Kirkovski and Secretary, Department of Family and Community Servi Ces

[2004] AATA 1356

Administrative

Appeals

Tribunal

 

DECISION AND REASONS FOR DECISION [2004] AATA 1356

ADMINISTRATIVE APPEALS TRIBUNAL      )

)          No W2003/149

VETERANS' APPEALS  DIVISION		)
Re		DOREEN THOMPSON

Applicant

And REPATRIATION COMMISSION

Respondent

DECISION

Tribunal Dr D Weerasooriya, Member

Date17 December 2004

PlacePerth

Decision The Tribunal sets aside the Decision of the Veterans Review Board of 17 January 2003 and, in substitution therefore, finds that the death of the veteran, Mr Thomas Thompson, was war-caused and the applicant Mrs Doreen Thompson is entitled to a war widow’s pension from 21 June 2000.

...............(sgd D Weerasooriya)..........

Member

CATCHWORDS

VETERANS’ AFFAIRS – widow’s application – Veteran had operational service with Australian Army -  chronic pancreatitis – application of Statements of Principles – death found to be war-caused – decision under review set aside.

REASONS FOR DECISION

17 December 2004 Dr D Weerasooriya, Member

Introduction

1.      This is a case that has come before the Tribunal where Mrs Doreen Thompson, the widow, is claiming acceptance of her husband's death as being related to operational service that he rendered from 16th April 1942 to 13th August 1946.

History of application

2.      The facts are as follows:

(a)On 26th July 2000, the Applicant claimed acceptance of her husband's ("the Veteran's") death as being war caused.

(b)On 9th August 20001 a delegate of the Repatriation Commission determined that the Veteran's death was not war caused.

(c)On 18th December 4000, the Applicant applied for review of the delegate's decision by the Veterans’ Review Board (VRB).

(d)On 9th Oct 2002 the VRB adjourned the hearing to enable Mrs Thompson to seek representation and to obtain a copy of the section 137 report prepared by the Department in relation to the appeal.

(e)On 17th January 2003 the VRB affirmed the delegate's decision. The Board noted that "there being no hypothesis put forward to link the Veteran's death to his war service, the Board concludes that his death is not war caused".

3.      On 7th April 2003 the Applicant applied for review of the Board's decision by the Administrative Appeals Tribunal (AAT). This application was written in the following terms and addressed to the Registrar of the AAT.

" My husband always maintained that there was a malarial germ lodged in his liver. Backed up by an Asian Doctor qualified in Tropical diseases in 1984, when he was admitted to RGH. His abnormal distended stomach received minimal attention in his final days at RGH".

4. The Tribunal was provided with documents T 1- T20 pages 1-74 lodged by the Respondent in accordance with s 37 of the Administrative Appeals Tribunal ACT 1975. The Respondent's advocate, Mr Ponnuthurai, provided the Tribunal with the Veteran's service record and also all medical documentation of his stay at Repatriation General Hospital, Hollywood, during his terminal illness. Mr Ponnuthurai also supplied the Tribunal with a medical report from a specialist Oncologist, Prof Fox, and a report from Dr Raymond Murray, a specialist Gastroenterologist, as requested by the Tribunal.

5.      The Tribunal collected for itself relevant material as follows, which was provided to the parties and to Dr Murray, as follows:

·Extracts from a standard textbook of general medicine -Harrison's Principles of Internal Medicine 14th edition pages 1737 -1750 dealing with general considerations, tests useful in the diagnosis of pancreatic disease, tests of pancreatic function. Acute and chronic pancreatitis, chronic pancreatitis, and pancreatic exocrine insufficiency, and, pages 580 -583 dealing with cholangio carcinoma and pancreatic cancer.

