Ross and Repatriation Commission - [2002] AATA 497

DECISION AND REASONS FOR DECISION [2002] AATA 497

ADMINISTRATIVE APPEALS TRIBUNAL )

) No V2000/1160

VETERANS APPEALS DIVISION        )
           Re      JOAN ROSS
  Applicant
           And    REPATRIATION COMMISSION
  Respondent

DECISION

Tribunal Mr J. Handley, Senior Member Mr A. Argent, Member Professor J. Maynard, Member

Date Place 21 June 2002 Melbourne

Decision The decision of the Veterans Review Board with respect to the applications made by the deceased in his lifetime insofar as it was decided that hypertension was not war-caused is set aside and in substitution IT IS DECIDED that hypertension is war-caused. The application is remitted to the respondent for calculation of General Rate Pension payable to the estate. The remaining part of the decision under review is otherwise affirmed. The decision of the Veterans Review Board with respect to the application made by Mrs Ross as widow is set aside and in substitution IT IS DECIDED that the death of the late Donald John Ross is war-caused.

........... Sgd J Handley.........................
Senior Member
CATCHWORDS
Veterans Affairs - Estate and widows claim - whether deceased suffered hypertension - whether contribution to ischaemic heart disease - whether death by myocardial infarction by hypertension and ischaemic heart disease - whether ingestion of 15 gms of salt - whether connection between service and consumption of salt - decision set aside - death war-caused.
Statement of Principle Instrument No. 26 of 1999
Statement of Principle Instrument No. 32 of 2001
Statement of Principle Instrument No 39 of 1999
Statement of Principle Instrument No 81 of 1998
Veterans' Entitlement Act 1986 – s.120(4)

REASONS FOR DECISION

21 June 2002 Mr J. Handley, Senior Member
Mr A. Argent, Member Associate Professor J. Maynard, Member

The applicant applies to review a number of decisions made by the Repatriation Commission and the Veterans Review Board ("VRB") which may be briefly summarised as follows-
On 22 August 2000, the VRB made two decisions concerning applications made by the veteran prior to his demise. An application to review the assessed general rate pension was withdrawn by the advocate who appeared and the VRB made that notation. The other application concerned entitlement of the conditions of macular degeneration, Parkinson's Disease with vertigo and of hypertension. The VRB affirmed a decision of the respondent made on 15 April 1988 with respect to those conditions, namely that they were not war-caused. The review of these decisions at this Tribunal was pursued by Mrs Ross on behalf of the Estate, but only with respect to the condition of hypertension. That is, the remaining part of the review concerning macular degeneration and Parkinson's Disease with vertigo was withdrawn. The deceased had an entitlement to pension at 20% of the General Rate for the condition of bilateral sensori-neural hearing loss. An assessment of pension was not pursued in the review before this Tribunal. Accordingly, the only review pursued by the Estate was for acceptance of the condition of hypertension.
On 22 August 2000 the VRB made another decision following an application lodged by Mrs Ross, as the widow of the deceased, claiming pension arising out of her late husband's death. The VRB then affirmed a primary decision made by the respondent on 11 June 1999 that the death of the late veteran was not war-caused.
The deceased died on 5 November 1988. The certified cause of death was "myocardial infarction".
At all relevant times, Mr Ross was a member of the Australian Army who served in Australia only between 29 July 1941 and 5 October 1945. He, therefore, engaged in "eligible service". The applications will be successful if the burden imposed by s120(4) of the Veterans' Entitlement Act 1986 ("the Act") is satisfied.
Mr Larkin appeared on behalf of Mrs Ross and Mr Purcell appeared on behalf of the respondent. A number of documents were received into evidence and a number of witnesses gave evidence. Those documents and the evidence of the witnesses will be referred to later in these reasons.
One of the "links" between service and death was the consumption of salt during service and subsequently as a civilian. By reason of the date of the application, enquiry needs to be made of Statements of Principles, which relate to hypertension and ischaemic heart disease.
Each Instrument concerning hypertension defines it. Instrument No. 26 of 1999 defines hypertension as-
"….. hypertension means elevated blood pressure evidenced by
(a) a usual blood pressure reading where the systolic reading is greater than or equal to 140mmHg and /or where the diastolic reading is greater than or equal to 90mmHg; or
(b) administration of ani-hypertensive therapy".
The definition of hypertension in Instrument No. 32 of 2001 is slightly different and it says-
"…. Hypertension means permanently elevated blood pressure evidenced by
(i) a usual blood pressure reading where the systolic reading is greater than or equal to 140 mmHg and / or where the diastolic reading is greater than or equal to 90 mmHg; or
(ii) the regular administration of anti-hypertensive therapy to reduce blood pressure".
Relevantly, there were two Statements of Principles with respect to hypertension issued by the Repatriation Medical Authority subsequent to the claims being made upon the respondent. Both instruments contain factors "that must exist before it can be said that on the balance of probabilities hypertension ….. is connected with the circumstances of a persons relevant service". In Instrument 26 of 1999, the applicable factor is 5(c) which says-
"Ingesting at least 15 grams (250 mmol) of salt supplements per day, on average for a continuous period of at least 6 months immediately before the accurate determination of hypertension".
Instrument No. 32 of 2001 is slightly different and it says at factor 5(c)-
"Ingesting at least 15 grams (250mmol) of salt supplements per day on average for a continuous period of at least 6 months immediately before the clinical onset of hypertension".
In both Instruments the words "salt supplement" are defined as-
"salt added to food when cooking or eating or salt contained in salt tablets".
There were two Statements of Principles with respect to the condition of ischaemic heart disease applicable during the relevant period, each of which had an identical factor. Both Instruments are No. 81 of 1998 and No. 39 of 1999. Each factor is enumerated as 5(a) and the prelude to each factor is that the factor must exist "before it can be said that on the balance of probabilities, ischaemic heart disease or death from ischaemic heart disease is connected with the circumstances of a persons relevant service". The applicable factor is-
"The presence of hypertension before the clinical onset of ischaemic heart disease".
In his opening, Mr Larkin said that the deceased was a cook and later became a catering officer. All service was within Australia and mainly within Western Australia, New South Wales and Queensland. It was the case of the applicant that the deceased was exposed to high temperatures and high levels of humidity. During service he was issued with salt tablets and salt was also added to meals.
Mr Larkin relied on a report completed by Writeway Research ("Writeway") who, at the request of the respondent, investigated the consumption of salt amongst service persons during the Second World War. At paragraph 34 of the report the following is recorded-
"The researcher has discussed this question with the current SO2 Corps AACC (Major Walpole) at ALTC Bandiana and with Mr Chris Forbes - Ewan at the Defence Nutrition Research Centre. Their informed opinion across the spectrum of Army catering and nutrition is that given the entitlement to salt during World War 2, the unique employment of the late veteran (as a caterer with constant access to salted food and salt tablets) coupled with the culture of diners of that era to liberally garnish meals with added salt, it is not considered remarkable that the late veteran would have taken the opportunity of ingesting more than the prescribed 15 grams of salt each day for a continuous period of at least 6 months".
Mr Larkin pointed to a recording of the deceased's blood pressure at discharge in 1945, which then showed a reading of 130/90. It was also submitted that the evidence would show that by 1978, and possibly earlier, the deceased had been diagnosed with and treated for hypertension.
Having regard to the deceased's service, the findings of Writeway and the combined operation's of the Statements of Principles, the case for Mrs Ross and the Estate was the deceased, by reason of his service, consumed quantities of salt which gave rise to hypertension. This then precipitated ischaemic heart disease, which in turn precipitated a fatal myocardial infarction on 5 November 1998.
Mr Purcell, on behalf of the respondent, urged a finding before the commencement of the hearing as to which Statement of Principles applied. It was noted that there were differing factors and definitions within the hypertension instruments, however after discussion between counsel it was agreed that identification of the applicable Statement of Principles could not be made until the evidence was heard.
Mr Purcell submitted that critical issues in the application would be the date of clinical onset of hypertension and whether the ingestion of salt subsequent to service (if the clinical onset was later than 1945), was related to service.
Mr Purcell said it was not conceded that the deceased did consume 15 grams of salt per day within service. He submitted that it was, however, open to the Tribunal to find consumption of that quantity did occur on the basis of the Writeway report.
Joan Ross
Mrs Ross is the widow of the late Donald John Ross and the applicant in these proceedings.
Mrs Ross said that she and her late husband married after he was enlisted. She recalled that he was a cook in the army, initially at Balcombe in Victoria and later in Western Australia, New South Wales and Queensland. Eventually he became a catering officer. She said that she and her husband were separated by reason of his service in Western Australia for a few years but when he was transferred to Queensland she moved and boarded with him. Mrs Ross recalled that Queensland had a very hot climate and she was "so heady" there were occasions where she could not get out of bed. She recalled that her husband suggested that she "put more salt on meals", which she did.
Mrs Ross recalled that she first met her husband in 1938 when they both lived in Bendigo. She said that she did not have many meals at his parent's house and she did not recall his consumption of salt at that time. She did recall that when he was on leave during enlistment that he "well and truly used it" (salt). She said that thereafter his salt consumption became a lifelong habit and she would frequently say to him that he did not need to consume the quantities of salt that he did. Apparently undeterred, Mr Ross continued to consume significant quantities of salt.
After discharge Mrs Ross said that she cooked at home and used salt in gravies and sauces and in the cooking of all vegetables. She said that each vegetable was cooked separately in its own saucepan of water and she would apply salt to the water. She estimated that the quantity was within a small salt ladle, which she approximated to be the size of a "thruppence". When pressed in cross-examination as to whether the quantity of salt within the ladle was flat or whether it was a mound, she said that it was "a little bit over".
When meals were consumed, Mrs Ross said that her husband would salt all food on his plate from a salt shaker, which was on the kitchen table. She said he did not taste food before salt was applied by him. Typically, Mrs Ross would prepare a cooked breakfast for her husband daily which was of tomatoes and/or eggs. She said that she would salt the tomatoes, but he would place salt on cooked eggs. She said he was "liberal" with his application of salt. She also used salt in the cooking of lamb and fish but not beef. Mrs Ross also prepared her husband's lunch which he took to work and which comprised either sandwiches or salads. Salt was again used.
With respect to her husband's employment, Mrs Ross said that for the first 20 years or so after discharge, L Yenken employed Mr Ross as a purchasing officer. When that firm closed in 1969, he obtained employment with a garage door manufacturer. Although medical records from Dr Nathaniel, who was treating the deceased at his death, were only available from 1981, Mrs Ross said that she had been attending a Doctor at the clinic presently occupied by Dr Nathaniel for "8-10 years before 1969" for treatment of blood pressure. She said that her husband had been prescribed medication.
In his latter years, Mrs Ross described the deterioration in her husband's health and his referral to a cardiologist in approximately 1994. She described her husband as frequently suffering from chest pain on exertion, breathlessness and observing his lips to be blue.
In cross-examination, Mrs Ross reaffirmed that her husband had been prescribed blood pressure medication for many years prior to 1981 when he first saw Doctor Nathaniel. She recalled that her husband used to attend Doctor Kendall and had been prescribed tablets, which she said were white in colour, but she could not recall the name. She also recalled that her husband had told her that the tablets that had been prescribed for him were to treat his blood pressure.
In answer to some questions from us, Mrs Ross described in some greater detail the quantities of salt used in the household. She said that a salt shaker used by members of the family was four or five inches in height and about two inches in diameter. She recalled that her husband would shake the salt shaker on 7 or 8 occasions (she demonstrated this to us) to apply salt to his breakfast and would shake it on a greater number of occasions for his evening meal. Mrs Ross recalled that she would fill up the salt shaker on a weekly basis and there was approximately ½ and inch of salt remaining in the salt shaker on each occasion that she filled it. She recalled that her husband also enjoyed consuming condiments, pickles and soy sauce, which she understood, all contained salt.
With respect to the salt that she used in the kitchen, she described it as "cooking salt" which she said was coarse. She recalled that she would purchase a box of cooking salt on an average of once per month and a box of table salt once per fortnight.
With respect to the medication that had been prescribed to Mr Ross from time to time for treatment of his blood pressure, Mrs Ross recalled that the tablets did change. On occasions, some tablets caused him to be dizzy and on other occasions some tablets caused him to urinate more frequently.
Phillip Nathaniel
Doctor Nathaniel is a general practitioner in Glenroy who treated the late Mr Ross between 1981 until his death in 1998.
The clinical notes of Dr Nathaniel were provided to the Tribunal. The notes indicated that treatment commenced on 2 November 1981, however Dr Nathaniel said in evidence - when referring to his notes - that he first attended Mr Ross on 11 June 1981. The witness said that he had acquired the medical practice in May 1981 from Dr Naidoo and Dr Kendall, who formerly treated Mr Ross. Dr Nathaniel said that he did not have any notes of treatment prior to 1981. He understood that either Dr Kendall or Dr Naidoo took patient notes with them following the sale of the practice in 1981 and retained them in a new practice that they opened nearby. In any event, Dr Nathaniel said that Dr Naidoo presently has Alzheimer's disease and any enquiry as to the whereabouts of his notes would be pointless. Dr Nathaniel said that he also understood that a Dr Lewis, who formerly practiced in Moonee Ponds and had a clinic in Glenroy, previously treated the late Mr Ross. He understood that Mr Ross had been treated by Dr Lewis for some years after he was discharged in 1946.
On examination of the deceased on 11 June 1981 Dr Nathaniel found blood pressure at 150/112. He also found arterial thickening of the fundus which indicated the presence of hypertension for "quite some time". Dr Nathaniel said that he was aware that Mr Ross had been treated for hypertension prior to his first consultation with him and was also aware that medication had been prescribed.
Dr Nathaniel initially treated the deceased's hypertension with "Moduretic" but changed it to "Visken" in 1986. From 1989 he prescribed "Isodil".
With respect to the claimed connection between service and death, Dr Nathaniel referred to a report of Dr Warren of 8 January 1994, to whom the deceased was referred and who found that he had been hypertensive for many years. He also referred to a report from Dr Wong, a cardiologist, of 8 October 1988 who found "long standing hypertension …. and transient ischaemic episodes". There was also ECG evidence of the deceased having suffered a prior infarct.
With respect to salt consumption Dr Nathaniel said that in his experience the normal daily intake of persons is between 3 and 5 grams. He regarded a daily intake of 15 grams to be excessive. With respect to the consumption by the deceased of salt tablets during service, Dr Nathaniel acknowledged that in tropical climates persons sweat profusely and excrete sodium excessively. With respect to the consumption of salt after it has been added to food, it was the experience of Dr Nathaniel that patients had reported to him that food tastes bland without salt and consumption of it continued. He regarded any reduction in salt consumption to be a conscious decision of a patient. He said with respect to patients of his who are hypertensive, that he discusses diet and recommends reduction in salt consumption but he had no record of such a discussion with the deceased.
In cross-examination, Dr Nathaniel said that when he first saw Mr Ross in 1981 he was then requested to prescribe Moduretic because the applicant's doctor had previously prescribed it. Dr Nathaniel was unaware of the types of medication being prescribed in the 1970's for hypertension because he was not then in practice, although he understood that diuretics such as Chlotride were prescribed.
With respect to salt consumption, Dr Nathaniel said that one teaspoon of salt per day added during a cooking process amounted to about 5 grams of salt. This, he said, was at the outer limits of what he regards as normal daily intake.
He reaffirmed that it was his practice to advise hypertensive patients to reduce salt consumption. He acknowledged that he had no records of such conversations with the deceased, but said that a conversation of this type would have occurred because it was his normal practice.
Additionally, