains – was prescribed Diclofenac (50mg 1 tablet three times a day after meals) and Panadeine Forte (500mg; 30mg 2 tablets four times a day).
19 March 2016 claimant stated that her prescriptions of Panadeine fore/diclofenac was not helping her right hip pains but was helping her knee pains – she was prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day).
24 March 2016 CT scan of the right hip ordered and was prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day).
8 April 2016 Prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day).
14 May 2016 Mechanical back pain – was prescribed Naproxen (250mg 2 tablets twice a day) and Panadeine Forte (500mg; 30mg 2 tablets four times a day).
1 June 2016 Complained of severe left foot heal pain – was prescribed Endone (5mg Tablet 1 Twice a day) and Panadeine Forte (500mg; 30mg Tablet 2 Four times a day).
21 June 2016 Left foot pain – the claimant was prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day) and Zaldiar (37.5mg; 325mg 1 tablets twice a day) – an opioid containing Tramadol hydrochloride and paracetamol.
10 July 2016 “Attended for review of L plantar fasciitis…Requests reports of recent USS and USS guided injection…USS revealed plantar fasciitis…Pain has improved however not fully resolved…Improved mobility…Still requires panadeine forte PRN and zaldiar PRN…Requests repeat scripts”. The claimant was prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day) and Zaldiar (37.5mg; 325mg 1 tablet twice a day).
9 August 2016 Requested repeat prescriptions – prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day) and Zaldiar (37.5mg; 325mg 1 tablet twice a day).
15 November 2016 “L knee pain over the past 6 months has worsened Pain over the lateral aspect of the joint Unsure of any specific trauma…No locking…No giving way… Some tingling and pins and needles over the L lateral proximal lower leg” – was prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day).
17 November 2016 Difficulty exercising due to chronic knee OA and pain.
6 December 2016 Prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day).
15 December 2016 Prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day).
19 December 2016 Prescribed Endone (5mg tablet, 1 tablet twice a day) and Celebrex (200mg capsule, 1 capsule twice a day after meals).
16 January 2017 Prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day).
16 February 2017 The claimant requested a repeat script for chronic left knee pain – she was prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day) and Movicol (30 sachets).
14 March 2017 The claimant reported a “significant improvement in bilateral knee pain” and that she felt ready to exercise again. Despite this account, she was prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day) in addition to Movicol (30 sachets with five repeats).
13 April 2017 “Suffered an exacerbation of lower back pain after heavy lifting 1 day ago… Run out of panadeine forte… Had 1x endone tablet last night which improved symptoms however have recurred again today” – prescribed Endone (5mg 1 tablet four times a day) and Panadeine Forte (500mg; 30mg 2 tablets four times a day).
9 May 2017 “requests repeat panadeine forte PRN for her knee and back pains” – prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day).
18 May 2017 “Developed an exacerbation of lower back pain and knee pains over the past week… Has been doing lots of home renovation and injured her back and R forearm whilst removing storm drain pipes… Bruising over R dorsal forearm”. The claimant was prescribed Endone (5mg 1 tablet four times a day) and Panadeine Forte (500mg; 30mg 2 tablets four times a day).
3 June 2017 “requests repeat panadeine forte for chronic knee pain” – Panadeine Forte (500mg; 30mg 2 tablets four times a day).
15 June 2017 “suffering with worsening R knee pain Needing regular panadeine forte to manage symptoms” – prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day).
22 June 2017 “Attended for referral to Dr Solomon for review of R knee hemiarthroplasty…5 years post op…Does continue to suffer with chronic pain of both knees managed with physio and panadeine forte PRN”.
27 June 2017 “requests repeat panadeine forte for chronic R knee pains” – prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day).
10 July 2017 “Suffered a flare of her bilateral knee pains L knee pain severe after falling whilst walking in the national park 2 days ago Suffered a bruise over the knee and superficial laceration No locking No giving way requests repeat panadeine forte and endone PRN” – the claimant was prescribed Endone (5mg 1 tablet four times a day) and Panadeine Forte (500mg; 30mg 2 tablets four times a day).
7 August 2017 “ongoing chronic R knee pains following R knee hemiarthroplasty managed with [sic] panadeine forte”.
11 August 2017 Presented for “review of knee pains” – the claimant requested repeat prescription of Panadeine forte and Movical and noted that she was “Constipated on panadeine”. She was prescribed Movicol (30 sachets with five repeats) and Panadeine Forte (500mg; 30mg 2 tablets four times a day).
18 August 2017 “Worsening knee pains and requests repeat panadeine forte…Also reprint of previous duromine script as lost it” – prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day).
