Insurance Australia Limited t/as NRMA Insurance v Woelms
[2023] NSWPICMP 150
•18 April 2023
| DETERMINATION OF REVIEW PANEL | |
| CITATION: | Insurance Australia Limited t/as NRMA Insurance v Woelms [2023] NSWPICMP 150 |
| CLAIMANT: | Evelyn Woelms |
INSURER: | Insurance Australia Limited t/as NRMA Insurance |
| REVIEW Panel | |
| PRINCIPAL MEMBER: | Josephine Bamber |
| MEDICAL ASSESSOR: | John Carter |
| MEDICAL ASSESSOR: | Michael Rochford |
| DATE OF DECISION: | 18 April 2023 |
CATCHWORDS: | MOTOR ACCIDENTS – Motor Accidents Compensation Act 1999; insurer’s application for review in relation to assessment of the bladder; urinary incontinence; Held – the Appeal Panel revoked the certificate of the Medical Assessor and the Combined Certificate and issued a fresh Certificate finding the injuries caused by the motor accident give rise to a whole person impairment which is, in total, not greater than 10%. |
| DETERMINATIONS MADE: | Medical Assessment – Permanent Impairment Review Panel Certificate The assessment made by the review panel under s 63(4) is as follows: The Panel revokes the Certificate of Medical Assessor Korbel dated 3 September 2021 and the Combined Certificate and issues a new Certificate together with a new Combined Certificate determining that the following injuries caused by the motor accident give rise to a whole person impairment which, in total, IS NOT GREATER THAN 10%: · head-traumatic brain injury- assessed by Medical Assessor Cameron; · left hand-metacarpal fracture- assessed by Medical Assessor Cameron; · lumbar spine- soft tissue injury- assessed by Medical Assessor Cameron; · cervical spine- soft tissue injury- assessed by Medical Assessor Cameron; · left foot- multiple fractures- assessed by Medical Assessor Cameron, and · visual system- assessed by Medical Assessor Steiner. The Panel finds that the following injury was not caused by the motor accident: · injury to the bladder- urinary incontinence. |
BACKGROUND
Mrs Evelyn Woelms was involved in a motor accident on 8 November 2017. She was aged 75 at the time of the accident and is now 80.
Insurance Australia Limited t/as NRMA Insurance insured the owner and/or driver of the other motor vehicle for liability to pay Mrs Woelms any damages to which she may be entitled under the Motor Accidents Compensation Act 1999 (the MAC Act).
The parties are in dispute as to 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 MAC Act.[1]
[1] See s 58(1)(d) of the MAC Act.
The degree of permanent impairment is determined by making an assessment pursuant to Motor Accident Permanent Impairment Guidelines (the Guidelines) Version 1, effective from 1 June 2018.[2] The Guidelines are based upon the American Medical Association Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4). However, where there is any difference between AMA 4 and the Guidelines, the Guidelines are definitive.[3]
[2] Issued pursuant to s 44(1)(c) of the MAC Act and see s 133 of the MAC Act.
[3] Clause 1.2 of the Guidelines.
On 25 February 2020 Mrs Woelms’ solicitors filed her Application for Assessment of a Permanent Impairment Dispute by the Medical Assessment Service (MAS). She sought assessment of various injuries.
On 1 March 2021 the Personal Injury Commission (the Commission) commenced. Matters formerly lodged with MAS now come within the jurisdiction of the Commission.
The following medical assessments were undertaken in Mrs Woelms’ case:
a. Medical Assessor Steiner on 29 March 2021 found no impairment of the visual system;
b. Medical Assessor Cameron on 18 April 2021 found 9% whole person impairment (WPI) comprised of 5% WPI for head-traumatic brain injury, 0% WPI for injury to the left hand- metacarpal fracture, 0% WPI for lumbar spine-soft tissue injury, 0% WPI for cervical spine- soft tissue injury and 4% WPI for injury to the left foot- multiple fractures;
c. Medical Assessor Friend on 19 May 2021 found no psychiatric injury, and
d. Medical Assessor Korbel on 3 September 2021 (replacing his certificate of
23 April 2021) found 5% WPI for injury to the bladder- urinary incontinence.A Combined Certificate was issued by Medical Assessor Cameron on 24 June 2021 for 14% WPI. An updated Combined Certificate was issued by Medical Assessor Korbel on 3 September 2021.
