Parrington v Ultimate Holiday Parks Pty Ltd ATF the Peate Family Trust

[2025] NSWPICMP 112

DETERMINATION OF APPEAL PANEL
CITATION:	Parrington v Ultimate Holiday Parks Pty Ltd ATF The Peate Family Trust [2025] NSWPICMP 112
APPELLANT:	Alyssa Parrington
RESPONDENT:	Ultimate Holiday Parks Pty Ltd ATF The Peate Family Trust
APPEAL PANEL
MEMBER:	Jane Peacock
MEDICAL ASSESSOR:	Nicholas Glozier
MEDICAL ASSESSOR:	Douglas Andrews
DATE OF DECISION:	24 February 2025
CATCHWORDS:	WORKERS COMPENSATION - Psychological Injury; appellant employer alleged assessment on the basis of incorrect criteria and demonstrable error in the making of assessments under four of the psychiatric impairment rating scale (PIRS) categories and for failing to allow for effects of treatment; Held – Appeal Panel found error; a re-examination was not considered necessary; Medical Assessment Certificate revoked.

BACKGROUND TO THE APPLICATION TO APPEAL

1. The worker Alyssa Parrington (the appellant), lodged an Application to Appeal Against the Decision of a Medical Assessor. The medical dispute was assessed by Dr Surabhi Verma, a Medical Assessor, who issued a Medical Assessment Certificate (MAC) on
   24 September 2024.

2. The appellant relies on the following ground of appeal under s 327(3) of the Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act):

   ·        availability of additional relevant information (being additional information that was not available to, and that could not reasonably have been obtained by, the appellant before the medical assessment appealed against);

   ·        the assessment was made on the basis of incorrect criteria, and

   ·        the MAC contains a demonstrable error.

3. The delegate is satisfied that, on the face of the application, at least one ground of appeal has been made out. The Appeal Panel has conducted a review of the original medical assessment but limited to the grounds of appeal on which the appeal is made.

4. Rule 128 of the Personal Injury Commission Rules 2021 (the PIC Rules) and Procedural Direction PIC7 - Appeals, reviews, reconsiderations and correction of obvious errors in medical disputes set out the practice and procedure in relation to the medical appeal process under s 328 of the 1998 Act. An Appeal Panel determines its own procedures in accordance with r 128(1) of the PIC Rules.

5. The assessment of permanent impairment is conducted in accordance with the SIRA NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4^th ed
   1 March 2021 (the Guidelines) and the American Medical Association Guides to the Evaluation of Permanent Impairment, 5^th ed (AMA 5).

PRELIMINARY REVIEW

1. The Appeal Panel conducted a preliminary review of the original medical assessment in the absence of the parties and in accordance with the WorkCover Medical Assessment Guidelines 2006.

2. The appellant requested that she undergo a re-examination. However, as a result of its preliminary review, the Appeal Panel determined that it was not necessary for the worker to undergo a further medical examination because although the Appeal Panel found error, there was sufficient material before the Appeal Panel to enable a determination to be made.

EVIDENCE

Documentary evidence

1. The Appeal Panel has before it all the documents that were sent to the Medical Assessor for the original medical assessment and has taken them into account in making this determination.

Fresh evidence

1. Section 328(3) of the 1998 Act provides that evidence that is fresh evidence or evidence in addition to or in substitution for the evidence received in relation to a medical assessment appealed against may not be given on an appeal by a party unless the evidence was not available to the party before the medical assessment and could not reasonably have been obtained by the party before that medical assessment.

2. The appellant seeks to admit the following evidence:

   (a)    further supplementary statement of the appellant. 

3. The appellant submits that the evidence is relevant and was not available prior to the medical assessment because it is about the assessment.  The respondent opposed the admission of the additional evidence.

4. The Appeal Panel declines to admit this additional evidence. There is a presumption of regularity in the conduct of the assessment and in the event that there are complaints about the manner in which the assessment was conducted then that is matter for the complaints process and not the appeal process. The appellant has had the opportunity to present statement evidence in these proceedings prior to the medical assessment taking place.

Medical Assessment Certificate

1. The parts of the medical certificate given by the Medical Assessor that are relevant to the appeal are set out, where relevant, in the body of this decision.

SUBMISSIONS

1. Both parties made written submissions. They are not repeated in full, but have been considered by the Appeal Panel.

FINDINGS AND REASONS

1. The procedures on appeal are contained in s 328 of the 1998 Act. The appeal is to be by way of review of the original medical assessment but the review is limited to the grounds of appeal on which the appeal is made.

2. In Campbelltown City Council v Vegan [2006] NSWCA 284 the Court of Appeal held that the Appeal Panel is obliged to give reasons. Where there are disputes of fact it may be necessary to refer to evidence or other material on which findings are based, but the extent to which this is necessary will vary from case to case. Where more than one conclusion is open, it will be necessary to explain why one conclusion is preferred. On the other hand, the reasons need not be extensive or provide a detailed explanation of the criteria applied by the medical professionals in reaching a professional judgement.