28 August 2017 “Requests repeat panadeine forte for chronic knee pains” – prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day).
7 September 2017 Claimant requested a “course of endone to bring with her for PRN use due to chronic knee pains…Currently stable with panadeine forte PRN… Also requests repeat movicol and lost previous script”. The claimant was prescribed Movicol (30 sachets with five repeats) and Endone (5mg 1 tablet tablet four times a day).
20 October 2017 “Now run out of panadeine forte for chronic knee pains” – was prescribed Panadeine Forte (500mg; 30mg 2 tablets four times a day)
4 November 2017 Right shoulder pain and ongoing chronic knee pains – was prescribed Endone (5mg 1 tablet twice a day).
23 November 2017 Subject accident.
SCHEDULE 2
Post motor accident opioid medications
Panadeine Forte
| No. | Date | Medication | Dose | Quantity |
| 1 | 28/11/2017 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 2 | 15/12/2017 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 3 | 22/12/2017 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 4 | 02/01/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 5 | 09/01/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 6 | 16/01/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 7 | 23/01/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 8 | 30/01/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 9 | 06/02/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 10 | 13/02/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 11 | 20/02/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 12 | 26/02/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 13 | 05/03/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 14 | 03/04/2018 | Panadeine Forte 500mg;30mg tablet | 1 tablet twice a day | 20 |
| 15 | 16/04/2018 | Panadeine Forte 500mg;30mg tablet | 1 tablet twice a day | 20 |
| 16 | 30/04/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 17 | 14/05/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| 18 | 21/05/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 19 | 04/06/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 20 | 18/06/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 21 | 03/07/2018 | Panadeine Forte 500mg;30mg tablet | 1 tablet four times a day | 20 |
| 22 | 12/07/2018 | Panadeine Forte 500mg;30mg tablet | 1 tablet four times a day | 20 |
| 23 | 27/07/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets three times a day | 20 |
| 24 | 16/08/2018 | Panadeine Forte 500mg;30mg tablet | 1 tablet four times a day | 20 |
| No. | Date | Medication | Dose | Quantity |
| 25 | 27/08/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 26 | 14/09/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 27 | 27/09/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 28 | 15/10/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 29 | 19/11/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 30 | 03/12/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 31 | 17/12/2018 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 32 | 02/01/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 33 | 14/01/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 34 | 05/02/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablet four times a day | 20 |
| 35 | 18/02/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| 36 | 04/03/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 37 | 19/03/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| 38 | 02/04/2019 | Panadeine Forte 500mg;30mg tablet | 1 tablet four times a day | 20 |
| 39 | 16/04/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets four times a day | 20 |
| 40 | 29/04/2019 | Panadeine Forte 500mg;30mg tablet | 1 tablet four times a day | 20 |
| 41 | 13/05/2019 | Panadeine Forte 500mg;30mg tablet | 1 tablet twice a day | 20 |
| 42 | 27/05/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| 43 | 11/06/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| 44 | 26/06/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| 45 | 08/07/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| 46 | 23/07/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| 47 | 05/08/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| 48 | 19/08/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets daily | 20 |
| 49 | 02/09/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| 50 | 16/09/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets daily | 20 |
| 51 | 30/09/2019 | Panadeine Forte 500mg;30mg tablet | 1 tablet four times a day | 20 |
| 52 | 14/10/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| No. | Date | Medication | Dose | Quantity |
| 53 | 28/10/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets daily | 20 |
| 54 | 11/11/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets daily | 20 |
| 55 | 02/12/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets daily | 20 |
| 56 | 23/12/2019 | Panadeine Forte 500mg;30mg tablet | 2 tablets daily | 20 |
| 57 | 13/01/2020 | Panadeine Forte 500mg;30mg tablet | 1 or 2 tablets daily | 20 |
| 58 | 04/02/2020 | Panadeine Forte 500mg;30mg tablet | 2 tablets daily | 20 |
| 59 | 25/02/2020 | Panadeine Forte 500mg;30mg tablet | 2 tablets daily | 20 |
| 60 | 16/03/2020 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| 61 | 06/04/2020 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| 62 | 27/04/2020 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| 63 | 19/05/2020 | Panadeine Forte 500mg;30mg tablet | 2 tablets twice a day | 20 |
| 64 | 09/06/2020 | Panadeine Forte 500mg;30mg tablet | 1 tablet twice a day | 20 |
| 65 | 22/06/2020 | Panadeine Forte 500mg;30mg tablet | 1 tablet twice a day | 20 |
| 66 | 06/07/2020 | Panadeine Forte 500mg;30mg tablet | 1 tablet twice a day | 20 |
| 67 | 27/07/2020 | Panadeine Forte 500mg;30mg tablet | 1 tablet twice a day | 20 |
