Morel v Carroll - [2001] WADC 221

JURISDICTION : DISTRICT COURT OF WESTERN AUSTRALIA
IN CIVIL

LOCATION: PERTH

CITATION: MOREL -v- CARROLL [2001] WADC 221

CORAM: FENBURY DCJ

HEARD: 11-13 SEPTEMBER 2001

DELIVERED : 21 SEPTEMBER 2001

FILE NO/S: CIV 815 of 2000

BETWEEN: MARIE JACQUELINE MOREL
Plaintiff
AND
DR GRAEME CARROLL
Defendant

Catchwords:

Negligence - Breach of duty - Rheumatologist - Treatment for rheumatoid arthritis - Duty to give advice - Negligent treatment - Causation - Turns on own facts

Legislation:

Nil

Result:

Claim dismissed

Representation:

Counsel:

Plaintiff: Mr C P Shanahan
Defendant: Mr J D Allanson

Solicitors:

Plaintiff: Butcher Paull & Calder
Defendant: Edwards Wallace

Case(s) referred to in judgment(s):

F v R [1983] SASR 189
Rogers v Whitaker (1992) 175 CLR 479

Case(s) also cited:

Chappel v Hart (1998) 195 CLR 232
Rosenberg v Percival (2001) 75 ALJR 734
Sidaway v Governors of Bethlehem Hospital [1985] AC 871
Kleinwort Benson Australia Ltd v Armitage, unreported; SCt of NSW; BC8902252; 26 April 1989

FENBURY DCJ: This is an action for damages for negligence brought by a woman who claims to have suffered a severe skin rash resulting in loss of pigmentation caused by injections of an anti‑rheumatic drug called Methotrexate.
The defendant is a specialist rheumatologist to whom the plaintiff was referred for treatment for rheumatoid arthritis.
In her statement of claim the plaintiff alleges that she took Methotrexate at the recommendation of the defendant and that it caused her severe adverse reactions that resulted in injury including:
"(i)erythematous inflammatory skin reaction; and
(ii)depigmentation or vitiligo reaction."
It is noted that causation is in dispute in the sense that the defendant does not concede that all the plaintiff's skin problems and particularly all the skin depigmentation were caused by the drug.

The issues and pleadings

The plaintiff alleges that her injury was caused by the negligence of the defendant and she particularises her allegations in par 8 of the statement of claim in five sub‑paragraphs. One of those allegations (sub‑par 8(b)) was abandoned at trial. Counsel for the plaintiff submitted that the remaining four particulars can be grouped into two groups, namely sub‑par (a), sub‑par (d) and sub‑par (e) which concern allegations of failure to advise the plaintiff in certain matters and then sub‑par (c) which is said to amount to, in essence, an allegation of negligent treatment.
Sub‑paragraph (a), sub‑par (d) and sub‑par (e) are in the following terms. It is alleged that the defendant:
"(a)Failed in February 1996 to advise the plaintiff of the possible adverse side-effects of the Methotrexate.
(d)Failed to advise the plaintiff in March 1996 to discontinue taking the Methotrexate.
(e)Failed to advise the plaintiff in March 1996 that her adverse side-effects as referred to in par 5 were possibly or indeed probably caused by Methotrexate, and that continuing to take the drug would cause further injury."
The allegation in sub‑par (c) is that the defendant:
"Failed to recognise that the side-effects referred to par 5 were caused by the Methotrexate."
Paragraph 5 of the statement of claim states:
"As a consequence of taking the Methotrexate the plaintiff suffered adverse reactions namely recurring facial swelling and erythema involving the eyelids."
The plaintiff's claim is for damages for pain and suffering and loss of enjoyment of life by reason of her cosmetic disability and associated or resultant problems. She also seeks special damages. There is no other claim for economic loss. As counsel put it "This is not a huge claim."
There is no dispute that the defendant prescribed Methotrexate to the plaintiff for the treatment of her rheumatoid arthritis. However it was asserted on behalf of the defendant that far from failing to give the plaintiff advice in February 1996 about the possible adverse side-effects, as pleaded in par 8(a), the defendant had given the plaintiff information and instruction on precisely those side-effects at that time and also on numerous occasions over the years prior to 1996.
As to the allegation in par 8(d) that the defendant failed to advise the plaintiff to discontinue taking the Methotrexate in March 1996, it appears that this is agreed but the defendant says that instructions to discontinue were given early the following month. The defendant was concerned about the plaintiff's skin problems and referred her to a dermatologist. Following advice received on or about 4 April, the plaintiff discontinued taking Methotrexate. Thus although it might appear to be conceded that the defendant did not advise the plaintiff to discontinue taking Methotrexate in March 1996, he asserts that he did so in early April and that the delay, if any, was justifiable therapeutically.
As to the allegation in par 8(e) the defendant asserts that the plaintiff was cognisant at all times of the side‑effects of Methotrexate and that some delay was occasioned by determination of the cause of her injury.
Finally as to the allegation in par 8(c) the defendant disputes that all the side‑effects were indeed caused by Methotrexate but if they were they were side‑effects of a kind about which due warning had been given and about which the plaintiff was aware at all material times.
The plaintiff's case relied heavily upon the evidence of the plaintiff, as is usually the case, and this was particularly so concerning her allegations that the defendant failed to give her proper advice about the dangers of Methotrexate.

