QBE Insurance (Australia) Limited v Zilic
[2023] NSWPICMP 405
•22 August 2023
| DETERMINATION OF REVIEW PANEL | |
| CITATION: | QBE Insurance (Australia) Limited v Zilic [2023] NSWPICMP 405 |
| CLAIMANT: | Elmedina Zilic |
INSURER: | QBE (Insurance) Australia Limited |
| REVIEW PANEL | |
| MEMBER: | Terence O'Riain |
| MEDICAL ASSESSOR: | Thomas Newlyn |
| MEDICAL ASSESSOR: | Gerald Chew |
| DATE OF DECISION: | 22 August 2023 |
| CATCHWORDS: | MOTOR ACCIDENTS – Motor Accidents Compensation Act 1999; The claimant suffered injury in a motor accident 25 October 2016; medical dispute under Part 3.4 about whether the motor accident caused psychological permanent impairment greater than 10%; Medical Assessor (MA) Mason diagnosed adjustment disorder with mixed anxiety and depressed mood, which was chronic and severe; medical review application based on MA assessing 19% permanent impairment from pain related conditions in breach of clause 1.215 Motor Accident Permanent Impairment Guidelines (Guidelines) and failed to consider evidence of existing psychiatric disorders; re-examined audio visually; Panel found that accident caused persistent somatic symptom disorder with predominant pain, which is not assessable under Guidelines; claimant’s high level functioning displayed before the accident did not support a symptomatic permanent impairment existing at the time of the accident; Held – Review Panel diagnosed persistent somatic symptom disorder with predominant pain; unable to apply the Permanent Impairment Rating Scale (PIRS) in accordance with the Guidelines’ clause 1.215; Panel could not attribute any psychological permanent impairment to the accident; permanent impairment is 0%; Review Panel revoked MA certificate and issued a new permanent impairment certificate. |
| DETERMINATIONS MADE: | CERTIFICATE OF DETERMINATION THE REVIEW PANEL’S ASSESSMENT UNDER S 63(4) IS AS FOLLOWS: The motor accident caused the following injuries which give rise to a permanent impairment of 0% which IS NOT GREATER THAN 10%: · persistent somatic symptom disorder with predominant pain. |
REASONS
INTRODUCTION
Ms Elmedina Zilic (the claimant) was injured on 25 October 2016. The insurer insured the owner and/or driver of the motor vehicle for liability to pay to the claimant any damages under the Motor Accidents Compensation Act 1999 (the MAC Act).
The dispute between the parties is whether this motor accident caused psychological injuries to Ms Zilic and whether these injuries can be assessed to have a degree of permanent impairment greater than 10%. This constitutes a medical dispute within the meaning of the MAC Act.[1]
[1] Sections 57 and 58 of the MAC Act.
On 14 April 2022, Medical Assessor Wayne Mason (the Medical Assessor) issued a certificate for the Personal Injury Commission (Commission) with his reasons in accordance with Part 3.4 of the MAC Act (the decision). The decision certified that the accident caused 19% whole person impairment (WPI)[2] arising from her psychiatric injuries.
[2] The terms permanent impairment and WPI are used interchangeably.
The decision was sent to the parties on 27 April 2022.
The insurer applied to the President of the Commission to review the decision. This was done within 28 days of receiving the certificate.[3]
[3] Section 63(7)(a) of the MAC Act.
On 25 July 2022, the President of the Commission constituted this Review Panel (the Panel) to review Medical Assessor Wayne Mason’s assessment (the Review).[4]
[4] Section 63(2B) of the MAC Act.
Conduct of the Review
The Panel met on 25 May 2023.
The Panel decided in order to reassess all aspects of the earlier assessment it was necessary to re-examine the claimant. Medical Assessors Newlyn and Chew agreed to re-examine Ms Zilic on behalf of the Panel.
The Panel directed it would examine Ms Zilic via Teams on 4 August 2023.
The Panel met again on 17 August 2023 to deliberate on the findings.