| 68 | 18/08/2020 | Panadeine Forte 500mg;30mg tablet | 1 tablet four times a day | 20 |
| 69 | 31/08/2020 | Panadeine Forte 500mg;30mg tablet | 1-2 tablets three times a day | 20 |
| 70 | 21/09/2020 | Panadeine Forte 500mg;30mg tablet | 1-2 tablets three times a day | 20 |
| 71 | 06/10/2020 | Panadeine Forte 500mg;30mg tablet | 1-2 tablets three times a day | 20 |
| 72 | 26/10/2020 | Panadeine Forte 500mg;30mg tablet | 1-2 tablets three times a day | 20 |
Endone
| No. | Date | Medication | Dose | Quantity |
| 1 | 04/12/2017 | Endone 5mg Tablet | 1 tablet four times a day | 20 |
| 2 | 26/03/2018 | Endone 5mg Tablet | 1 tablet four times a day | 20 |
| 3 | 03/04/2018 | Endone 5mg Tablet | 1 tablet four times a day | 20 |
| 4 | 16/04/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 5 | 23/04/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 6 | 14/05/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| No. | Date | Medication | Dose | Quantity |
| 7 | 28/05/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 8 | 04/06/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 9 | 18/06/2018 | Endone 5mg Tablet | 1 tablet in the evening | 20 |
| 10 | 03/07/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 11 | 12/07/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 12 | 27/07/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 13 | 09/08/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 14 | 16/08/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 15 | 27/08/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 16 | 03/09/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 17 | 14/09/2018 | Endone 5mg Tablet | 1 to 2 tablet before bed | 20 |
| 18 | 21/09/2018 | Endone 5mg Tablet | 1 to 2 tablets before bed | 20 |
| 19 | 15/10/2018 | Endone 5mg Tablet | 1 tablet daily | 20 |
| 20 | 05/11/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 21 | 19/11/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 22 | 29/11/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 23 | 13/12/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 24 | 20/12/2018 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 25 | 02/01/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 26 | 14/01/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 27 | 22/01/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 28 | 05/02/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 29 | 15/02/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 30 | 26/02/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 31 | 12/03/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 32 | 23/03/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 33 | 02/04/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 34 | 16/04/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 35 | 29/04/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| No. | Date | Medication | Dose | Quantity |
| 36 | 06/05/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 37 | 13/05/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 38 | 23/05/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 39 | 06/06/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 40 | 20/06/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 41 | 05/07/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 42 | 12/07/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 43 | 26/07/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 44 | 08/08/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 45 | 23/08/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 46 | 05/09/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 47 | 16/09/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 48 | 30/09/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 49 | 14/10/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 50 | 28/10/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 51 | 11/11/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 52 | 25/11/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 53 | 09/12/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 54 | 19/12/2019 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 55 | 05/01/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 56 | 20/01/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 57 | 04/02/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 58 | 17/02/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 59 | 02/03/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 60 | 16/03/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 61 | 30/03/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 62 | 14/04/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 63 | 27/04/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 64 | 04/05/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| No. | Date | Medication | Dose | Quantity |
| 65 | 12/05/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 66 | 25/05/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 67 | 09/06/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 68 | 22/06/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 69 | 06/07/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 70 | 20/07/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 71 | 03/08/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 72 | 14/08/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 73 | 27/08/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 74 | 07/09/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 75 | 21/09/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 76 | 06/10/2020 | Endone 5mg Tablet | 1 tablet before bed | 20 |
| 77 | 19/10/2020 | Endone 5mg Tablet | 1 tablet three times a day | 20 |
| 78 | 30/10/2020 | Endone 5mg Tablet | 1 tablet three times a day | 20 |
Targin
| No. | Date | Medication | Dose | Quantity |