3. The matter was referred to the Medical Assessor for assessment as follows:

   “The following matters have been referred for assessment (s 319 of the 1998 Act):

   ·        Date of injury: 23 March 2020

   ·        Body parts/systems referred: Psychiatric/psychological disorder

   ·        Method of assessment: Whole person impairment”

4. The Medical Assessor issued a MAC certifying as follows:

Body Part or system	Date of Injury	Chapter, page and paragraph number in NSW workers compensation guidelines	Chapter, page, paragraph, figure and table numbers in AMA5 Guides	% WPI	WPI deductions pursuant to S323 for pre-existing injury, condition or abnormality (expressed as a fraction)	Sub-total/s % WPI (after any deductions in column 6)
1. Psychological Injury	23 March 2020	Chapter 11 Guidelines 11.1-11.3 11.4-11.6	Guidelines 11.11,11.12 Table :11.1,11.2,11.3,11. 5,11.5,11.6	7%	0%	7%
Total % WPI (the Combined Table values of all sub-totals)					7%

1. The assessment was based on his assessment under the psychiatric impairment rating scale (PIRS) as required by the Guidelines as follows: (emphasis in original)

“Table 11.8: PIRS Rating Form

Name	Alyssa Parrington	Claim reference number (if known)	W24412/24
DOB	Age at time of injury	32 years
Date of Injury	23 March 2020	Occupation at time of injury
Date of Assessment	9 September 2024	Marital Status before injury	Married

Psychiatric diagnoses

1. Post-traumatic Stress Disorder

2. Major Depressive Disorder

Psychiatric treatment

Yes

Is impairment permanent?

Yes

PIRS Category			Class		Reason for Decision
Self Care and personal hygiene			2		Ms Parrington reported that she is unable to stand for long and has pain in her side, lower back and right knee and has been using boots for four years and has to use crutches. She said, ‘I hang the washing and do the dishes but standing too long causes pain.”  She said that it is because she showers 2-3 times a week and said that ‘when the hot water touches the legs it hurts and also I don't function well enough.’ She brushes her teeth every day and changes into clean clothes every second day.  She avoids doing some household chores because of the pain.  She said that the reason for not cooking is ‘pain and not having the drive to do anything anymore.’
Social and recreational activities			2		She enjoyed riding horses, and motorbikes, swimming in the ocean, bush walking, canoeing and fishing.  She reported that she tried to do some of these but found them overwhelming.  She now spends a lot of time with her kids and watches movies and watches her kids when they play. She first said, ‘A lot of my friends have disappeared.’ However, two of her friends, one of which lives four hours away from her home, ring her on most days to check on her.  She has also made a new friend, Alicia, who lives on the other side of the town. She also talks to one of her neighbours.  She said that Alicia comes home at least twice a week.  Her mum too visits her every couple of months.  She said that she also visits the farmer's market every three weeks.
Travel			2		Ms Parrington leaves her home for grocery shopping, picking up and dropping off her kids.  She is also able to drive long distances. She has driven to Tamworth but reported feeling anxious and panicky when driving long distances.
Social functioning			2		Ms Parrington reported that her husband and her kids are ‘incredible’ and have been supporting her.  She however feels like a burden since her family members have been doing a lot of chores for her. She also added that her mum too has been supporting her and visits her whenever she can.  She has lost some friendships.
Concentration, persistence and pace			2		Ms Parrington reported experiencing difficulties in her attention and concentration.  She said that she was unable to focus, even on things like movies, listening to podcasts, etc.  She at one time attempted to complete a Disney jigsaw puzzle but had to abandon it because of her distractibility.  She was able to focus and concentrate during the assessment and answer questions in detail. She scored 3/3 on three-word repeat and 3/3 on three-word recall accurately and very quickly.
Employability			4		I asked her what she wanted to do with regard to work, to which she replied that she was looking to retrain, however, felt that she would not be able to do that because of her current physical and mental health issues.  She reported that she could not swim because of the chronic regional pain syndrome. At one point, she also thought of doing social work but felt that might not be appropriate since she has been struggling with her pain. Psychologically, I believe that Ms Parrington however can work less than 20 hours per fortnight at a reduced pace and in a more supportive environment.
Score										Median Class
2	2	2		2		2	4		=2
Aggregate Score Impairment								Total			%
+2	+4	+6		+8		+10	14			7

Deduction for pre-existing impairment = 0%.

Final WPI = 7 – 0 = 7%.”

1. The worker appealed.

2. In summary, the appellant submitted that the Medical Assessor made assessments on the basis of incorrect criteria and/or made demonstrable errors in the assessments she made under five of the PIRS categories, as follows:

   (a)    in assessing class 2 for self-care and personal hygiene when she should have assessed a class 3;

   (b)    in assessing class 2 for social and recreational activities when she should have assessed a class 3;

   (c)    in assessing class 2 for concentration, persistence and pace when she should have assessed a class 3;

   (d)    in assessing class 4 for employability when he should have assessed a class 5, and

   (e)    in failing to address the effects of treatment.

3. In summary, the respondent employer Ultimate Holiday Parks Pty Ltd ATF The Peate Family Trust (the respondent) submitted that the Medical Assessor did not err or make an assessment on the basis of incorrect criteria and the MAC should be confirmed.

4. The role of the Medical Assessor is to conduct an independent assessment on the day of examination. The Medical Assessor is required to take a history, conduct a mental state examination, make a psychiatric diagnosis and have due regard to other evidence and other medical opinion that is before the Medical Assessor. The Medical Assessor must bring her clinical expertise to bear and exercise his clinical judgement when making an independent assessment of impairment under the PIRS categories. The assessment is not to be based upon self-report alone. An appeal panel cannot disturb ratings under the PIRS scale for mere difference of opinion but must be satisfied as to error.

5. The path of reasoning disclosed by the Medical Assessor must be adequate. This is also dependent on the extent of the history taken and a thorough examination of the worker so that self- report can be properly evaluated in the context of other evidence before the Medical Assessor.

6. The Medical Assessor took a history which she recorded as follows: (emphasis in original)

   “● Brief history of the incident/onset of symptoms and of subsequent related events, including treatment:

   Identifying Information

   Ms Parrington is a 36-year-old female who lives with her husband Chris and three children aged 14, 12 and 10 years in Gunnedah, New South Wales.  She commenced working with Surf Beach Holiday Park in 2019, and her last day at work was on 20/03/2020.  She denied having any secondary employment or owning any businesses.  She said, ‘I was making scrunchies before I started my job in 2019 and then stopped doing after a week of starting it.’ She added, ‘I did the market stall in January 2021 and became overwhelmed and anxious and then did not do it again.’