STATUTORY PROVISIONS/GUIDELINES
Part 5 of the Personal Injury Commission Act 2020 (the PIC Act) enables the Commission to make rules with respect to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a Merit Reviewer or a Medical Assessor.[5]
[5] Section 41(2) of the PIC Act.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) empowers a Review Panel to determine how it conducts and determines the proceedings including making its decision based solely on the written application.[6]
[6] Rule 128 of the PIC Rules.
Section 57 of the MAC Act defines a “medical dispute” as a disagreement or issue to which Part 3.4 of the MAC Act applies.
Under s 58 of the MAC Act a claimant and an insurer may disagree on three distinct matters, which are “medical assessment matters”. This includes “whether the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident is greater than 10%”.
Section 44(1)(c) of the MAC Act states the State Insurance Regulatory Authority (SIRA) may issue guidelines to assess an injured person’s permanent impairment, known as the Motor Accident Permanent Impairment Guidelines version effective from 1 June 2018 (the Guidelines).[7]
[7] Issued pursuant to s 44(1)(c) of the MAC Act and see s 133 of the MAC Act.
The Guidelines adopt the fourth edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment (AMA 4). The Guidelines prevail if AMA 4 and the Guidelines differ.[8]
[8] Clause 1.2 of the Guidelines.
Section 60 of the MAC Act provides either party may refer a medical dispute to the President who is to arrange for the dispute to be referred to one or more Medical Assessors. Clauses 1.5-1.7 of the Guidelines relate to the assessment of permanent impairment and provide:
“1.5 An assessment of the degree of permanent impairment is a medical assessment matter under Section 58 (1)(d) of the (MAC) Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident. A determination as to whether the injured person’s impairment is related to the accident in question is implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA4 Guides, as well as the common law principles that would be applied by a court (or claims assessor) in considering such issues.
1.6 Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows ‘Causation means that a physical, chemical or biological factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:
1. The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination.
2. The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.’
This involves a medical decision and a non-medical informed judgement.
1.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question ‘Would this injury (or impairment) have occurred if not for the accident?’ may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.”
The Civil Liability Act 2002 (the CL Act) applies to the MAC Act in determining whether the subject accident caused an injury. Sections 5D and 5E of the CL Act are particularly relevant to the MAC Act][9]. In Raina v CIC Allianz Insurance Ltd[10] Campbell J stated:
“One may accept that a review panel is engaged in a process of dispute resolution by expert assessment of medical issues arising under the Act. However, the questions arise in a legal context and it is incumbent upon the panel, medical practitioners they may be, to correctly apply the law including the law of causation in the exercise of their powers. This includes the provisions of Division 3 of Part 1A of the Civil Liability Act 2002(NSW), ss 5D and 5E: see s 3B(2)(a) of that Act. Although it may be expected that questions about the appropriate scope of liability will arise but rarely.”
[9] See s 3B(2) of the CL Act.
[10] [2021] NSWSC 13 (Raina) at [65].
The Guidelines’ clauses 1.213 to 1.228 prescribe how Medical Assessors are to assess mental and behavioural disorders.
The correct method for deducting pre-existing or subsequent psychiatric permanent impairment is set out at in the Guidelines at paragraphs 1.218 (It is similarly stated in all versions):
“Pre-existing impairment
In order to measure impairment caused by a specific event, the medical assessor must, in the case of an injured person with a pre-existing psychiatric diagnosis or diagnosable condition, estimate the overall pre-existing impairment using precisely the method set out in this part of these Guidelines, and subtract this value from the current impairment rating. These observations were made regarding a review panel of three medical experts before the MAC Act was amended, as opposed to the present panel composition of two medical experts and a legal Commission Member.”
Assessment under Review
Medical Assessor Mason certified the motor accident caused an adjustment disorder with mixed anxiety and depressed mood, chronic and severe which he assessed as 19% permanent impairment.
He also certified there was no requirement to apportion the permanent impairment to deduct pre-accident and subsequent conditions. The Medical Assessor opined that the motor accident caused various psychological problems which Ms Zilic experienced after the motor accident, rather than any condition existing before the accident.
Disputes and issues identified by the parties
The insurer contends that the assessment was incorrect in a material respect as the Medical Assessor:
(a) failed to comply with the Guidelines;
(b) improperly, incorrectly and erroneously considered the evidentiary position;
(c) overlooked the evidence, and
(d) failed to give proper consideration to the objective evidence.