The insurer filed an Application for Review of the certificate/reasons of Medical Assessor Korbel, relying on submissions dated 21 September 2021.
The President’s delegate on 6 October 2021 issued a statement of reasons referring the matter to a review panel.
Pursuant to s 63(3) of the MAC Act and Schedule 1, cl 14F(2) of the Personal Injury Act 2020 (the PIC Act), the President by his delegate constituted the present Medical Review Panel (the Panel) which consists of two Medical Assessors and a Member of the Motor Accidents Division of the Commission.
The review is by way of new assessment of all matters with which the medical assessment is concerned.[4]
[4] Section 63(3A) of the MAC Act.
CONDUCT OF THE REVIEW
Part 5 of the PIC Act enables 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 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 PIC 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.
On 22 December 2021 the Panel issued a Direction requiring the parties to each file an indexed, paginated bundle of documents upon which they wished to rely in relation to the review. The parties filed their respective bundles of documents on 20 and 24 January 2022 respectively.
The Panel members conducted a preliminary review of the matter in their telephone conference on 18 February 2022. The Panel considered all the documents in both parties’ document bundles and issued a Direction dated 24 February 2022 to advise the parties of the course it intended to take to determine the matter. The substantive part of this Direction is set out below:
“[8] The Panel advises that in order to assess permanent impairment of the urinary system it is necessary to apply chapter 1.252 of the Motor Accident Permanent Impairment Guidelines (Version 1- effective from 1 June 2018) which states:
‘Objective evidence of neurological impairment is necessary to assess incontinence related to spinal injury (AMA4 Guides, Chapter 4, 4.3d). Objective evidence of injury to the bladder and urethra associated with urinary incontinence is necessary to assess urinary incontinence due to trauma (AMA4 Guides, Chapter 11, 11.3 and 11.4)’
[9] The Panel observes that in the documents provided to it there is no objective evidence that Ms Woelms sustained trauma to her bladder or urethra in the motor accident.
[10] The Panel advises that in order to find that there has been neurological impairment there needs to be objective evidence and there is no evidence before the Panel that urodynamic investigations have been conducted.
[11] In a recent decision of the Court of Appeal in Sydney Trains v Batson[7] Leeming JA (with White JA and McCallum JA agreeing) stated:
[7] [2021] NSWCA 143, Batson.
‘Under the motor accidents legislation, the default position where there is review of a medical assessment is that the review ‘should generally include a re-examination of the claimant’, especially where a party objects to the review being conducted on the papers, unless there is no dispute, ambiguity or uncertainty as to the relevant clinical findings: see cl 4(a)(i) and (ii) of the ‘Review Panel Practice Note 3/2005’, reproduced in Partridge v IAG Ltd t/as NRMA Insurance [2019] NSWSC 127 at [36]. Importantly, the review ‘is not limited to a review only of that aspect of the assessment that is alleged to be incorrect’, but rather ‘is to be by way of a new assessment of all the matters with which the medical assessment is concerned’: Motor Accidents Compensation Act 1999 (NSW), s 63(3A); Motor Accident Injuries Act 2017 (NSW), s 7.26(6).’
[12] The Panel has taken into account the principles in Batson and advises the parties that re-examination of Ms Woelms is not required because a clinical examination will not be able to detect neurological impairment of the bladder, noting that Assessor Korbel in his examination found that Ms Woelms’ ‘abdomen was soft, no masses were felt. She has normal sensation in the genital region. Vaginal examination revealed no evidence of stress leakage. She was noted to have a rectocele.’
[13] The Panel also draws attention to the following evidence:
a.Associate Professor Jaeger, Ms Woelms’ treating neurosurgeon, in report dated 9 March 2020 advised her general practitioner:
‘I understand that urinary incontinence is an issue for her and after careful review of her scans, and her clinical symptoms, I think it is safe to say that this does not stem from a lumbar nerve root compression issue. Her symptoms are really not compatible with a cauda equina-type picture…I would also be grateful if you would consider a urological review regarding the cause for her incontinence.[8]’
[8] Insurer’s bundle p 533.
b.In his earlier report dated 30 July 2019 Associate Professor Jaeger on physical examination did not find any weakness or sensory impairment and he stated there was no evidence for myelopathy or cauda equina syndrome. He examined the CT scan of the lumbar spine of March 2019 and stated it showed multi-level, age-appropriate degenerative changes and although, the canal narrowing was moderate, the doctor stated in his opinion it did not explain her symptoms in the sense of spinal claudication[9].