The Tribunal also provided the following articles:

·"Chronic relapsing pancreatitis – a study of 29 cases without associated disease of the biliary or gastro intestinal tract" by Manfred W Comfort et al. from the Mayo Clinic Rochester Minnesota in the Journal of Gastroenterology 1946 and continued in the next volume covering pages 239 -285 and pages 376 -408 (note page 264 is missing)

·An article from the New England Journal of Medicine Vol 3 -8, No 20 of May 1993 entitled "pancreatitis and the risk of pancreatic cancer" by Albert B Lowenfels et al and the International Pancreatitis Study Group.

·Some short extracts from a synopsis of surgical anatomy by McGregor 11th edition page 84 dealing with the anatomy of the gall bladder. Pages 78,80 and 81 dealing with the biliary passages.

6.      The Tribunal received oral evidence from Mrs Thompson (the widow) and Mr A Thompson the son of the veteran, and from Dr Murray.

Evidence of Mrs Thompson and Mr Thompson

7.      As there was a large hiatus of medical information between 1978 and 2000, the Tribunal asked Mr and Mrs Thompson whether they were aware of the conditions for which the veteran consulted general practitioners:­

8.      Mr Thompson stated, "Sir, can l just say that my father was a sort of person that didn't actually like going to doctors and spending time in hospital. He always sort of prided himself on being reasonably fit and from the old school, he was a stubborn old bugger and hated medication…until the day he died I can remember him saying he had malaria, always sweating profusely, always ill, you know that sort of soldiering on" (Transcript,page 12).

9.      Later on Mr Thompson added "But I think the point that should be discussed I guess is we believe and I believe you know because I was sort of brought up with it, that something has – that was war caused, service caused, has caused my father's death" (Transcript, page 17).

10.     Mrs Thompson told the Tribunal that she and the Veteran were married in 1949 and that "The only thing he complained about was malaria and had to be for all those fussy cooking meals because he said that it always interfered with his ulcer".

She was asked by the Tribunal whether there were spells when he appeared to be normal for months on end:

“MRS THOMPSON:   Well, if he ate pastry or that, he - - -

DR WEERASOORIYA:   Yes.  But if he didn't do all that, would he be free of symptoms, is my question? --- Yes, he would have been.

He would be? --- Yeah”.

…

MR THOMPSON: I am not sure of the length of the spells, sir, but he would have spells where he was okay.  But the slightest thing would set him off…And I can remember, you know, as mum was saying, he wouldn't eat any form of take-aways.  Probably never had any in his life.  Anything fatty. 

MRS THOMPSON:   Pastry…Alcohol, it would set him off. He had, I suppose you would call it, quite a, you know, delicate sort of stomach in some areas…He prided himself in sort of being a non-smoker and a relatively non drinker…And it was with great surprise that, you know, a thing like a piece of battered fish would, sort of, set him off. 

(Transcript, page 38)

11.     In answer to the question, "And he continued to work through the whole period?" Mrs Thompson answered, "Yes" (Transcript, page 39).

12.     After some further questioning by the Tribunal Mr Ponnuthurai was asked if he had anything to ask the Applicant and her son and he said he did not have any questions for them.

Analysis of Evidence of Mr and Mrs Thompson

13.     The Tribunal found Mr and Mrs Thompson to be honest and credible witnesses.

14.     On the basis of their evidence the Tribunal made the following findings about the Veteran.

(1) The Veteran did not totally cease taking alcohol after leaving the army, although

he reduced his intake significantly over the years;

(2) The Veteran was reluctant to see doctors and put up with bouts of pain, was very careful with his diet, avoiding fatty foods in particular;
(3) The Veteran did not exaggerate his symptoms;
(4) The Veteran trusted the Repatriation Commission doctors.

15.     The Tribunal also noted, that though the Veteran was suffering from pain and nausea when he presented with his liver abscess, he still managed to complete the course of medications prescribed by Dr Waters(which the Tribunal knows ranks high on the unpalatability scale of medications), and finds therefore that he was likely to rigidly comply with doctor's orders.