The Medical Assessor summarised an extensive list of psychologically relevant events that preceded the accident.
The parties’ submissions to the Presidential delegate, which are relevant to this Panel’s considerations are summarised below.
Insurer’s submissions
The insurer submitted that failing to comply with the Guidelines can constitute a constructive failure to exercise jurisdiction.[11]
[11] Boyce v Allianz Australia Insurance Ltd (2018) 96 NSWLR 356.
Clause 1.215 of the Guidelines provides that the Permanent Impairment Rating Scale (PIRS) must not be used to measure impairment due to somatoform disorders or pain.
The Medical Assessor failed to comply with the Guidelines in two respects.
The Medical Assessor reasoned that the claimant’s chronic and severe adjustment disorder with mixed anxiety and depressed mood arose due to a somatoform disorder, i.e., her somatic symptom disorder (pain).
The Medical Assessor was therefore precluded from utilising the PIRS in relation to the claimant’s adjustment disorder and mixed anxiety and depressed mood as those conditions, based on the Medical Assessor’s own reasoning, were due to a somatoform disorder.
Secondly, it was incorrect for the Medical Assessor to apply the PIRS in relation to the claimant’s pain.
In assessing the claimant’s self-care and personal hygiene as class 2, the Medical Assessor noted that her difficulty with showering was ‘partly because showering is painful’. The Medical Assessor also noted that the claimant relied on her mother to perform laundry and ironing, which was ‘largely because of her physical injuries’ and ‘She does very limited cooking and housework mostly because of pain.’
In assessing the claimant’s social and recreational activities as class 3, the Medical Assessor noted that the claimant was ‘physically limited in her ability to participate in social and recreational activities’.
In assessing the claimant’s concentration, persistence and pace as class 3, the Medical Assessor noted that the claimant’s reported difficulties in reading, watching television programmes, and involvement with her family business were ‘due directly to pain’.
In respect to the complaint the Medical Assessor improperly, incorrectly and erroneously considered the evidentiary position the insurer referred to Ms Zilic being involved in a series of unsuccessful relationships which resulted in the development of an adjustment disorder with mixed anxiety and depressed mood requiring treatment with antidepressant medication and counselling from a psychologist.
The Medical Assessor opined that condition had largely resolved at the time of the motor accident when Ms Zilic was happily involved in a relationship with the man she would marry, employed in a good job and being successful in her university studies.
The Medical Assessor also obtained a history the claimant used an antidepressant in early to mid-2015 and noted in his review of the clinical records of Newtown Medical Practice that the claimant had been prescribed ‘…Citalopram continuing in September 2015’.
The Medical Assessor did not acknowledge, that the claimant had been prescribed celepram tablets 10mg 1 daily on 16 June 2016, only 18 weeks before the accident.
It was incorrect for the Medical Assessor to find the claimant had ceased taking antidepressant medication in mid-2015 and her pre-accident psychiatric condition had ‘largely resolved’.
The rest of the complaints reiterate the above grounds.
Claimant’s submissions
The claimant as respondent opposed the application.
In stating the Medical Assessor incorrectly applied the PIRS to measure impairment due to somatoform disorders and pain the insurer overlooked clause 1.213 of the Guidelines which provides:
“The impairment must be attributable to a psychiatric diagnosis recognised by the current edition of the Diagnostic & Statistical Manual of Mental Disorders (DSM) or the current edition of the International Statistical Classification of Diseases & Related Health Problems (ICD). The impairment evaluation report must specify the diagnostic criteria on which the diagnosis is based.”
The insurer contends that the following finding of the Medical Assessor meant that he was precluded from considering the use of the PIRS in assessing permanent impairment. Under the heading causation and reasons on page 12 of his certificate, the Medical Assessor commented as follows:
“The claimant has developed a Somatic Symptom Disorder (pain) as a consequence of the subject motor accident. This is the case whether she suffers from CRPS or simply from chronic pain. She was initially hopeful this could be cured and her psychiatric condition deteriorated greatly when this proved not to be the case. This in turn created a great deal of disruption in her life. She has been unable to continue with a valued job and university study which would have most likely led to career advancement. It has created difficulties for her in all of her relationships. It has also created difficulties for her in her ability to function as a mother. In my opinion her chronic and severe Adjustment Disorder with Mixed Anxiety and Depressed Mood has arisen secondarily to the ongoing Somatic Symptom Disorder (pain).”