   Ms Parrington reported that on 20/03/2020, when her boss's daughter asked her to wash things down, she went and opened the maintenance shed. On doing that, a drill weighing about 60 to 80 kg fell on her foot. She reported that she called her boss's daughter and was later taken by ambulance to Bega Hospital.

   She was admitted for about two days.  She underwent debridement and placement of K-wire for eight weeks, but when the wound did not heal, then the K-wire was taken out.  Ms Parrington also underwent a bone graft surgery in July 2021, which too failed, and in December 2021, her big toe was partially amputated.

   She has had five surgeries for her toe until now.  She reported that after that, she has developed symptoms of ‘complex regional pain syndrome’ and started seeing pain specialist, Dr Jain from the ACT Pain Clinic.  She said that she has been consulting the psychologist from the pain clinic, and the doctor and her specialist has recommended spinal cord stimulator to address the chronic pain symptoms.

   Ms Parrington reported that she started experiencing mental health symptoms about eight weeks, from when she was told that she would have to wait for the operation.  She said that she became ‘very anxious and worried’ about the outcome.  She also experienced ‘hopelessness’ about her foot and she started experiencing nightmares in about a year after the accident.

   She reported the ‘nightmares were about the accident happening again.’  She reported that the ‘loud noise’ used to make her uncomfortable, and was told that the next hope was spinal cord stimulator, but it was ‘knocked off’ by the insurance company.  She said that when that happened, her anxiety and depression worsened.  She also started gradually gaining weight, and said that her weight gradually increased from 89 kg to 120-127 kg.

   Ms Parrington reported that she was ‘confined to her home’ and remained in the ‘vicinity’ of her home or her mum's house.  She stopped seeing her friends as ‘there was no fun.’ She was referred to start seeing the psychologist in July 2022 as her mental health symptoms did not subside.  I asked her why she did not see the psychologist initially to which she replied ‘the symptoms made me feel vulnerable and it did not feel like opening up.’

   However, in July 2022, she had an awful weekend watching her friends doing things on social media and hence decided to talk to a Psychologist.  She was referred to see Lanhow Chen, a Psychologist, and later she saw another Psychologist, Brittany.  She reported that she has worked on EMDR and ‘stopped the session’ when there was a factual investigation and there was a deterioration in her mental health.

   She said that the factual investigation reported that ‘because I went to one wedding, they said that I could smile with my kids.’  She said that ‘it was not real, it was a mask.’  She was referred to see Dr Prakriti Jain and saw her on 7 May 2024.  Dr Jain recommended trialling Sertraline which she started and has been on for the last eight weeks.

   Personal History:  Ms Parrington reported that she was born in Australia and grew up with her two sisters and mother.  She reported having good relationship with her family members.  She denied witnessing any traumatic incidents or experiencing any adverse events.

   Her parents divorced when she was 12 years, and she was quite angry mostly at her parents and her family but was not physically aggressive.  She denied experiencing any significant mental health symptoms at that time or seeking any professional help for her anger.

   She completed year 10 and then started a hairdressing apprentice but was not able to finish it.  She has variously worked as a receptionist, Woolworths, swimming instructor.  She has been with her partner for the last 15 years who works as a conveyor belt technician.

   Forensic History:  Ms Parrington denied having any criminal convictions.

   Family History:  She denied having any family history of mental health illnesses.

   Drug and Alcohol:  She denied imbibing alcohol.  She smokes about 10 to 15 cigarettes a day.  She denied using any other illicit drugs or gambling.

   ·    Present treatment:  Ms Parrington has seen Dr Jain, Psychiatrist twice until now and is currently on 50 mg.  She continues to see Brittany, Psychologist every week.  She said she was unable to complete EMDR and was looking into completing all the sessions very soon.

   ·    Present symptoms:  Ms Parrington reported that her overall mental health remains the same.  She reported that she has been socially avoidant and feels anxious even when going out on her own.  She also experiences chronic left foot pain which impacts her overall functioning, like not being able to drive for long, experiencing pins and needles.

   She now has to be supported by her partner when doing intense physical activities.  She reported having low mood, lack of interest in activities and difficulties in her attention and concentration.  She also reported having persistent fatigue and low motivation to do things.  She continues to experience nightmares.  However, the frequency has decreased than before.

   She has been feeling extremely emotional, and at times, she feels overwhelmed and is unable to regulate her emotions. She often thinks of how her life was and how it has changed with one incident. She said that she has anxiety about having to go to new shops, and hence, she always Googles before she goes to see when they will have the minimum number of people.

   ·    Details of any previous or subsequent accidents, injuries or condition:  Ms Parrington reported that ‘they thought that I have ADHD and I was medicated.’  She noted that she ‘bounced around the classroom’ but denied that it was a long-term difficulty.  She said that she, however, was not a very hyperactive child and denied having any inner restlessness.

   She said that her mum stopped the medications.  She denied having long-term attention difficulties and procrastinating.  She reported that her organisational capacity was good and that she was able to get things done.

   ·    General health:  Haemochromatosis, idiopathic intracranial hypertension.

   ·    Work history including previous work history:  She sustained a shoulder injury in 2018 at her workplace and needed surgery.  She said that she has ‘huge issues with her shoulder’ till date.

   ·    Social activities/ADL:

   Ms Parrington reported that she is unable to stand for long and has pain in her side, lower back and right knee. She has been using boots for four years and has to use crutches.

   She said ‘I hang the washing and do the dishes but standing too long causes pain.’  She said that it is because she showers 2-3 times a week and said that ‘when the hot water touches the legs it hurts and also I don't function well enough.’

   She brushes her teeth daily and changes into clean clothes every second day.  She avoids doing some household chores because of the pain.  She said that the reason for not cooking is ‘pain and not having the drive to do anything anymore.’

   She enjoyed riding horses, and motorbikes, swimming in the ocean, bush walking, canoeing and fishing.  She reported that she tried to do some of these but found them overwhelming.  She now spends a lot of time with her kids and watches movies and watches her kids when they play.

   She first said ‘A lot of my friends have disappeared.’ However, two of her friends, one of whom lives four hours away from her home, ring her on most days to check on her.  She has also made a new friend, Alicia, who lives on the other side of the town.

   She also talks to one of her neighbours.  She said that Alicia comes home at least twice a week.  Her mum, too, visits her every couple of months.  She said that she also visits the farmer's market every three weeks. 

   Ms Parrington leaves her home to go grocery shopping, pick up, and drop off her kids.  She is also able to drive long distances.  She has driven to Tamworth but reported feeling anxious and panicky when driving long distances.  Ms Parrington reported that her husband and her kids are ‘incredible’ and have supported her.

   She however feels like a burden since her family members have been doing a lot of chores for her.  She also added that her mum has been supporting her and visits her whenever she can.  She has lost some friendships.

   Ms Parrington reported experiencing difficulties with her attention and concentration. She said that she was unable to focus, even on things like movies, listening to podcasts, etc. At one point, she attempted to complete a Disney jigsaw puzzle but had to abandon it because of her distractibility.

   She could focus and concentrate during the assessment and answer questions in detail.  She scored 3/3 on three-word repeat and 3/3 on three-word recall accurately and very quickly.

   On a typical day, she may get up at around 6:00 to 7:00 am.  She then has her coffee and a smoke.  She also helps her kids to get ready and makes lunch for her kids.  She then makes sure that they leave home on time and drives them off to school.  She then comes home and sits in her bedroom.

   She watches TV and sometimes does puzzle board.  She said that she watches ‘short clips on YouTube and shows on Netflix.’  She is currently watching Vampire Diaries and said that she is watching it for the third time.  In the afternoon, she then goes to pick up her kids.  She also drops her daughter to dance lessons and comes home to hang out with her son.

   She said that she cooks with a slow cooker.  She said, ‘I wash the dishes, do laundry, cook dinner with my slow cooker which takes up most of my day, and I don't do a lot of other activities.’

   The Medical Assessor conducted a mental state examination of which she recorded as follows:

   ‘I reviewed Ms Parrington via video.  She engaged well during the assessment and was cooperative.  She presented as a 36-year-old Caucasian female who looked her stated age.  She engaged well during the interview.  There was no evidence of any psychomotor agitation or retardation.

   No abnormal motor movements like tics or mannerisms were noted.  She was casually dressed with her hair tied, was bespectacled and wearing a neck chain.  She was able to give a clear account of her symptoms and difficulties.  She reported her mood to be low and her affect was dysphoric.

   Her speech was spontaneous and normal in volume and tone.  Her thoughts were logical and goal-directed.  She currently reports ongoing nightmares, negative ruminations, anxiety and anhedonia.  There was no evidence of any manic, psychotic or any perceptual abnormalities.  Ms Parrington was able to focus and pay attention during the assessment.  She was not distracted.

   She was able to give a detailed account of the symptoms and was able to remember the events and the incidents and stated them in chronological order.  She had insight into her condition and her judgment was intact.”

1. The Appeal Panel is satisfied that an adequately detailed history was taken, which is broadly consistent with the other evidence before the Medical Assessor. Medical Assessors have to obtain a focussed history and undertake a mental state assessment within a finite appointment time.

2. The Medical Assessor had regard to the following investigations: (emphasis in original)

   “I have noted the attachment with regard to the factual investigation and photos attached.  She said that the photo of kids riding bike dated 25/07/2021 was when her mom took the photo and sent it to her.  There is another image dated 23/04/2023 where she said that she went out for camping in April 2023 in Matthew Point and camped for one night.  However, the kids stayed for the entire week.  She said that she stayed at home on her own and managed things.

   There is also a video mentioning ‘moving to home’ and she said that she did ‘those silly videos to keep herself happy.’  There is another video dated 28/07/2021 and said that she ‘just watched but did not engage.’

   I have noted the Insight Intelligence Group open-source online search report dated 23 January 2024.  The report summarizes:

   ‘97. Information obtained indicates that the Claimant has the capacity and the ability to socialise with family and friends where she is seen to be well groomed, smiling, happy, singing, camping, going to the hairdressers all without showing any signs of discomfort or anxiety.

   98. Information located indicates that the Claimant is actively working and engaging in undertaking a start-up business in selling scrunchies, head bands, bracelets, earrings and teenage girls’ tights/clothes at local markets, fetes and online on Facebook.

   99. Information located indicates that the Claimant is engaging in activity which is inconsistent with her alleged injuries or impairment as noted above’.”

3. The Medical Assessor summarised the injury and her diagnosis as follows: (emphasis in original)

   “● summary of injuries and diagnoses:

   Ms Parrington during her course of employment sustained injuries on her left foot, for which she required five operations including a bone graft that failed.  Ms Parrington started experiencing deterioration in her mental health, including persistent anhedonia, being emotional, teary, anxious, avoidant, and re-experiencing symptoms, including nightmares and changes in her cognition and memory.

   At the time of her assessment, her symptoms were consistent with the diagnosis of Post-traumatic Stress Disorder and Major Depressive Disorder.  She continues to have symptoms of anhedonia, avoidance, intrusive, hypervigilance, emotional dysregulation, insomnia and disturbances in her mood and cognition. The diagnosis is based on the DSM 5 criteria which I have highlighted in bold.