| 1 | 26/02/2018 | Targin 5mg; 2.5mg modified release tablets | 1 tablet before bed | 28 |
| 2 | 12/03/2018 | Targin 10mg; 5mg modified release tablets | 1 tablet before bed | 28 |
| 3 | 19/03/2018 | Targin 10mg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 4 | 26/03/2018 | Targin 10mg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 5 | 16/04/2018 | Targin 10mg; 5mg modified release tablets | 1 tablet daily | 28 |
| 6 | 30/04/2018 | Targin 10mg; 5mg modified release tablets | 1 tablet daily | 28 |
| 7 | 21/05/2018 | Targin 10mg; 5mg modified release tablets | 1 tablet daily | 28 |
| No. | Date | Medication | Dose | Quantity |
| 8 | 21/06/2018 | Targin 10mg; 5mg modified release tablets | 1 tablet daily | 28 |
| 9 | 03/07/2018 | Targin 10mg; 5mg modified release tablets | 1 tablet daily | 28 |
| 10 | 20/07/2018 | Targin 10mg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 11 | 02/08/2018 | Targin 10mg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 12 | 09/08/2018 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 13 | 16/08/2018 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 14 | 27/08/2018 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 15 | 14/09/2018 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 16 | 27/09/2018 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 17 | 22/10/2018 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 18 | 05/11/2018 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 19 | 19/11/2018 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 20 | 03/12/2018 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 21 | 17/12/2018 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 22 | 02/01/2019 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 23 | 14/01/2019 | Targin 10mg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 24 | 22/01/2019 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 25 | 05/02/2019 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| No. | Date | Medication | Dose | Quantity |
| 26 | 18/02/2019 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 27 | 04/03/2019 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 28 | 19/03/2019 | Targin 15mg; 7.5mg modified release tablets | 1 tablet twice a day | 28 |
| 29 | 23/03/2019 | Targin 10mg; 5mg modified release tablets | 1 tablet before bed | 28 |
| 30 | 02/04/2019 | Targin 15mg; 7.5mg modified release tablets | 1 tablet in the morning | 28 |
| 31 | 16/04/2019 | Targin 1omg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 32 | 29/04/2019 | Targin 10mg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 33 | 13/05/2019 | Targin 10mg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 34 | 27/05/2019 | Targin 10mg; 5mg modified release tablets | 1 tablet in the morning | 28 |
| 35 | 27/05/2019 | Targin 5mg; 2.5mg modified release tablets | 1 tablet before bed | 28 |
| 36 | 11/06/2019 | Targin 10mg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 37 | 26/06/2019 | Targin 10mg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 38 | 08/07/2019 | Targin 10mg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 39 | 23/07/2019 | Targin 10mg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 40 | 05/08/2019 | Targin 10mg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 41 | 19/08/2019 | Targin 10mg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 42 | 02/09/2019 | Targin 10mg; 5mg modified release tablets | 1 tablet twice a day | 28 |
| 43 | 16/09/2019 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 |
| No. | Date | Medication | Dose | Quantity | |||||
| 44 | 30/09/2019 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 | |||||
| 45 | 14/10/2019 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 | |||||
| 46 | 28/10/2019 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 | |||||
| 47 | 11/11/2019 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 | |||||
| 48 | 25/11/2019 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 | |||||
| 49 | 09/12/2019 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 | |||||
| 50 | 23/12/2019 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 | |||||
| 51 | 05/01/2020 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 | |||||
| 52 | 20/01/2020 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 | |||||
| 53 | 04/02/2020 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 | |||||
| 54 | 17/02/2020 | Targin 5mg; 2.5mg modified release tablets | 1 tablet in the morning | 28 | |||||
| 55 | 16/03/2020 | Targin 5mg; 2.5mg modified release tablets | 1 tablet before bed | 28 | |||||
| 56 | 14/04/2020 | Targin 5mg; 2.5mg modified release tablets | 1 tablet before bed | 28 | |||||
| 57 | 12/05/2020 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 | |||||
| 58 | 25/05/2020 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 | |||||
| 59 | 09/06/2020 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 | |||||
| 60 | 06/07/2020 | Targin 5mg; 2.5mg modified release tablets | 1 tablet before bed | 28 | |||||
| 61 | 03/08/2020 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 | |||||
| No. | Date | Medication | Dose | Quantity |
| 62 | 31/08/2020 | Targin 5mg; 2.5mg modified release tablets | 1 tablet twice a day | 28 |
| 63 | 28/09/2020 | Targin 5mg; 2.5mg modified release tablets | 1 tablet daily | 28 |
| 64 | 30/09/2020 | Targin 10mg; 5mg modified release tablets | 1 tablet daily | 28 |
| 65 | 26/10/2020 | Targin 5mg; 2.5mg modified release tablets | 1 tablet daily | 28 |
| No. | Date | Medication | Dose | Quantity |
| 1 | 30/01/2018 | Tramadol 50mg Capsule | 1 capsule before bed | 20 |
| 2 | 06/02/2018 | Tramadol 50mg Capsule | 1-2 capsules before bed | 20 |
| 3 | 13/02/2018 | Tramadol 50mg Capsule | 1-2 capsules before bed | 20 |
| 4 | 20/02/2018 | Tramadol 50mg Capsule | 1-2 capsules before bed | 20 |
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