[9] Insurer’s bundle p 509.
c.Dr Tam, geriatrician engaged by the insurer, in his report dated 2 July 2019 found no significant neurological deficits[10].
[10] Insurer’s bundle p 567.
d.Assessor Cameron found there was no evidence that Ms Woelms sustained an injury to her cauda equina in the subject accident[11].
[14] The Panel seeks to put the parties on notice that in light of the above-mentioned evidence, together with all the material before the Panel, without urodynamic investigations a diagnosis cannot be made in accordance with the Guidelines that Ms Woelms has objective evidence of neurological impairment to assess that her incontinence is related to spinal injury.
[15] However, before finally determining the review, the Panel wishes to ascertain if in fact urodynamic investigations have been carried out. Accordingly, the Panel makes the following directions:
[16] On or before 24 March 2022 the claimant is to:
(a)file and serve copies of any urodynamic investigations that have been undertaken or if such investigations are pending to advise the date when they will be completed.
(b)file and serve any further submissions she wishes to rely upon addressing the matters raised above.
[17] On or before 11 April 2022 the insurer is to file and serve any submissions in response.”
[11] Insurer’s bundle p 585.
On 24 March 2022 the Panel was advised by the Commission that Mrs Woelms’ solicitors had advised that she “has an initial consultation in June 2022 with a urologist and can undergo the Urodynamic Investigations thereafter as she has not yet undergone such testing”.
On 25 May 2022 the Panel was advised by the Commission that Mrs Woelms’ solicitors had advised that the testing was rescheduled to 8 July 2022.
On 21 July 2022 the Panel was advised by the Commission that Mrs Woelms’ solicitors asked if the Panel could determine the matter without the studies given Mrs Woelms age and condition and that she is in hospital. The Panel issued Directions advising it would issue its decision by 1 September 2022 and if in the meantime urodynamic studies are undertaken, a copy should be immediately served upon the insurer and forwarded to the Panel, together with any further submissions that the parties wish to make.
On 17 October 2022 the Panel was advised by the Commission that Mrs Woelms’ solicitors had notified them that Mrs Woelms had undergone the urodynamic testing on
30 September 2022 and would receive the results on 22 November 2022. The Panel requested the Commission to advise the parties that it would not issue its decision until after a copy of the testing has been served on the insurer and forwarded to the Commission and both parties have made submissions relating to the testing.On 21 November 2022 Mrs Woelms’ solicitors advised that the urodynamic testing had to be re-done, as apparently the results of the tests could not be found, and that new testing was scheduled for 30 January 2023.
On 6 February 2023 Mrs Woelms solicitors filed urodynamics EMG dated
30 September 2022 and report of Dr Rasha Gendy, robotic and urological surgeon dated 30 January 2023.
SUBMISSIONS
The insurer submitted on 21 September 2021 that the assessment of Medical Assessor Korbel was incorrect in a material respect as he failed to adhere to cl 1.252 of the Guidelines and he had failed to provide adequate reasoning in relation to his determination on causation. At paragraph 16 above the Panel has set out the terms of cl 1.252.
The insurer submits that Medical Assessor Korbel made no reference to any relevant neurological factors in his assessment of Mrs Woelms’ incontinence issues, nor did he identify any neurological pathology in his determination of causation. The insurer points to Associate Professor Matthias Jaeger, neurosurgeon, who in his report dated 9 March 2020 found the urinary incontinence was not related to any lumbar spine pathology and was not compatible with a cauda equina picture.
The insurer submits there is no indication of bladder or urethra injuries or trauma. It observes the clinical examination of Medical Assessor Korbel was essentially normal.
The insurer argues that there is no evidence to support Medical Assessor Korbel’s conclusion that the accident caused Mrs Woelms’ incontinence issues and whole person impairment.