   DSM5-MDD

   Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
   Note: Do not include symptoms that are clearly attributable to another medical condition.

   ·    Depressed most of the day, nearly every day as indicated by subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful)

   ·    Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by subjective account or observation)

   ·    Significant weight loss when not dieting or weight gain (e.g., change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day

   ·    Insomnia or hypersomnia nearly every day

   ·    Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

   ·    Fatigue or loss of energy nearly every day

   ·    Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

   ·    Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

   ·    Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

   -    The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

   -    The episode is not attributable to the physiological effects of a substance or to another medical condition.
   Note: The above criteria represent a major depressive episode.

   -    The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

   -    There has never been a manic episode or a hypomanic episode.

   Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition

   DSM5-PTSD

   Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see the DSM-5 section titled ‘Posttraumatic Stress Disorder for Children 6 Years and Younger’ (APA, 2013a).

   A.  Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

   1.   Directly experiencing the traumatic event(s).

   2.   Witnessing, in person, the event(s) as it occurred to others.

   3.   Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

   4.   Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

   B.  Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

   1.   Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

   2.   Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content.

   3.   Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.

   4.   Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

   5.   Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

   C.  Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

   1.   Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

   2.   Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

   D.  Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

   1.   Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia, and not to other factors such as head injury, alcohol, or drugs).

   2.   Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., ‘I am bad,’ ‘No one can be trusted,’ ‘The world is completely dangerous,’ ‘My whole nervous system is permanently ruined’).

   3.   Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.

   4.   Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

   5.   Markedly diminished interest or participation in significant activities.

   6.   Feelings of detachment or estrangement from others.

   7.   Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

   E.  Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

   1.   Irritable behaviour and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.

   2.   Reckless or self-destructive behaviour.

   3.   Hypervigilance.

   4.   Exaggerated startle response.

   5.   Problems with concentration.

   6.   Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

   F.   Duration of the disturbance (Criteria B, C, D and E) is more than 1 month.

   G.  The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

   H.  The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

   Ms Parrington has since received EMDR by her Psychologist which is an evidence-based treatment.  She was however unable to tolerate trauma-focused therapy, that is EMDR, when her symptoms increased after she received the results of the factual investigation about her social media use.  She has also started taking the antidepressant Sertraline and has been on the same for eight weeks.  I believe that she has received evidence-based treatment including intense psychological sessions for her PTSD and Major Depressive Disorder, and hence has reached maximal medical improvement.

   ·    consistency of presentation

   Ms Parrington's presentation was broadly consistent with the history given during clinical interview, documentation received and mental status examination except:

   ·    Ms Parrington reported, ‘I did a market stall in 2021 and then became overwhelmed and anxious and I did not do it again.’  I have however noted in the factual investigation that Ms Parrington's post dated 23 January 2022 mentioned a market stall at Narooma Markets.

   ·    Ms Parrington reported that she struggles with her attention and concentration and forgets things quickly. However, during the assessment, she was able to give me a correct timeline of the incidents, including accurate dates. In fact, she scored 3/3 on three-word repeat and 3/3 on three-word recall.”

4. The Medical Assessor made an assessment of WPI in accordance with her assessment under the six PIRS categories as set out above noting that her assessment was based upon the following:

   “The facts on which I have based my assessment of whole person impairment are:

   -Clinical Interview

   -Mental Status Examination

   -Documentation received including previous IME”

5. The Medical Assessor made brief comment on the other opinions as follows: (emphasis in original)

   “My brief comments regarding the other medical opinions and findings submitted by the parties and, where applicable, the reasons why my opinion differs

   ·    Noted letter by Dr Romil Jain dated 10 May 2022 mentioning:

   1.   As a first step, I will arrange for a cream of multiple neuropathic agents to apply three times a day to decrease some of the peripheral sensitisation.

   2.   I have referred her to our Multidisciplinary Team of pain physiotherapist, psychologists and occupational therapists and I believe she needs early intensive treatment to reverse changes of CRPS. She will be offered graded motor imagery to help her reversal of changes, and I would request the insurance company to approve this as a matter of priority as delaying treatment would result in significant disability.  The longer we delay appropriate treatment, the reversal of CRPS become prolonged.

   3.   I have started her on Endep 10 mg nocte which can be increased to 20 mg.  I plan to review her in six weeks’ time to monitor progress.

   ·    Letter by Lanhowe Chen, Clinical Psychologist dated 4 July 2022 mentioning ‘Secondary to her CRPS, Ms Parrington appears to be experiencing depressive symptoms with anxious distress in the form of excessive negative self-talk, low mood and self-worth and elevated anxiety around being alone and social situations.  She also exhibits neglect and some avoidance of her left foot, which is a worrying indicator of her CRPS progression.’

   ·    Noted letters by Lanhowe Chen, various dates. I have noted in one of the letters dated 4 December 2023, Mr Chen mentions ‘Nevertheless Alyssa is making slow but steady progress and with the help of her medication recently she has been more willing to confront her anxiety to do more, example, challenging herself to open closed doors rather than keeping them open all the time and increased willingness to leave the house to attend events outdoor.’

   ·    Letter by Dr Prakriti Jain, Psychiatrist dated 2 May 2024. The letter mentions the impression:

   ‘Alyssa fulfils the criteria for PTSD symptoms including intrusive symptoms, avoidance, hypervigilance and negative mood and cognition due to her PTSD.  She also meets the criteria for comorbid major depressive disorder, moderate to severe intensity with some atypical features, and comorbid anxiety symptoms overlapping with PTSD symptoms.  This is associated with occasional suicidal thoughts without intention or plan.  Her symptoms seem to have been exacerbated in the context of her insurance rejecting the claim for a spinal cord stimulator, which has reduced her hopes for recovery.  The symptoms further worsened when the insurance has investigated her social media and she felt judged when she was occasionally socialising.  She has struggled to adjust to these and possibly perceived it as rejections.  Alyssa has further adopted some maladaptive coping behaviours like smoking, caffeine and lack of activity and withdrawing to manage her negative emotions which is likely to further worsen her depressive and anxiety symptoms.  I note that she has failed to tolerate trauma-focused therapy for PTSD, and so it is appropriate to trial medications focussing on her PTSD symptoms as well as the comorbid depression.’