The plaintiff

The plaintiff, 51 years old at trial, gave evidence that she was born in the Seychelles in 1949 and arrived in Australia at the age of about six. In spite of the length of time she has spent in Australia she spoke with an accent and had unusual pronunciations. The plaintiff stated that she had had limited education apparently leaving school at about aged 12. She completed no high schooling. She said that she could read "a little bit but not much" and that she could write "simple things". She could sign her name and address but she could not write letters.
The plaintiff has been married on two occasions and has four grown up children. She has had a close friendship (short of a relationship) with a man named Desmond Michaud in whose house she has been living for some 12 or more years.
The plaintiff gave evidence about the physical problems that she has had in her life. Suffice it to say that they are many. One of her major difficulties has been that she suffers from severe rheumatoid arthritis, a condition which she has lately accepted was triggered by her suffering a fall in about 1987 or 1988. It took many years for her to accept that she suffered from rheumatoid arthritis. Initially she blamed all her symptoms on having fallen and commenced some legal proceedings in respect of that matter.
Amongst other health difficulties the plaintiff has suffered, she has had a hip replacement. Over the years she appears to have had a number of emotional difficulties in addition to poor health. These apparently may have been related to her matrimonial problems.
The plaintiff presented as a tense sort of woman, perhaps highly strung, who, there can be no doubt, has had a miserable time over the years. In the early 1990's prior to 1996 she had many contacts with the medical profession for many reasons. She has taken a wide variety of drugs and medications. She has great difficulty in recollection about a large number of matters.
Having heard and assessed the plaintiff I have no doubt whatsoever that she suffered from very unpleasant skin problems in 1996 and indeed in earlier years. I also have no doubt that she honestly believes the cause of her problems concerning her skin has been Methotrexate. However, as a witness for her cause, the plaintiff's evidence raised significant concerns about reliability. I thought she was doing her best, basically, to be honest with the Court but she has a poor recollection of events. She did not dispute this and indeed on one occasion candidly described herself during a critical period in the early 90's as "not knowing if she was Arthur or Martha".
The plaintiff's reliability as a witness in relation to these matters made the question of whether she had discharged her onus of proof that she did not receive appropriate advice at relevant times difficult to assess. Indeed, she was not often able to say that, as a fact, she was not given advice. She was only able to assert that she could not recall whether she got such advice.
It is for the plaintiff to prove on the balance of probabilities that she was not given the appropriate advice she claims. Her evidence as to what she was or was not told was not reliable.
On behalf of the defendant it is asserted that the plaintiff was told on numerous occasions prior to 1996 of the adverse side‑effects of Methotrexate. True it may be that she was not specifically told that there was a possibility of her suffering a loss of pigmentation. But she was told of the risk of skin rashes amongst a large number of other much more significant potential adverse side‑effects. Indeed she had previously experienced skin rashes following treatment with this drug.
The evidence establishes that the plaintiff suffered from a severe form of rheumatoid arthritis and that she had undergone a variety of treatments including injections of gold and sulfasalazine amongst other drugs. She had adverse reactions to many forms of drugs that were prescribed for her arthritis.
In spite of the plaintiff's lack of recollection, or denial of it, the documentation clearly establishes that the option of taking Methotrexate as a treatment for her rheumatoid arthritis was discussed with her on a number of occasions prior to 1996. Indeed, over a lengthy period she declined to accept advice to take the drug. For a time she was suffering from severe rheumatoid arthritic symptoms, was advised to take Methotrexate, but declined to do so. The inevitable inference from that reluctance is that she was concerned about side‑effects.
In spite of her lack of recollection there was evidence that in about 1995 the plaintiff did take a course of Methotrexate in tablet form. She had an adverse skin reaction. It is hard to accept the experience vanished from her memory.
Apart from the defendant's sworn testimony that he did give the plaintiff appropriate advice about the risks of Methotrexate, the contemporaneous documentation in the form of letters, case notes and the like are all consistent with the defendant's response. The plaintiff was provided with a booklet on one occasion that set out the adverse side‑effects of Methotrexate. Although she may not have been able to read this and understand it fully herself she was able to rely on others if she chose to do so.
I do not think an analysis of every item of documentary evidence put before the Court in this case is required in assessing the question of whether the plaintiff has proved that she did not receive the appropriate advice about the adverse effects of taking Methotrexate. Not only am I unconvinced that the plaintiff was not so advised, having heard from the defendant and perused the contemporaneous documentation, I have no doubt that she was given appropriate information and advice about taking Methotrexate. This is a factual matter in relation to which the plaintiff has the burden of proof which she has failed to discharge.
Although not pleaded, counsel for the plaintiff also alleged that even if she had been advised about the side‑effects of taking Methotrexate in years prior to 1996, and even if she had taken the drug previously, by reason of her poor literacy, her personality and the effect her many emotional problems had had, the defendant should have realised the plaintiff may have forgotten what she had been told or learnt. Thus, according to counsel, special consideration was required and she should have been fully advised again when the drug was reconsidered in February 1996. Counsel relied on Rogers v Whitaker (1992) 175 CLR 479 and F v R [1983] SASR 189.
The evidence of the defendant was that the plaintiff was given appropriate warnings by him or on his behalf in early 1996. Exhibit I, p 25 and p 26 refers. Detailed unequivocal contemporaneous records of every conversation had with the plaintiff are non existent but the notations, especially recorded on p 26, combined with the weight I attach to the defendant's evidence on the point lead me to a preference for the defence case on this issue.
If I am wrong in the conclusion I reach concerning whether the plaintiff was given appropriate advice and information, and she was not so given that advice, then a consequential issue relates to whether she would have undergone the treatment if she had been given that advice.