Mrs Woelms’ solicitors made submissions dated 23 September 2021.[12] It is submitted that Medical Assessor Korbel did not err in his assessment in relation to Mrs Woelms’ urinary incontinence. Reliance is placed upon the fact that the incontinence only commenced after the motor accident, as demonstrated by the documents in the general practitioner’s file. It is argued that there is objective neurological evidence as on 6 May 2019 it is recorded that Mrs Woelms was getting up five times a night to pass urine and had one episode of being completely incontinent and the doctor noted she had cauda equina compression between L2 and L5.
[12] AD2 p 1.
It is also submitted on behalf of Mrs Woelms that she has been consistent in her recount of her symptoms and therefore her evidence can be relied upon.
At [23] of the submissions reference is made to Medical Assessor Korbel’s assessment wherein he stated:
“She was noted to be wearing an incontinence pad in her underwear.”
“On examination today…she was noted to have a rectocele.”
“.. she goes to the toilet once a day but gets up 5 x at night…she has urgency during the day but has to sit on the toilet to void a second time before she leaves.”It is argued that Medical Assessor Korbel did have regard to all the medical evidence and concluded the incontinence was caused by the injuries sustained in the subject accident and the urgency and occasional urge incontinence started after the motor vehicle accident.
Mrs Woelms’ solicitors quoted from Chapter 11 page 254 of AMA 4 that “symptoms and signs of impairment of function of the bladder may include urinary frequency… incontinence…”. It is submitted that a patient will belong to class 1 impairment when requiring intermittent treatment and normal functioning between the episodes of malfunctioning and the range of WPI is 0% to 15% and Medical Assessor Korbel found Mrs Woelms came within this category, and he made a clinical assessment of 5%WPI.
It is submitted that Medical Assessor Korbel came to this conclusion twice and this finding ought not be the subject of review.
In the Panel’s Direction to the parties dated 24 February 2022 it required the parties to file any further submissions if urodynamic tests had been undertaken. As noted earlier in these reasons, Mrs Woelms’ solicitors requested the Panel to not finalise its determination until the urodynamic studies were undertaken. These were filed in the Commission on 6 February 2023 and thereafter made available to the Panel. No further submissions from either party have been filed.
SUMMARY OF RELEVANT DOCUMENTS
In the records prior to the accident, Mrs Woelms suffered from a number of medical conditions such as an attendance at Wollongong Hospital on 8 June 2016 for investigation in relation to a stroke, osteoarthritis affecting her right knee and left hip as noted by Dr Sheikh on 6 April 2016.[13] She had also fractured her right ankle in December 2015. On 1 August 2017 an annual health assessment was performed by Dr Jusvanti Hargovani where some dementia was recorded. In the questionnaire there appears to be a tick against the question “have you any problems with continence bowels/urine related to coughing or sneezing?” Apart from this reference the Panel is not aware of any other mention of urinary incontinence prior to the motor accident.
[13] Insurer’s bundle p 56.
At the time of the motor accident on 8 November 2017 Mrs Woelms was aged 75. The ambulance report states that Mrs Woelms was driving when the other car pulled out in front of her and there was substantial damage to the car after the collision and a concrete shop front. She was unable to recall her full medical history. She complained of pain to her chest, left ankle, lacerations to her forehead and left hand. She had seat belt bruising to her chest and chest wall pain due to seatbelt/steering wheel impact, she was ambulant with assistance, she had bruising to her left ankle.[14]
[14] Insurer’s bundle p 542.
She was taken to Wollongong Hospital where it is noted she was T-boned by the other car and had extensive damage to her vehicle. She was admitted to ICU with severe haemothorax, left fifth metacarpal fracture, left third and fourth metatarsal fractures, fractured midfoot injuries including significant tarsometatarsal joint disruption.[15] She was treated with a first to third tarsometatarsal joint fusion with calcaneal bone graft on 23 November 2017. She was discharged on 29 November 2017 to Bulli District Hospital.[16]
[15] Insurer’s bundle p 551.
[16] Insurer’s bundle p 548.
Mrs Woelms was an in-patient at Coledale Hospital for rehabilitation after the motor accident from 22 February 2018 to 27 March 2018. The discharge summary refers to her having gait retraining and lower limb strengthening following the accident and that she suffered from fracture to her right second rib, pneumothorax, fractures to her left third to seventh ribs, fractures of her left fifth metatarsal and metacarpal.[17] There is no mention in the discharge summary or the hospital records to an injury to Mrs Woelms’ bladder, urethra or to urinary incontinence.