   ·    IME by Dr Michael Hong dated 7 June 2023.  I have noted that Dr Hong concluded that Ms Parrington's presentation was consistent with Post-traumatic Stress Disorder with depressive symptoms.  He also calculated the WPI as 22%.

   Kindly note the differences in self-care and personal hygiene, social and recreational activities, concentration, persistence and pace and employability. Kindly refer to my PIRS table for details around the reasons for decisions.

   ·    IME by Dr Michael Hong dated 26 July 2024.  I have noted the supplementary report dated 26 July 2024.  Dr Hong mentioned the WPI as 19%.  He mentioned

   ‘The category of adaptation was the most difficult for me to comment on, but accepting that she no longer engaged in business activity and that she had briefly tried to do a business, possibly as an attempt to test her capacity to be productive, but could not continue to do so due to psychological injury, then her adaptation would remain at 5.  On the other hand, if she was able to perform that online business activity, and I noted in her statement, she said she did very little of it before she ceased, then adaptation may be 4 – in other words, she is not devoid of productivity and she can be productive less than 20 hours per fortnight.  In this case, her WPI would be 19%.’

   ·    IME by Dr Russell Davies dated 24 February 2023.  I have noted that Dr Davies concluded that her presentation was consistent with Major Depressive Disorder with agitated distress with Post-traumatic Stress Disorder.

   ·    I have also noted another IME by Dr Davies dated 6 December 2023.  He has mentioned ‘She remains engaged in a program of care encompassing contact with her Psychologist, General Practitioner is undergoing periods of treatment with EMDR and has commenced an antidepressant that being duloxetine.’  He also calculated the WPI as 19%.

   ·    Clinical notes by Narooma Medical and Specialist Centre.

   ·    Activities of daily living assessment report dated 02/09/2020, which mentioned the recommendation including fortnightly domestic assistance for three months, single point walking stick, shower stool and knee walker.

   ·    IME by A/Prof Paul Miniter, Orthopaedic Surgeon, dated 27 July 2022

   ‘The matter as it transpires is rather unusual. I do not believe that a diagnosis of CRPS is sustainable based on her presentation today which I regard as largely nongenuine. I believe that an independent observation of her functional behaviour would indicate that she has more than functional capability and I would suggest that she is fit to return to work. My findings on examination have been given and I have drawn your attention to the previous history of a workers’ compensation claim relating to her left shoulder. I have also drawn your attention to the fact that there is no muscle wasting nor convincing features of CRPS. In addition, she has had no benefit from the treatment provided by Dr Jain. In my opinion, she has no demonstrable incapacity. I regard her presentation as largely non-genuine and inconsistent’.

   ·    File review by Dr Russell Davies dated 5 February 2024.  The WPI mentioned is 5%.”

6. The Medical Assessor explained her reasons for assessment under each of the PIRS categories as set out in the table above.

7. The appellant complains that the Medical Assessor has erred in respect of four out of the six categories assessed, namely Self-care and Personal Hygiene, Social and Recreational Activities, Concentration, Persistence and Pace, and Employability.

8. The MAC must be read as a whole. The Appeal Panel cannot interfere with these ratings absent error by the Medical Assessor. The Appeal Panel cannot interfere with the rating because opinions might differ as to the best fit in each category. There must be error or assessment on the basis of incorrect criteria. The Appeal Panel will deal with each category complained about on appeal in turn.

9. In respect of self care and personal hygiene, Table 11.1 of the Guides provides as follows:

   Table 11.1: Psychiatric impairment rating scale – self care and personal hygiene

Class 1	No deficit, or minor deficit attributable to the normal variation in the general population
Class 2	Mild impairment: able to live independently; looks after self adequately, although may look unkempt occasionally; sometimes misses a meal or relies on take-away food.
Class 3	Moderate impairment: Can’t live independently without regular support. Needs prompting to shower daily and wear clean clothes. Does not prepare own meals, frequently misses meals. Family member or community nurse visits (or should visit) 2–3 times per week to ensure minimum level of hygiene and nutrition.
Class 4	Severe impairment: Needs supervised residential care. If unsupervised, may accidentally or purposefully hurt self.
Class 5	Totally impaired: Needs assistance with basic functions, such as feeding and toileting.

1. The Medical Assessor rated a mild impairment at Class 2 with the following reasoning: (emphasis in original)

   “Ms Parrington reported that she is unable to stand for long and has pain in her side, lower back and right knee and has been using boots for four years and has to use crutches.

   She said, ‘I hang the washing and do the dishes but standing too long causes pain’  She said that it is because she showers 2-3 times a week and said that ‘“when the hot water touches the legs it hurts and also I don't function well enough.’

   She brushes her teeth every day and changes into clean clothes every second day.  She avoids doing some household chores because of the pain.  She said that the reason for not cooking is ‘pain and not having the drive to do anything anymore.”

1. The appellant submitted that a class 3 should have been assessed.

2. The Appeal Panel is not satisfied that an error was made in the assessment of Class 2 or a mild impairment. The Medical Assessor has taken an adequate history and appropriately addressed the correct criteria for assessing a mild impairment. The Medical Assessor also records the appellant stating that she can ‘wash the dishes, do laundry, cook dinner with my slow cooker which takes up most of my day.’ Her psychologist’s detailed assessment of her “ADLs” in late 2023 confirms these activities but limited by “energy conservation and pacing for pain management”. The Appeal panel can discern no error in the assessment of Class 2 for self care and personal hygiene because the Medical Assessor has appropriately assessed the impairment that arises from the psychological injury as opposed to that arising from the physical injury (pain), and there is no indication the appellant cannot care for herself adequately and live independently.

3. In respect of Social and Recreational Activities, Table 11.2 of the Guides provides as follows:

   Table 11.2: Psychiatric impairment rating scale – social and recreational activities

Class 1	No deficit, or minor deficit attributable to the normal variation in the general population: regularly participates in social activities that are age, sex and culturally appropriate. May belong to clubs or associations and is actively involved with these.
Class 2	Mild impairment: occasionally goes out to such events eg without needing a support person, but does not become actively involved (eg dancing, cheering favourite team).
Class 3	Moderate impairment: rarely goes out to such events, and mostly when prompted by family or close friend. Will not go out without a support person. Not actively involved, remains quiet and withdrawn.
Class 4	Severe impairment: never leaves place of residence. Tolerates the company of family member or close friend, but will go to a different room or garden when others come to visit family or flat mate.
Class 5	Totally impaired: Cannot tolerate living with anybody, extremely uncomfortable when visited by close family member.

1. The Medical Assessor assessed a mild impairment at class 2 with the following reasoning:

   “She enjoyed riding horses, and motorbikes, swimming in the ocean, bush walking, canoeing and fishing.  She reported that she tried to do some of these but found them overwhelming.  She now spends a lot of time with her kids and watches movies and watches her kids when they play.

   She first said, ‘A lot of my friends have disappeared.’ However, two of her friends, one of which lives four hours away from her home, ring her on most days to check on her.  She has also made a new friend, Alicia, who lives on the other side of the town.

   She also talks to one of her neighbours.  She said that Alicia comes home at least twice a week.  Her mum too visits her every couple of months.  She said that she also visits the farmer's market every three weeks.” 

2. The appellant submitted that a class 3 or moderate impairment should have been assessed.

3. The Appeal Panel considers there is an error in the rating of a mild impairment. The appellant is not undertaking regular social activity or recreational activity. Although the panel accepts that some of this e.g. riding bikes and horses may be due to physical injuries the appellant’s statement records avoidance of meaningful social activities outside of her family, consistent with her treating clinicians’ observations over 2024. Supervision of her children at play is not a recreational activity for her but is the role of a parent. At most the sole recreational activity that is pointed to by the Medical Assessor is a visit to the farmers market every three weeks. There is no indication of how this is either recreational or has a social component and could be more correctly characterised as shopping. Whilst quality of friendships has been maintained (a friend is ringing to check on her), this conduct is more correctly dealt with in the category of social functioning which deals with the quality of relationships as opposed to socialising activities. Other social activities, such as attending weddings in 2020 and 2023 are rare events and are not recent. The treating evidence supports a moderate impairment rating. The report of the treating psychologist in March 2024 noted that the appellant was regressing socially, has to be encouraged to leave the home independently and she suffers from avoidance and anxiety about leaving the home.  The Appeal Panel considers that there has been error in assessment on the basis of incorrect criteria and that assessment on the basis of correct criteria gives a Class 3 or moderate impairment rating for social and recreational activities.

4. In respect of Concentration, Persistence and Pace, Table 11.5 of the Guides provides as follows:

Class 1	No deficit, or minor deficit attributable to the normal variation in the general population. Able to pass a TAFE or university course within normal time frame.
Class 2	Mild impairment: can undertake a basic retraining course, or a standard course at a slower pace. Can focus on intellectually demanding tasks for periods of up to 30 minutes, then feels fatigued or develops headache.
Class 3	Moderate impairment: unable to read more than newspaper articles. Finds it difficult to follow complex instructions (eg operating manuals, building plans), make significant repairs to motor vehicle, type long documents, follow a pattern for making clothes, tapestry or knitting.
Class 4	Severe impairment: can only read a few lines before losing concentration. Difficulties following simple instructions. Concentration deficits obvious even during brief conversation. Unable to live alone, or needs regular assistance from relatives or community services.
Class 5	Totally impaired: needs constant supervision and assistance within institutional setting.

1. The Medical Assessor assessed class 2 or mild impairment with the following reasoning: (emphasis in original)

   “Ms Parrington reported experiencing difficulties in her attention and concentration.  She said that she was unable to focus, even on things like movies, listening to podcasts, etc.  She at one time attempted to complete a Disney jigsaw puzzle but had to abandon it because of her distractibility.  She was able to focus and concentrate during the assessment and answer questions in detail.

   She scored 3/3 on three-word repeat and 3/3 on three-word recall accurately and very quickly.”

2. The appellant submitted that a moderate impairment or class 3 should have been assessed.

3. Assessment cannot be based on self-report alone, and the Medical Assessor must make an independent assessment on the day of examination using her clinical expertise. However, what the appellant reported to the Medical Assessor has not been given sufficient weight and there has been an over-reliance on the ability to concentre during the assessment (one -hour) and the score on the three-word repeat and recall which as tests which are rudimentary at best, and test short term memory, rather than concentration, persistence or pace. The appellant reported difficulties in her concentration. She said that she could not focus, even on things like movies, listening to podcasts, etc.  She once attempted to complete a Disney jigsaw puzzle but had to abandon it because of her distractibility. This is consistent with what has been reported to her treating psychologist. The Medical Assessor has not taken adequate account of the appellant’s self-report or clinician records over 2024, which accord with moderate impairment. She has not explained why she discounted these in relying solely on the ability to answer questions during the one-hour interview and to do the three word repeat and recall tests to classify the appellant as mildly impaired. The Medical Assessor has not based her assessment on the correct criteria and the Appeal Panel considers that an assessment of class 3 is the best fit

4. In respect of Employability, Table 11.6 of the Guides provides as follows:

Class 1

No deficit, or minor deficit attributable to the normal variation in the general population. Able to work full time. Duties and performance are consistent with the injured worker’s education and training.

The person is able to cope with the normal demands of the job.

Class 2

Mild impairment. Able to work full time but in a different environment from that of the pre-injury job. The duties require comparable skill and intellect as those of the pre-injury job. Can work in the same position, but no more than 20 hours per week (eg no longer happy to work with specific persons, or work in a specific location due to travel required).

Class 3

Moderate impairment: cannot work at all in same position. Can perform less than 20 hours per week in a different position, which requires less skill or is qualitatively different (eg less stressful).

Class 4

Severe impairment: cannot work more than one or two days at a time, less than 20 hours per fortnight. Pace is reduced, attendance is erratic.

Class 5

Totally impaired: Cannot work at all.

1. The Medical Assessor rated class 4 with the following explanation:

   “I asked her what she wanted to do with regard to work, to which she replied that she was looking to retrain, however, felt that she would not be able to do that because of her current physical and mental health issues.  She reported that she could not swim because of the chronic regional pain syndrome.

   At one point, she also thought of doing social work but felt that might not be appropriate since she has been struggling with her pain.

   Psychologically, I believe that Ms Parrington however can work less than 20 hours per fortnight at a reduced pace and in a more supportive environment.”

2. The appellant says the rating should have been total impairment at class 5.

3. The Appeal Panel considers that the Medical Assessor did not err in rating a Class 4. The assessment was open to the Medical Assessor and is in accordance with the correct criteria. The Appeal panel notes that the most recent opinion of her treating psychologist considered the appellant could do limited work 2 – 3 hours work per week, with flexibility “from a psychological perspective”. She continues to identify the additional impairments arising from the appellant’s physical condition. The rating of a class 4 as opposed to class 5 separates the severe impairment in employability arising from the psychiatric condition from any additional impairment attributable solely to the physical injury. An individual may conflate these in their opinion of the cause of impairment experienced in any domain, but, as in para 1.22, it is the role of the assessor to use the evidence and their clinical judgement to assess the impairments resulting from primary psychiatric injuries separately from that resulting from physical injuries arising out of the same incident. Class 4 is the correct fit, and the appeal panel can discern no error in this rating.

4. In summary, the classes of self care and personal hygiene (class 2), and employability (Class 4) as assessed by the Medical Assessor have been confirmed on appeal. However there was error in the assessments for social and recreation activities which was assessed as Class 2, and should have been assessed as Class 3, and concentration persistence and pace which was assessed as Class 2 and should have been assessed as Class 3.

5. This means the calculations become as follows:

Score								Median Class
2	3	2	2	3	4		=3
Aggregate Score Impairment						Total			%
+2	+5	+7	+9	+12	4	16			17

1. The appellant complained on appeal that the Medical Assessor erred in failing to allow any adjustment in the impairment rating for the effects of treatment.

2. The Appeal Panel is satisfied that no error was made in this regard as the Medical Assessor was constrained by the criteria in the Guides which provides at para 1.32 as follows:

   “Where the effective long term treatment of an illness or injury results in apparent substantial or total elimination of the claimant’s permanent impairment but the claimant is likely to revert to the original degree of permanent impairment if treatment is withdrawn the assessor may increase the percentage of WPI by 1%, 2% or 3%.”

3. The treating psychologist, as recently as March 2024, describes the appellant as regressing, despite ongoing treatment. There is no evidence either on the history taken by the Medical Assessor or in the other evidence that the treatment has been “effective” or led to a substantial or total elimination of her impairment. As the requisite criteria were not satisfied on the evidence in this case, in accordance with the assessment of the Medical Assessor, there is no justification for an allowance for the effects of treatment, and the Medical Assessor was correct to make no such allowance.

4. The total permanent impairment assessed because of the referred injury is 17% WPI with no allowance for the effects of treatment.

5. For these reasons, the Appeal Panel has determined that the MAC issued on
   24 September 2024 should be revoked and a new MAC issued. The new certificate is attached to this statement of reasons.

WORKERS COMPENSATION DIVISION

APPEAL PANEL

MEDICAL ASSESSMENT CERTIFICATE

Injuries received after 1 January 2002

Matter number:	W24412/24
Applicant:	Alyssa Parrington
Respondent:	Ultimate Holiday Parks Pty Ltd ATF The Peate Family Trust

This Certificate is issued pursuant to s 328(5) of the Workplace Injury Management and Workers Compensation Act1998.

The Appeal Pane revokes the Medical Assessment Certificate of Medical Assessor Surabhi Verma and issues this new Medical Assessment Certificate as to the matters set out in the table below:

Table - whole person impairment (WPI)

Body Part or system	Date of Injury	Chapter, page and paragraph number in NSW workers compensation guidelines	Chapter, page, paragraph, figure and table numbers in AMA5 Guides	% WPI	WPI deductions pursuant to S323 for pre-existing injury, condition or abnormality (expressed as a fraction)	Sub-total/s % WPI (after any deductions in column 6)
1. Psychological Injury	23 March 2020	Chapter 11 Guidelines 11.1-11.3 11.4-11.6	Guidelines 11.11,11.12 Table :11.1,11.2,11.3,11. 5,11.5,11.6	17%	0%	17%
Total % WPI (the Combined Table values of all sub-totals)					17%

The above assessment is made in accordance with the SIRA NSW Guidelines for the Evaluation of Permanent Impairment for injuries received after 1 January 2002.