The Medical Assessor’s comment that this has arisen secondarily to an ongoing somatic symptom disorder does not mean that he was precluded from using PIRS to measure permanent impairment.
The suggestion that the PIRS was being used to measure a somatoform disorder is entirely incorrect. It was being used to measure a disorder which is known under the DSM. It would be an error to think otherwise. The certificate states:
“I agree with the conclusion reached by psychiatrist Dr Graham Vickery that she has developed a Somatic Symptom Disorder (pain). I do not agree with his conclusion that there is no psychiatric condition. In my opinion she suffers from an Adjustment Disorder with Mixed Anxiety and Depressed Mood which is severe in intensity and chronic. In this regard I agree with the conclusions reached by psychiatrist Dr Anthony Dinnen, treating psychologist Ms Jo Gorrell, treating pain management psychiatrist Dr Matthew Holton and the psychiatric consultant at the Northern Beaches Hospital. I note that a number of psychiatrists have indicated the presence of cluster B personality traits. This refers to the claimant's tendency for intense emotional experience and expression, characteristics which have caused problems in the past. In my opinion this tendency was exacerbated by the subject motor accident. I do not believe a personality disorder diagnosis was possible prior to the motor accident. I believe these issues of emotional intensity and dysregulation are satisfactorily addressed under the diagnosis of a severe chronic Adjustment Disorder with Mixed Anxiety and Depressed Mood.”
The Medical Assessor explained that the accident caused “issues of emotional intensity and dysregulation” which “are satisfactorily explained under the diagnosis of a severe chronic Adjustment Disorder with Mixed Anxiety and Depressed Mood.”
Secondly the insurer argues that the Medical Assessor assessed pain to assess the various categories of permanent impairment, which misrepresents the assessment.
Clause 1.127 of the Guidelines says that the psychiatrist’s clinical judgement is the most important tool in the application of the scale. The impairment rating must be consistent with a recognised psychiatric diagnosis and based on the psychiatrist’s clinical experience.
The insurer contends that it is impermissible to consider pain in respect of assessing self-care and personal hygiene, social and recreational activities and concentration persistence and pace. The claimant says whilst the Medical Assessor mentions pain he did not assess permanent impairment purely based on pain.
In respect of self-care and personal hygiene, the Medical Assessor commented that her mild deficiencies were partly because of pain and partly due to lacking motivation. The Medical Assessor utilised his clinical judgement as clause 1.217 requires.
In respect of social and recreational activities, the Medical Assessor pointed out that “the claimant is physically limited in her ability to participate in social and recreational activities.” He does not refer to pain. He then points out,
“However, she has no interest or desire to do so because of anxiety and depression. She no longer visit friends and they do not visit her. She does not attend entertainment venues. She is moderately impaired.”
Finally, the insurer contends that the Medical Assessor directly attributed pain as causing the claimant’s moderately impaired concentration persistence and pace. The claimant refers though to the entire sentence:
“some of this difficulty is directly due to pain but much of it is due to her anxiety and depression.”
The Medical Assessor used his clinical judgement to apply the scale to find a moderate impairment taking into account that “much of” the impairment was due to anxiety and depression.
The Medical Assessor dealt with the insurer’s suggestion that the claimant was dealing with only a somatic symptom disorder underneath the heading of Diagnosis and reasons on page 12 of his certificate. The Medical Assessor pointed out he agreed with Dr Vickery’s diagnosis,[12] but disagreed with his conclusion that there was no psychiatric condition.
[12] 21 October 2020 R11.
The Medical Assessor opined the claimant had a severe and chronic adjustment disorder with mixed anxiety and depressed mood.
The Medical Assessor pointed out this matches Dr Anthony Dinnen’s conclusion in his report dated 30 March 2020 and her treating doctors’ reports.