[17] Insurer’s bundle p 367.
On 20 May 2018 Dr Joshi, geriatrician, reported to Dr Smith about his assessment of her noting the main issue is her fluctuating back pain that was impeding her independence, as part of the history he noted Mrs Woelms had a few occasions of urge incontinence. The examination did not deal with her incontinence.[18]
[18] Insurer’s bundle p 475.
A CT abdomen and pelvis scan was performed on 10 September 2018 which found the urinary bladder, uterus and ovaries were unremarkable.[19]
[19] Insurer’s bundle p 378.
Professor Jaber, gastroenterologist, provided a report dated 18 September 2018 but did not refer to a history of urinary incontinence.[20]
[20] Insurer’s bundle p 381.
On 22 November 2018 an aged care assessment was performed by Debra Lopez, clinical nurse specialist, and she included the history that “Ms Woelms can experience difficulty getting to the toilet, resulting in some incontinence, wearing a small pad for protection and she is self-managing continence care”.[21]
[21] Insurer’s bundle p 389 at 390.
On 1 April 2019 Dr Smith recorded in his clinical notes that Mrs Woelms had urinary incontinence since her accident in November 2017 and it was getting worse. He referred her to Wollongong Hospital for assessment in the emergency department.[22]
[22] Insurer’s bundle p 232 and the referral is at p 317.
On 2 April 2019 Mrs Woelms was admitted to Wollongong Hospital and discharged the next day. The discharge letter to Dr Smith noted she presented with a mild exacerbation of her longstanding spinal canal stenosis. She was assessed by the neurosurgical team who included in their recommendations she be monitored for deterioration including urinary retention/faecal incontinence. It was also added that she could be referred to Associate Professor Jaeger’s rooms for review if she would like to consider elective operative management of stenosis which is likely contributing to her back and leg pain which the author stated was likely related to her recent trauma and longstanding arthritis.[23]
[23] Insurer’s bundle p 450.
In the history taken at the hospital it is recorded that Mrs Woelms felt there had been no sudden deterioration in her symptoms, though they are gradually worsening, particularly since her motor vehicle accident and the various accident caused fractures are listed. It is recorded she has had lumbar back pain present for years, with osteoarthritis in her hips, shoulders and back. She has bilateral leg pain extending to the soles of both feet, with throbbing pain and paraesthesia. It is recorded that she had:
“mixed stress and urge urinary incontinence, passing urine frequently, unable to hold for long periods in context of 3 x vaginal deliveries (specifically denies passive incontinence of urine without urge or retention episodes). In the last few months – 3 episodes of faecal incontinence- felt urge and had to rush to toilet, but didn’t make it.”
At the hospital a neurological examination of her lower limbs was performed, and lumbar spine CT scan dated 20 March 2019 reviewed. It noted she had “L2-S1 spinal stenosis 2° degenerative changes. Severe L4/5 degenerative disc disease and bilateral radiculopathy, L5/S1 IV disc prolapse and bilateral radiculopathy”. The examining doctor, Dr Mintz, said he discussed Mrs Woelms’ case with Associate Professor Jaeger and records that Mrs Woelms cannot have an MRI as she has a pacemaker, however at most the spinal canal stenosis is moderate. He states the urinary symptoms are more consistent with urge incontinence.[24]
[24] Insurer’s bundle p 452.
On 10 April 2019 Dr Smith recorded that Mrs Woelms complained of bladder incontinence.[25] He issued a referral to Pamela Mann for physiotherapy treatment and included the history that she suffered from bladder caused incontinence.[26] Ms Mann wrote to Dr Smith noting that Mrs Woelms was referred for pelvic floor rehabilitation for her bladder urgency. She advises that Mrs Woelms voids twice in the day time and six times at night. She added:
“It appears she has chronic constipation & her rectocele is blocking her urethra in the daytime so she voids very little. She may also have nocturnal polyuria & venous return so her urgency in night time is severe & she has urge urinary incontinence from the bed to the toilet.”[27]
[25] Insurer’s bundle p 231.
[26] Insurer’s bundle p 325.
[27] Insurer’s bundle p 464.