Dr Murray's evidence

16.     Dr Murray was questioned by Mr Ponnuthurai:

“MR PONNUTHURAI: If he had had a chronic coli systisis (sic), I suppose they could have removed his gall bladder?

DR MURRAY: Yes, but you see, subsequently he had multiple scans and multiple blood tests, none of which demonstrated any evidence that this was - that he was slowly getting progressive changes in the biliary or in his gall bladder, which if it was a chronic coli systisis (sic), in the end it would shrink up into a rather small thick-walled organ which would be evident over a period of time.

(Transcript 21 September 2004, page 35)

17.     The Tribunal questioned Dr Murray about the cause of pancreatitis. He replied,

"In males it is - the most common cause is still alcohol consumption…”

Now, with alcohol, sorry, just to come back to alcohol, is it a direct…is it a direct toxic effect on the pancreas or - - -? --- Yes.  It seems to also, a protein called lactopherin.  And lactopherin precipitates in the tiny little ductuals (sic) in the pancreas.

…

And I think - correct me if I'm wrong - the effect will depend on the volume of alcohol taken? --- That is right.  It is very much a sort of dose response type of problem.  You would be very unlucky if you had alcoholic pancreatis from anything other than excess, genuine excesses of alcohol.

…

Somebody who is drinking moderately in the army, would that alcohol sort of consumption be enough to have precipitated - - -? --- Yes, if it is regular drinking.”

(Transcript 21 September 2004, pp 36-37)

18.     Dr Murray was asked about the age incidence of chronic pancreatitis. He answered:

“Unless you're a heavy drinker, it is going to be in the 40s and 50s where it is more obvious.  But of course in heavy drinkers there is 20 year olds with severe chronic relapsing pancreatitis.

How would 29 sort of come somewhere halfway between the two, isn't it? --- Yes, sure, and if he was drinking heavily, yeah, I mean, that is possible.

And he was 29.  That could be reasonable for starting off chronic pancreatitis? --- Yes.

Unless of course he stopped drinking? --- Yes.

Right, okay? --- And that is the point.  I mean, if it was at that age and he did stop drinking, it can settle down.  If he is in the same age group unfortunately, the older age, towards the 50s, if he is still drinking, of course, so it never really gets the chance to settle down, and then it is a progressive complaint.  Even when he has stopped drinking it leaves a lot of damage.”

…

So what is the commonest sort of presentation symptoms of these chronic pancreatitis patients? --- They can be extremely vague and difficult to diagnose.  That is one of the problems, of course, especially in those early days when he was having very elementary and rudimentary type scanning techniques.  They may not have been able to pick up enough detail…And indeed, chronic pancreatitis can remain as a pain syndrome at least, without any evidence of the raised amylase or alteration of liver function tests.  Indeed, there is very little to show of many - many investigations.

…

Yes, so it would be a very difficult diagnosis to make? --- Yes, but on the other hand, I suppose my point is that with his recurrent presentations with his pain, that if it was chronic pancreatitis in the end there would be changes with the valve, (sic) especially on the scanning techniques.  That his pancreas would either start showing calcification or it would shrink or would have, you know, various and uneven sort of texture, things like that where they would be able to say:  look, this is showing here and it is an ongoing process…And those things did not appear to occur.  Even on his last admission they couldn't find any specific pancreatic lesion.

(Transcript 21 September 2004, pp 38-39).

19.     Dr Murray was asked about serum lipase and whether it was a test available in Australia around the time Mr Thompson was having these problems. He answered, “Yes we did use lipase, but apparently it took so long to get a result, something like three days, that in fact -this is from our own laboratories -that it was dismissed after awhile, because you really want to know what sort of – within sort of 24 hrs...But they have reintroduced it in the last two years" (Transcript 21 September 2004 page 42).

20.     The Tribunal notes that serum lipase is specific for the pancreas. If it is raised (and though it may take three days to come back), it would be diagnostic of a pancreatic problem. I.e. rapid results help in management not in diagnosis. The Tribunal asked Dr Murray,

"If you had a patient who had a history and physical signs which were suggestive of gall bladder disease or stomach ulcers, and reasonable tests for both were negative, would you then consider pancreatitis in the differential diagnosis?” --- Yes, sure (Tribunal’s emphasis).

Dr Murray went on to explain that the pain in chronic pancreatitis is neuropathic pain.

"The sort of continuous background pain? --- Yeah."

(Trans page 43)

21.     The Tribunal questioned Dr Murray on nervous dyspepsia:

"May be you might like to tell us a bit more about nervous dyspepsia. It seems like a bit of an old fashioned diagnosis to me?” --- "Yes, of course it is, that is the trouble. Even now, you wouldn't find many people using the term because it – it’s very broad reaching and we now appreciate many of the situations where somebody was told they had nervous dyspepsia, probably had irritable bowel or variations on that…But in those days it was thought to be related to functional problems in the stomach. In other words, they felt that it was more to do with hyper secretion of acid.          In those days of course then the term was used, people unaware of the entity of helicobacter as a cause of ulcers…So it was felt that most dyspepsias if you like, was an acid related phenomena. We now think that a lot of dyspepsias nowadays are actually problems with motility of the stomach. So it is much more to do with muscle spasm in the stomach than acid.

So in those days...they would give them antacids and they would give them antispasmodics like Tincture Belladonna. --- Yeah.

And they would give them Phenobarb to calm their nerves? Well of course the use of Belladonna in this man -covered both grounds because Belladonna, the old Belladonna alkaloid had antacid properties, I mean it would get rid of acid, but it reduced muscle spasm...so it was a win win situation no matter what caused the actual-

Yes – so that would have been sort of symptomatic and useful treatment even for somebody that might be having a chronic pancreatitis isn't it --- Oh yes, in fact it was those sort of things as are indicated, in the 50s and 60s ­people were using atropine to reduce pancreatic secretions on the ground that that might be a good thing if somebody has an injured pancreas for whatever reason. If you reduce the secretions then you know you are going to at least temporarily improve the person's lot.”

The Tribunal asked him how alcohol will affect nervous dyspepsia.

"--- Well, strangely, some people actually feel better with nervous dyspepsia taking some alcohol...because if their nervous dyspepsia really was a case of stress induced flare up of the nervous dyspepsia, and they actually felt more at ease after some alcohol."

He was asked what physical signs can be expected in nervous dyspepsia.

"--- Well, actually very few physical signs.  It's usually what they complain of rather than…what you find in any examinations and - let alone any tests… It's a...bit like nausea.  You might say it's a very subjective complaint.” (Tribunal’s emphasis)

The Tribunal asked whether he would expect people with nervous dyspepsia to need repeated hospitalisation. Dr Murray answered, "No".

He was also asked if somebody can have nervous dyspepsia and a mild chronic pancreatitis. Dr Murray answered, "Oh you can have both, certainly have both".

Analysis of Dr Murray's evidence

22.     In his evidence Dr Murray indicated that chronic pancreatitis was a possibility, but had some reservations because he expected "that if it was a chronic pancreatitis in the end there would be changes with the gland especially on scanning techniques, that the pancreas would either start showing calcification or it would shrink or it would have you know various and uneven texture, things like that where they would be able to say, look this is showing here and it is an ongoing process and these things did not appear to occur even on his last admission we couldn't find any pancreatic lesion" (Transcript 21 September 2004, page 39).

23.     The Tribunal finds that the issue here was not whether the Veteran had a severe chronic pancreatitis that causes all the changes to his pancreas that Dr Murray mentions above – which only applies to a chronic pancreatitis at the more severe end of the spectrum. If the chronic relapsing pancreatitis had been of lesser intensity, and had the exacerbations been caused by much less exposure to the causative factor, "alcohol ingestion", then, short of a post mortem and macroscopic and microscopic examination of the pancreas -no modern modality would be able to answer this question. The only scans he had of the pancreas were done pre terminally and these were two ultra sound scans (13 5 00) and (9 6 00) The second did not show the pancreas because of gas obscuring the retroperitoneal area in which the pancreas lies.

24.     No computerised Tomography High Resolution Spiral CTscans/Ct Angiography, Magnetic Resonance Cholangio pancreatography and PET scans (the list of modern techniques quoted in Dr Murray's report (page 6)) were done in 1978 as they were not available at that time. Nor were any of them that were available done in 2000 either. Dr Murray's reservations are therefore not supported by the material before the Tribunal. The Tribunal is satisfied therefore, on the balance of probabilities, that the Veteran did suffer chronic pancreatitis of the relapsing type during operational service.

Consideration and findings

25.     The Tribunal perused all of the material in detail to see whether the diagnosis of pancreatitis was entertained at any stage of the Veteran's very long medical history between 1946 and 2000 and especially during the early years post discharge from the Army.

26.     Chronic pancreatitis was not considered in the differential diagnosis during his operational service when the history and symptoms and physical signs pointed to that possibility much more clearly than to the provisional diagnosis of Nervous Dyspepsia made at the time. Dr Murray's evidence supports this view. Again, even when he was seen in 1954 with an accumulated history indicating that the cause of his complaints was yet not clear, the stomach was investigated and the barium meal examination was normal, the gall bladder was to be investigated but there is no evidence that the cholecystogram considered was done. (T 5 Page 026) His Complaints continued and in 1975 he was seen at the Repatriation hospital gastroenterological unit and had a barium meal and a cholecystogram both of which were normal (T7 Page029). Dr Murray agreed in effect, that, faced with this situation, chronic pancreatitis should have been included in the differential diagnosis and excluded. There is no evidence that this was done.

27.     The article provided by the Tribunal from 1946 shows that chronic pancreatitis was not a rare disease or one difficult to diagnose using the medical know how at that time even though this depended more on analysing the history and clinical physical signs and even diagnostic surgical exploration, than on the "primitive" X Rays and Blood tests available at the time.

28.     The Tribunal found that the first indication that the pancreas was even considered as a possible source of the Veteran's ongoing problem was in 1978, (30 odd years after his symptoms commenced) when a serum amylase test, (a test for pancreatic function) was ordered. He was however found to have an amoebic liver abscess on this occasion.

29.     The Tribunal finds that if a diagnosis of chronic pancreatitis was made at this stage, it would have been too late to have made a difference to the Veteran.

30.     After considering all of the material including the Specialist Oncologist report and the Specialist Histopathologist's report, the Tribunal is of the opinion that that material raises a hypothesis connecting death from a disease of the Biliary tree or death from a disease of the Pancreas with the circumstances of the Veteran's operational service.

31.     As this is a post June 1999 case, it has to follow the steps laid down in Repatriation Commission Vs Deledio (Repatriation Commission v Deledio FFC 980391; 22498; Beaumont Hill and O'Connor JJ)

The Biliary Tree hypothesis

32.     Dr Fox, the Specialist Oncologist, opined that the primary could have arisen either in the pancreas or the biliary tree. The hepatobiliary tract or biliary tree includes the gall bladder, the bile duct, and its branches. The Tribunal ascertained that there were separate SoP's determined by the RMA for:

(a) The gall bladder
(b) The bile duct.

The Tribunal was obliged therefore to look at each of these separately as a cancer affecting each one could have different effects. It therefore applied the Deledio steps to each one in turn.

The Gall Bladder

33.     The Tribunal took the following steps:

(1) The Tribunal considered all the material before it and determined that the material points to a hypothesis connecting cholecystitis, a gall bladder disease, with the circumstances of the operational service rendered by the veteran.

(2) The Tribunal ascertained that there is in force an SoP determined by the Authority instrument 36 of 1999 in relation to malignant neoplasm of the gall bladder.

(3) The Tribunal finds that the hypothesis does not fit the template to be found in the SoP as it does not contain one or more of the factors which the authority had determined to be the minimum which must exist and be related to the person's service. Cholecystitis is not a disease referred to in the minimum factors required by the Sop. Therefore the hypothesis is deemed not to be reasonable and the claim must fail as far as the gall bladder is concerned.

The Bile Duct

34.     Applying the Deledio steps again:

1) The Tribunal finds that step (1) is satisfied and a hypothesis is raised by the material connecting a disease of the bile duct, cholangitis, with the circumstances of his operational service.

(2) The Tribunal has ascertained an SoP instrument no 17 of (2000 ) concerning malignant neoplasm of the bile duct is in force and therefore step 2 is satisfied.

(3) The Tribunal finds that the hypothesis is not a reasonable one because it does not contain any of the factors that the authority has determined must as a minimum exist, as set out in the SoP. In particular, there is no evidence that factor b – “suffering from schlerosing cholangitis before the clinical onset of malignant neoplasm of the bile duct” or factor d – “suffering from cholelithiasis before the clinical onset of malignant neoplasm of the bile duct” are satisfied.

The hypothesis is therefore deemed not to be reasonable and the claim must fail as far as the bile duct is concerned.

35.     The Tribunal finds, therefore, that the biliary tree hypothesis, as regards both the gall bladder and the bile duct is not upheld by the SoPs.

The Pancreatic Hypothesis

36.     The Tribunal took the following steps:

(1) Having considered all the material before it, the Tribunal finds that the material does point to a hypothesis connecting death from a disease of the pancreas with the circumstances of the operational service rendered by the Veteran.

(2) The Tribunal ascertained that there are SoPs in force that are relevant to this matter, namely:

(i) Instrument no 57 of2001 dealing with chronic pancreatitis; and

(ii) Instrument no 55 of 1997 dealing with malignant neoplasm of the pancreas (as amended by instrument no 20 of 2002).

37.     As the hypothesis really consisted of two sub hypotheses, the Tribunal first considered that part of the hypothesis dealing with the disease chronic pancreatitis, and its connection with the Veteran's operational service and his death.

38.        The Tribunal finds that the hypothesis does contain one of the factors that as stated in the SoP concerning chronic pancreatitis, must at a minimum exist, namely factor 5(f) "inability to obtain appropriate clinical management for chronic pancreatitis" which is subject to clause 6 which states "Paragraph 5 (f) applies only to material contribution to, or aggravation of, chronic pancreatitis, where the person's chronic pancreatitis was suffered or contracted before or during (but not arising out of) the person's relevant service…”.

The Tribunal finds that factor 5 (f) and clause 6 are satisfied and the sub hypothesis is therefore deemed to be reasonable as the Veteran was not able to obtain appropriate clinical management for chronic pancreatitis which he contracted during operational service.

(4) The Tribunal then proceeded to consider under section 120 (1) whether it is satisfied beyond reasonable doubt that the disease of chronic pancreatitis was not war caused.

39.     The Tribunal finds that the disease chronic pancreatitis was not diagnosed during or after operational service and that he could not therefore obtain appropriate management for his disease. Appropriate management for this disease would include explaining to the patient that alcohol was not only the cause, but that it could keep the disease process active and could trigger relapses. Without this advice, the veteran continued to drink alcohol (though to a lesser degree) .The Tribunal finds that this failure of management i.e. not explaining the importance of ceasing alcohol intake altogether when he suffered this disease during operational service, materially contributed to maintaining his chronic pancreatitis for many years after his service.

40.     The Tribunal is not satisfied therefore, beyond reasonable doubt, that the veteran's chronic pancreatitis was not war caused.

41.    The Tribunal then considered the other sub hypothesis which connects this war caused chronic pancreatitis with the development of adenocarcinoma of the pancreas, and applied the SoP concerning malignant neoplasm of the pancreas. Instrument no 20 of 2002.

42.     According to that SoP, one of the factors that at a minimum must exist for this connection is factor 5(a)(iii) "suffering from chronic pancreatitis for at least five years immediately before the clinical onset of malignant neoplasm of the pancreas".

43.     The Tribunal notes that this factor does not specify the level or degree of severity of the chronic pancreatitis. It requires that the person must be suffering from chronic pancreatitis for at least five years immediately before the clinical onset of malignant neoplasm of the pancreas. The clinical onset refers to when symptoms referable to carcinoma of the pancreas started or when the diagnosis of malignant neoplasm of the pancreas was made. In this case the symptoms relating to the pancreas could arise from the chronic pancreatitis that could be occasionally triggered by his occasional ingestion of alcohol, and such symptoms could be difficult to disentangle from those due to cancer of the pancreas and even those due to a nervous dyspepsia which the Tribunal finds he had.

44.     The Tribunal submitted material from Harrison's Text Book that indicate that finding the primary in the pancreas, even in this modern era, can be extremely difficult. It is often detected at post mortem. The material indicates however that once a tumour is diagnosed, death occurs within a few years.

45.     On this basis the Tribunal estimates that the clinical onset of his primary in the pancreas would have been around 1996. According to this, the factor prescribes that the Veteran should have been suffering from chronic pancreatitis during at least the years 1991 to 1996. Based on the material before it, and the Tribunal accepting the evidence of the wife and son that the veteran was stubborn, reluctant to see doctors, did consume alcohol though to a much lesser degree, and suffered bouts of pain throughout his life (as the causal factor continued to operate albeit intermittently) and he soldiered on – the Tribunal finds that factor 5(a) (iii) is satisfied because his chronic pancreatitis was not allowed to settle. It finds therefore that a reasonable hypothesis is raised connecting chronic pancreatitis with operational service on the one hand and death from malignant neoplasm of the pancreas on the other.

46.     The evidence supporting this link is found in the article in the New England Journal of medicine which in its conclusion notes "The risk of pancreatic cancer is significantly elevated in subjects with chronic pancreatitis and appears to be independent of sex, country, and type of pancreatitis."

Step 4) directs that the Tribunal must then proceed to consider under section 120 (1), whether it is satisfied beyond reasonable doubt that the death was not war caused.

47.     Having considered all the material before it;

(1) The Tribunal finds that the Veteran suffered a disease chronic pancreatitis of the type known as relapsing chronic pancreatitis, during operational service; and continued to suffer this disease, with lessening intensity and minor exacerbations, until 1996 at least;
(2) This chronic pancreatitis was materially contributed to by service and triggered the development of adenocarcinoma of the pancreas many years later;
(3) This adenocarcinoma of the pancreas so triggered, then metastasised to the liver which led to liver failure and his death;

48.     Having considered all the material in relation to other potential sites of an adenocarcinoma and having excluded them, and in particular having excluded the biliary tree as a site of his primary adenocarcinoma, the Tribunal is therefore not satisfied beyond reasonable doubt that the death was not war caused.

Decision

49.     The Tribunal sets aside the Decision of the Veterans Review Board of 17 January 2003 and, in substitution therefore, finds that the death of Mr Thomas Thompson was war-caused and the applicant Mrs Doreen Thompson is entitled to a war widow’s pension from 21 June 2000.

I certify that the 49 preceding paragraphs are a true copy of the reasons for the decision herein of Dr D Weerasooriya, Member

Signed:         ...............(sgd V Wong).................................
  Associate

Date/s of Hearing                      2 February, 26 July, 1 September, 21 September 2004

Date of Decision  17 December 2004
Counsel for the Applicant         In person with Mr A Thompson
Counsel for the Respondent     Mr C Ponnuthurai
Solicitor for the Respondent     Department of Veterans' Affairs