Although some doctors suggested Ms Zilic had a personality disorder, it was the Medical Assessor’s opinion that this diagnosis was not possible before the accident, although the accident aggravated the incipient tendencies.
The claimant disputes the insurer’s assertion the Medical Assessor did not consider Ms Zilic being prescribed antidepressant medication 18 weeks before the accident in calculating her permanent impairment in accordance with Guidelines’ clause 1.31.
The claimant says there was no evidence of any pre-existing symptomatic permanent impairment at the time of the accident. At the time of the accident the claimant held down full-time employment, was in a happy relationship and was performing well in a Master of laws degree at Sydney University. She was also in a business venture with her partner.
A prescription of a mild dose of antidepressant medication 18 weeks before the subject accident, without the claimant seeking additional treatment is not evidence of a pre-existing symptomatic permanent impairment, which ought to have been taken into account.
Documentation
The Review Panel considered the following documentation:
· Medical Assessor Mason’s certificate dated 14 April 2022;
· insurer applicant’s bundle with the review application marked AD5;
· Reply bundle marked AD6, and
· the Presidential delegate’s reasons dated 25 July 2022 referring this matter to a Review Panel.
The parties did not submit additional evidence.
REVIEW PANEL FINDINGS
Who attended the assessment
Elmedina Zilic attended the assessment on 4 August 2023 via audio-visual link from her home in Killarney Heights. She was unaccompanied at the interview. She was examined by Medical Assessors Gerald Chew and Thomas Newlyn who were both in their Sydney rooms. The assessment took approximately one hour.
Psychosocial history and pre-accident history
Ms Zilic is a 40-year-old woman who lives between her home in Killarney Heights with her husband Christopher and her parent’s house in Hurstville with her brother and sister. When at home in Killarney Heights her parents are often present as well. She has a 3-year-old daughter Sophia Sabina Haikalis and is also 32 weeks pregnant with their second child.
She confirmed her developmental, educational and vocational history as reported previously. She was born in Blacktown Hospital. She attended Riverstone primary school until year 4 then Seven Hills West primary school in years 5 and 6 where she was vice captain of the school. She attended Blacktown Girls High School until year 9 and performed well there and was on the student representative counsel. She then attended Kingsgrove High School completing year 12. She then studied for a combined business and law degrees at the University of Western Sydney graduating in 2006. She completed College of Law studies and was admitted as a solicitor in 2007. She worked as a paralegal for one year then got a job at Macquarie Bank in their treasury department for two years until the bank made her redundant because of the Global Financial Crisis. She then travelled for a year visiting family in Europe. She returned to Australia and worked for an insurance company as a business analyst and legal counsel for two years.
At the time of the subject accident she had been working for Westpac Bank for seven months. She was also completing a Master of Law degree at Sydney University.
Her past medical history included asthma and eczema as a child. She had sinus surgery in 2010 and was diagnosed with polycystic ovarian syndrome in 2011.
Ms Zilic was quick to inform that her past psychiatric history was “all resolved” and framed past issues as short, time limited reactions to stressful situations.
She reported that she first sought help for mental health issues when she was travelling in Germany and had a brief relationship with a Bosnian man.
She reported that the Bosnian removed the condom during intercourse without her consent, she became pregnant and had a termination. This is recorded in the Newtown Medical Centre notes as happening in late November 2013.[13] She told the Panel that it was the termination that affected her emotionally. She attended some psychological therapy and had short term antidepressant therapy. She reported that she later had a flare up in symptoms later when she had a “crazy neighbour” with unwanted advances and sought help again.
[13] Page 1353 AD6.
She reported that before the accident she also had some stress related to working full time and post graduate study and sought help and was given a prescription for an antidepressant which she did not take.
History of the motor accident
Ms Zilic reported that on 25 October 2016 she was riding her Vespa scooter along the Western Distributor heading towards the Anzac Bridge at around 50-60kmph. She reported that a BMW motorcycle cut in front of her accelerating and she braked however his back wheel clipped her front wheel and she skidded across the road with the scooter on top of her. She reported that her shoe and glove were ripped open. She reported that the BMW kept riding. She reported that some bystanders helped her with one of the men stopping the motorcycle which had an L plate. She recalled a conversation with the BMW rider who claimed that he was not at fault and that while he had a learner’s permit he had been “riding in Greece for years.” She said that he told the police an incorrect version and she felt that the police didn’t listen to her. An ambulance took her to hospital.
History of symptoms and treatment following the motor accident
She was admitted to hospital following the accident and had a skin graft taken from her left thigh for her left foot. She had abrasions to her left hand and right hip, bruising of her left hip and pain in her back, neck left shoulder and hand. She remained at hospital for approximately a week and was discharged on crutches however, she said she was unable to walk because of leg pain.
She was followed up regularly about her plastic surgery and was taking opioid pain medication.
She reported that around six weeks after the accident she developed complex regional pain syndrome. The Royal Prince Alfred Pain Management Centre managed her condition with Lyrica and citalopram. She attended various specialists there including psychiatrist
Dr Holton.She said that the pain has persisted and evolved over time and has not abated.
Details of any relevant injuries or conditions sustained since the motor accident
There are no further diagnosed injuries or conditions. There have been further stressful events including relationship difficulties noted in some documentation as well as coping with a second pregnancy while caring for her young child.
Current status
She reported that her predominant current symptom is “skin sensitivity” making it at times even impossible to have a shower. Associated with this there is pain ongoing in the leg and back in particular. She reported poor sleep because of the pain. She said that because of this she struggles to look after her baby or even pick the baby up at times. Her parents help her with this child care.
Mental state examination
She appeared her stated age and had adequate grooming. She was visibly anxious and upset at times. She was difficult to interrupt at times and gave extremely detailed answers to most questions. She reported her mood as low and stressed and her affect was congruent with mood and dysphoric. There was no evidence of psychosis. She was oriented to time, place and person and demonstrated good concentration during interview.
Comments of Consistency
There were no gross inconsistencies.
Diagnosis and Reasons
Based on Ms Zilic’s account, her presentation and review of provided documentation, her primary psychiatric diagnosis is persistent somatic symptom disorder with predominant pain.
She presents with significant physical symptoms which are distressing and cause her significant disruption of her daily life. She has a persistently high level of anxiety about her symptoms. Her symptoms predominantly involve pain, are severe with marked impairment and of long duration (more than six months).
Panel deliberations
The Panel discussed the re-examination findings on assessing Ms Zilic’s mental and behavioural disorder in accordance with the Guidelines. The Panel decided it would adopt the re-examination report as evidence in its decision.
The medically trained Members confirmed that the accident caused the diagnosed condition and that it was the most appropriate fit for the symptoms Ms Zilic displayed during the re-examination. It also fit the symptoms the Panel had seen in the clinical notes and reports the claimant and insurer provided.
The Panel decided that the written material and the re-examination was sufficient to assess the claimant’s psychological condition.
The Panel also found there was no pre-existing impairment that could be deducted from any impairment assessment. Based on the high level functioning Ms Zilic displayed up to the time of the accident the Panel agreed the evidence did not support a symptomatic permanent impairment existing at the time of the accident.
The examination caused the Panel to disagree with Medical Assessor Mason’s assessment that the accident caused Ms Zilic to have an adjustment disorder with mixed anxiety and depressed mood, which was chronic and severe.
As the Panel had diagnosed persistent somatic symptom disorder with predominant pain it was unable to apply the PIRS in accordance with the Guidelines’ clause 1.215.
Accordingly the Panel could not attribute any psychological permanent impairment to the accident. Therefore the total permanent impairment is 0%.
Permanent impairment ratings take symptoms into account; however the percentage WPI is not a direct measure of disability. A finding of 0% WPI indicates that the accident caused an injury and that there may be continuing symptoms, however, the relevant Guidelines rate the associated impairment at 0% WPI.
Accordingly, the Review Panel revokes Medical Assessor Mason’s certificate and issues a new permanent impairment certificate.
Review Panel Certification
Member O’Riain, Medical Assessor Chew and Medical Assessor Newlyn viewed this certificate and have confirmed that they agree on the outcome.
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