On 6 May 2019 Dr Smith recorded in his clinical notes that Mrs Woelms was getting up five times in a night to pass urine and one episode a week earlier she was completely incontinent. The doctor also recorded that she is known to have spinal stenosis, cauda equina compression from L2 to L5 and she was to be referred to a neurosurgeon.[28] In the referral to Associate Professor Jaeger Dr Smith refers to Mrs Woelms suffering from incontinence.[29]
[28] Insurer’s bundle p 230.
[29] Insurer’s bundle p 338.
On 22 May 2019 Mrs Woelms was admitted to Bulli District Hospital for treatment for depression post the motor accident. She was discharged on 29 May 2019.[30]
[30] Insurer’s bundle p 480.
On 30 May 2019 Associate Professor Nguyen-Dang, cardiologist, reported to Dr Smith.[31] It was noted her main problem was her back and she was due to see a surgeon “but she has had a problem with incontinence because of the back problem”.
[31] Insurer’s bundle p 483.
On 2 July 2019 Dr Tan, geriatrician, for the insurer reported to the insurer having examined Mrs Woelms on 3 June 2019.[32] Dr Tan noted at Bulli Hospital in April 2019 there was reference to mixed stress and urge urinary incontinence. Otherwise, the doctor does not refer to urinary incontinence.
[32] Insurer’s bundle p 561.
On 17 July 2019 the Illawarra Shoalhaven Local Health District Community Home Nursing service issued a discharge referral which had a discharge plan;
“continence assessment attended 14 August. Education and management plan provided. Pad trial arranged on behalf of client and provided with CAPS application form… Client reports some improvement in nocturia…”[33]
[33] Insurer’s bundle p 514.
On 30 July 2019 Associate Professor Jaeger reported to Dr Smith talking a history that
Mrs Woelms had a six month history of increasing problems with her walking, and she was now using a walking frame. In the history the doctor notes “recently, she also had episodes of worsening incontinence and now has to get up around 5-6 times per night. Currently she takes Eliquis and is also on Palexia, Panadeine Forte and Lyrica for analgesia”.[34][34] Insurer’s bundle p 509.
Associate Professor Jaeger advised on his examination of Mrs Woelms that he:
“did not find any weakness or sensory impairment. Reflexes were weak, present and equal and there was no evidence for myelopathy or cauda equina syndrome. Evelyn was not in a great deal of pain today, but I was able to elicit some of her pain on provocative testing of the right hip.
CT scan of the lumbar spine performed in 03/2019 showed multi-level, age-appropriate degenerative changes although the canal narrowing is moderate at most and in my opinion does not explain her symptoms in the sense of spinal claudication. I am unable to exclude the unlikely possibility of an intraspinal tumour causing her symptoms.
At this stage, I have suggested a bone scan of the lumbar spine and hips and a hip x-ray.”[35]
[35] Insurer’s bundle p 509.
On 12 August 2019 the bone scan was performed with the finding of:
“moderately active discovertebral degenerative changes at left L4/5 level and mildly active facet arthropathy at left L4/5 facet joint. There is mild arthritis in the SI joints with more prominent arthritis noted in both hips.”[36]
[36] Insurer’s bundle p 510.
Associate Professor Jaeger reported to Dr Smith on 9 March 2020.[37] The doctor states it was difficult again to obtain a clear picture of her problems from her. He states that after a careful review of her scans and clinical symptoms “this does not stem from a lumbar nerve root compression issue. Her symptoms are really not compatible with a cauda equina-type picture”. The doctor requested a urological review regarding the cause for her incontinence.
[37] Insurer’s bundle p 533.
On 26 March 2020 Dr Smith refers to Mrs Woelms suffering from visual issues and incontinence.
Dr Rasha Gendy, robotic and urological surgeon, in his report dated 30 January 2023 advises that he has reviewed Mrs Woelms urodynamic studies for the investigation of her overactivity symptoms of frequency, urgency and nocturia which has deteriorated since her accident. Dr Gendy refers to the voided volume pre-test of 200ml with a minimal residual. He adds her bladder was able to be filled to 400ml with some unstable contractions, but that none resulted in incontinence, and none were associated with any significant strong sense of urgency. Dr Gendy states that Mrs Woelms reported a desire to void that was normal at about 400ml. He says she voided to completion with a good bladder contraction.
Dr Gendy provides his opinion that “Overall, this was found not to be consistent with a neurogenic bladder”. He said there was some decreased bladder sensory input of which the aetiology is not entirely clear, and some detrusor overactivity identified. Dr Gendy states she has been trialled on Mirabegron 25mg daily and she has found some moderate improvement. He added a repeat renal tract ultrasound confirmed her bladder fills to 200ml and emptied with about a 65ml residue. The upper tracts were normal with no hydronephrosis.
Medical Assessor Korbel
Medical Assessor Korbel issued his further Certificate dated 3 September 2021. He found on examination “her abdomen was soft, no masses were felt. She has normal sensation in the genital region. A vaginal examination revealed no evidence of stress leakage. She was noted to have a rectocele”.
He noted Associate Professor Jaeger’s finding that there was no evidence of cauda equina syndrome. He had no urodynamic studies available to him as none had been undertaken at that time.
Medical Assessor Korbel did not make reference to the requirements in the Guidelines. He nonetheless assessed Mrs Woelms as having 5% WPI for bladder- urinary incontinence caused by the motor accident.
PANEL DETERMINATION
In order to assess permanent impairment of the urinary system it is necessary to apply Chapter 1.252 of the Guidelines which states:
“Objective evidence of neurological impairment is necessary to assess
incontinence related to spinal injury (AMA4 Guides, Chapter 4, 4.3d). Objective evidence of injury to the bladder and urethra associated with urinary incontinence is necessary to assess urinary incontinence due to trauma (AMA4 Guides, Chapter 11, 11.3 and 11.4)”
The Panel finds there is no evidence in any of the hospital records or in the treating medical practitioners documents that Mrs Woelms’ sustained trauma to her bladder and urethra in the motor accident.
Mrs Woelms’ solicitors have relied in their submissions on Dr Smith’s entry on 6 May 2019 that Mrs Woelms has cauda equina compression between L2 and L5 to demonstrate there is objective evidence of neurological impairment related to her spinal injury sustained in the motor accident.
However, Associate Professor Jaeger, Mrs Woelms’ treating neurosurgeon, in his reports dated 30 July 2019 and 9 March 2020 advised her general practitioner that there is no evidence of cauda equina syndrome and that Mrs Woelms’ symptoms are not compatible with a cauda equina type picture. Dr Tam, geriatrician engaged by the insurer, in his report dated 2 July 2019 found no significant neurological deficits.[38] Medical Assessor Cameron found there was no evidence that Mrs Woelms sustained an injury to her cauda equina in the subject accident.[39]
[38] Insurer’s bundle p 567.
[39] Insurer’s bundle p 585.
The Panel finds the evidence of Associate Professor Jaeger should be preferred to the entry of Dr Smith because Associate Professor Jaeger is a neurosurgeon, and he has specifically examined Mrs Woelms and considered the radiological testing and concluded her symptoms are not compatible with cauda equina syndrome. This conclusion is supported by the findings of Dr Tan and Medical Assessor Cameron.
The Panel has considered the urodynamic study results and the evidence of Dr Gendry in addition to all of the evidence filed by the parties. Dr Gendry considered that the urodynamic testing was not consistent with a neurogenic bladder.
The medical members of the Panel have reviewed the urodynamic study results and have come to the same conclusions as Dr Gendry.
Accordingly, the Panel finds there is no evidence to satisfy the requirements of Chapter 1.252 of the Guidelines. In this situation the Panel finds no assessable impairment of the urinary system.
COMBINED CERTIFICATE
This is to certify that Mrs Woelms was assessed by the following Medical Assessors appointed by the Commission to assess permanent impairment disputes.
Details of the assessments and full reasons are given in the following certificates:
Certificate of Medical Assessor Steiner dated 29 March 2021
·the permanent impairment of the visual system is 0%.
Certificate of Medical Assessor Cameron dated 18 April 2021
The permanent impairment in relation to the following injuries is 9%:
·head-traumatic brain injury 5%;
·left hand- metacarpal fracture 0%;
·lumbar spine-soft tissue injury 0%;
·cervical spine- soft tissue injury 0%, and
·left foot- multiple fractures 4%.
Certificate of the Medical Review Panel dated 17 April 2023
·no injury caused by the accident to bladder-urinary incontinence.
The combined WPI equals 9% using the combined values chart, AMA 4 page 322.
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