The plaintiff appears to have been a woman who, from photographs tendered in evidence and her presentation in Court, enjoyed her social life. She was photogenic and appeared socially outgoing. She was a person that might well have been reluctant to take medication that posed a risk to her physical appearance.
On the other hand she suffered from a very painful and debilitating disease which had not been significantly alleviated by a variety of different medications and treatment. She had an array of associated problems. So far as can be ascertained, my view of the plaintiff as a witness and my assessment of her as a person drives me to the conclusion that she would have undergone treatment with Methotrexate, knowing the possible side effects, as she did indeed do.
In my view the plaintiff has failed to make out the allegation pleaded in par 8(a) of the statement of claim.
The other allegations made by the plaintiff in the statement of claim require a closer analysis of the period February to April 1996.
Whilst on holiday in the Eastern States in early 1996 the plaintiff had a flare‑up of her symptoms and upon returning to Western Australia and seeking further medical attention in due course she was admitted to hospital on 14 February 1996.
Discussion and debate concerning the appropriate treatment of the plaintiff is apparent from the case notes for and during her admission between 14 February and 20 February 1996 (Exhibit I, pp 19‑26). At the time of her discharge reference is made in the notes to the likelihood that the defendant would be discussing commencement of the plaintiff on Methotrexate at a dosage of 5 milligrams per week by injection. Following her discharge from hospital the plaintiff attended upon her general practitioner, Dr Sembi. She was also referred to her dermatologist, Dr Singh. She was also referred to the defendant.
The defendant's view was that the plaintiff should commence injections of Methotrexate by injection once per week at the rate of 5 milligrams despite her qualms. It appears that the plaintiff finally agreed to this procedure and there can be no doubt that her agreement was influenced by the fact that she wished her symptoms of rheumatoid arthritis to be alleviated.
The plaintiff had her first injection, which was administered by her general practitioner, on 26 February 1996. She said that she had a skin reaction a couple of days later. However she did not go in to see her general practitioner. She raised it with him when she was due for her second injection on 4 March 1996.
The plaintiff said that she brought to Dr Sembi's attention the fact that she was having problems with her skin and he expressed the view that perhaps it was dermatitis. No issue about problems was raised with the defendant by either Dr Sembi or the plaintiff at this time.
The plaintiff had her second injection and fairly shortly afterwards she developed severe redness of her skin and itching. She sought and obtained an urgent consultation with Dr Sembi and he referred her, also on an urgent basis, to Dr Singh. She saw Dr Singh on about 15 March 1996 by which time she had had two injections but not the third injection.
It is during this period that the plaintiff asserts in par 8(d) that the defendant failed in his duty to give her appropriate advice in that, having been made aware of difficulties concerning the plaintiff's skin problems, he did not advise immediate discontinuance of Methotrexate. The relevant documentation arose as follows. By undated facsimile referral but probably about 14 March, reproduced at Exhibit I p 32, Dr Carroll referred the plaintiff to Dr Singh, as follows:
"Thank you for reviewing Ms Morel at short notice. She has developed a rash which may be due to anti‑rheumatic drug therapy. Attached is her recent discharge summary detailing her drug therapy. I would value your assessment. She has an appointment for review by me on 18 March 96. Could you let me have your opinion and advice by them."
The discharge summary was Exhibit J and it was dated 20 February 1996.
It was common ground that although she was convinced she had had three Methotrexate injections by this time, in fact the plaintiff had only had two injections being on 26 February and 4 March. She saw Dr Singh about 10 days after the second injection.
Dr Singh examined the plaintiff and then sent a handwritten response dated 15 March 1996 which is reproduced at Exhibit I p 33. It says as follows:
"Much of the rash had settled by the time she presented today. However there was some evidence of mild erythema and slight dryness of the skin of the exposed (sunlight exposed) areas of the neck, sparing the retroauricular and submental regions.
She claimed that the rash was itchy, had been more florid with swelling of the skin. There was slight involvement of her leg.
She is adamant that on each occasion of her having had MTX injections (which she claims she has had three to date) she has developed skin eruptions. It would appear that there is a causal‑temporal relationship with this drug and the skin eruptions. Photo sensitivity has been documented with MTX.
This I realise, will pose a problem in that MTX appears to be an important part of your anti‑rheumatic drug therapy for her. …"
In evidence the defendant stated that he did not regard this note from the dermatologist Dr Singh as amounting to advice forthwith to discontinue the use of Methotrexate for the plaintiff. The defendant pointed to the language of the note, for example the fact that Dr Singh used the words "it would appear" as indicating he was not sure. Given his own lack of certainty (as evidenced six days later - see Exhibit I p 13) the defendant did not feel immediate discontinuance of Methotrexate was warranted at that time. The defendant expanded on this at transcript 253 et seq.
In my view, especially having regard to the contents of Dr Singh's communication of 4 April to which I shall shortly refer (Exhibit I p 35), the defendant's explanation for his decision not to discontinue Methotrexate on or about 15 to 18 March was reasonable. Or rather, I am not persuaded it was not reasonable. In other words the allegation in par 8(d), although perhaps proved as a fact, was not conduct of a negligent character.
On 21 March 1996 the plaintiff attended upon the defendant at Royal Perth Hospital and from the case notes reproduced at Exhibit I p 13 for that visit the following appears:
"Methotrexate prescribed 5 milligrams S/C nil since 11/3…
Discharged 1/12 ago. Has had Methotrexate injections 5 milligrams subcutaneously x 3 (?). Complained of recurring facial swelling and erythema ‑ eyelids puffy and face also, associated with sweating. Episodes last approximately 12 hours. ?Prednizilone induced.
? Other drug ‑ Ranitidine? ?Plaquinil ?Methotrexate ‑ not temporally related."
It appears on the evidence that the plaintiff had another injection of Methotrexate on 25 March which was the last injection she had. This caused a more serious but similar reaction to her. She felt she was burning up. She developed rashes and blisters over various parts of her body and these are approximately in the locations where, at least in many respects, she asserts that she has suffered depigmentation of her skin.

In his letter of 29 March 1996 the defendant wrote to the plaintiff's GP Dr Sembi, and the letter is reproduced at Exhibit I p 34 as follows:
"Thank you for your telephone call about Ms Morel during the week. I note the difficulties that she is continuing to have with the Methotrexate injections. As mentioned I arranged for Dr Sing to review her in the light of this difficulty and I enclose copy of his handwritten report that may be of interest to you.
When I saw her last on 21.3.1996 she complained of recurrent facial swelling and erythema and puffiness of the eyelids and face. This has been associated with sweating. The episodes last for about 12 hours. They are not temporally related to the Methotrexate injections but it is possible that they are a consequence of these or perhaps the ongoing treatment with Prednizilone.
I recommended a gradual reduction in the dose of Prednizilone to just 5 mm per day over the course of the next week or two and suggested that she continue with the Methotrexate despite the difficulties that she has had with her skin."
The next relevant letter is that dated 4 April 1996 written by Dr Singh the dermatologist to the defendant which is reproduced at Exhibit I p 35. Dr Singh states:
"I reviewed this patient following your call on 2 April 1996. She complained bitterly of persistent pruritus over her arms in particular. There was evidence of mild erythema, dryness of the skin and excoriations from the scratchings… I would favour drug eruption as the most likely cause.
It would appear that Methotrexate will need to be ceased, as discussed with you. It certainly limits your options of managing her joint symptoms."
It is common ground that thereafter the plaintiff did not have any further injections of Methotrexate. The treatment was ceased by the defendant.
There then follows a large collection of documents in evidence which reveal the debate amongst the medical practitioners concerning the causation of the plaintiff's symptoms. For the purposes of this case, and without going into a detailed analysis of every comment made by those who cared at the time, it appears likely that the injections of Methotrexate did, perhaps in combination with other drugs the plaintiff was taking, cause her difficulty.
However, that finding is not determinative of the question.
What requires examination is the evidence concerning the conduct of the defendant as a specialist rheumatologist during the critical period in February and March 1996. True it is that Dr Singh was of the view that there appeared to be a causal and temporal relationship between the Methotrexate and the plaintiff's symptoms. However the defendant does not appear to have accepted this at that time. Permeating his consideration of these issues was the need for the plaintiff to continue treatment for her severe rheumatoid arthritis.
It is apparent from the evidence that it takes between 4‑6 weeks for dosages of Methotrexate to have therapeutic affect. The doses being administered to the plaintiff, being 5 milligrams per week, were very low doses.
The evidence establishes that the defendant was feeling his way with a very difficult problem and doing his best to find the right balance between alleviating the plaintiff's severe rheumatoid arthritis symptoms but at the same time not permitting her to suffer adverse side‑effects for too long a period.
Looking at the matter now, with the wisdom of hindsight, I do not feel it is possible to say the decision made by the defendant to allow the plaintiff to undergo that third injection was an unreasonable decision; was a decision that no reasonably careful practitioner of similar special skill would make. That is a conclusion I reach even without a detailed consideration of the expert evidence to which I shall now turn.
Dr Mark Awerbuch gave expert evidence by video from Adelaide on behalf of the defendant.
Dr Awerbuch's impressive qualifications and curriculum vitae appear in Exhibit L. Suffice it to say he is a very highly qualified expert in his field.
Dr Awerbuch's report, Exhibit H, was a very lengthy document and on occasions strayed into the judicial area. That of course is a common fault of expert witnesses in cases of this kind.
Dr Awerbuch reviews all of the documentation that was sent to him. On p 10 at par 5 after reviewing he states as follows:
"On the most parsimonious view, Dr Carroll's management of Ms Morel appears to have been cautious and considered if not exemplary. … Moreover, Dr Carroll employed an extremely conservative Methotrexate dosage regime using what some rheumatologists might consider to have been subtherapeutic doses of Methotrexate and as such least likely to cause side‑effects. Furthermore, when Ms Morel developed skin rashes, Dr Carroll referred her expeditiously to a dermatologist and only recommenced Methotrexate therapy once he had been given advice by the dermatologist that it was improbable that the plaintiff's warts were related to the Methotrexate therapy. When subsequently Ms Morel developed a further rash…he again prevailed on Dr Singh a dermatologist to review Ms Morel expeditiously."
Dr Awerbuch's report then turns to a consideration of a survey of medical knowledge concerning Methotrexate and relevant literature. He refers to the information source called "MEDLINE", and at p 17 of his report he states as follows:
"Adverse skin reactions due to the use of low dose Methotrexate in the treatment of rheumatoid arthritis are rare and when they do occur, are usually mild and self limiting. Examples of Methotrexate discontinuance due to skin reactions in patients with rheumatoid arthritis are conspicuous by their absence."
At p 19 of his report Dr Awerbuch says as follows:
"Given the severity of Ms Morel's rheumatoid arthritis, the lack of a temporal relationship between the rash and the Methotrexate injections and the absence of any published data indicating 'recurring facial swelling and erythema involving the eyelids' as a post dosing reaction to Methotrexate injections, it was not unreasonable for Dr Carroll to have recommended ongoing Methotrexate treatment as being in the best interests of Ms Morel."
Dr James Rohr, is a highly qualified dermatologist who gave evidence on behalf of the defendant. His curriculum vitae was Exhibit O1. His report dated 1 September 2000 was Exhibit O2 and in par 3 on p 2 in his opinion Dr Rohr states:
"This patient clearly had severe symptoms with her rheumatoid arthritis. A decision had to be made as to whether she should continue to be very incapacitated by her arthritis or whether she would risk some of the potentially adverse reactions from Methotrexate. It is not an easy decision to make but, if her arthritis was as severe as is obvious from the notes, then I feel most reasonable people, either patients or doctors, would have proceeded to Methotrexate after other modalities of therapy had clearly failed."
Further, in the last paragraph of his report, Dr Rohr states as follows:
"Numerous toxic effects of Methotrexate therapy are recognised. In one long term study, 73 per cent of patients had side‑effects, most frequently abnormal liver function tests, nausea and upper gastrointestinal symptoms. Bone marrow depression can occasionally occur. Methotrexate is also recognised as being hepatotoxic. These are the most sinister side‑effects of this drug and it is important to realise that Ms Morel did not experience any of these symptoms. Dermatological side‑effects do occur but, when one has to regard the overall spectrum of severe arthritis against cutaneous side‑effects, then I feel one should manage the arthritis adequately rather than worry unduly about skin side‑effects. At present I feel this patient's main problem is that of vitiligo which is thought to be an autoimmune disorder and I do not feel it has been caused by her adverse drug reaction. …"
The expert witness called on behalf of the plaintiff was Dr Christopher Browne from Sydney whose two reports are reproduced in Exhibit I p 47 to p 50 and p 52 to p 56.
Dr Browne was a consultant physician and rheumatologist of considerable experience and he had an impressive curriculum vitae. In his initial report on 1 December 1998 p 49 he expressed the view:
"In the light of a skin reaction reported by your client in the temporal relationship to the use of Methotrexate it would have seemed prudent to consider Methotrexate as a potential causative agent of the skin reaction." (sic)
And later:
"I would emphasise that despite your client's history of adverse drug reaction to other agents including salazopyrin and gold, it was reasonable to introduce Methotrexate therapy, but it was not reasonable to continue use of Methotrexate in the face of a worsening skin reaction while continuing Methotrexate therapy."
In short Dr Christopher Browne's view appears to have been that if he had been the treating rheumatologist in the position of the defendant on or about 15 March then he would not have permitted the plaintiff to undergo a third injection of Methotrexate and he felt it was not reasonable for the defendant to do so.
That is as may be. Clearly in the circumstances there is room for a debate about the appropriate decision that might have been made especially given the wisdom of hindsight. However, in spite of Dr Browne's opinion, I am unconvinced having regard to the evidence of the defendant, (who was the treating doctor and "on the spot" so to speak) and of Dr Awerbuch and Dr Rohr, that the defendant's decision to permit the plaintiff to have the third injection of Methotrexate amounted to a beach of his duty to exercise reasonable skill and care in the treatment of the plaintiff in all the circumstances.
Consequently the plaintiff has failed to establish her allegations of negligence as pleaded in par 8(e) and indeed par 8(c) of the statement of claim and this action must be dismissed.

Assessment

In the event that I am wrong in my view on the question of liability I shall very briefly assess damages. It is apparent that this is "not a huge claim". To put it more bluntly, it is a small claim which would more appropriately have been commenced in the Local Court.
The assessment of the plaintiff's claim for damages for pain and suffering and loss of enjoyment of life is complicated by the fact that she had a catalogue of other difficulties, health problems and emotional problems at the relevant time.
In her evidence the plaintiff gave me the strong impression that she keenly felt the loss of pigmentation problems that she had. She was obviously a person who particularly cared about her physical appearance, perhaps more so than many people her age. The depigmentation, which is evidenced in photographs that were tendered and was apparent in Court could not be described as significantly disfiguring. There was a difference in shading in parts of her skin but the depigmented areas were not white. They were simply of lighter colour than the surrounding skin. Nevertheless, however, I can accept that the plaintiff felt very strongly that her appearance had been adversely affected significantly.
Very little time was spent by counsel for the plaintiff on the issue of quantum. It is very difficulty to isolate the effect of this experience from the wide variety of other health difficulties and problems the plaintiff has. In my view an appropriate award for damages for the effects of the Methotrexate including the skin blemishes in the nature of depigmentation that she suffers together with the stress and embarrassment caused thereby would be the sum of $7,500.
On the evidence presented, I am unable to assess special damages.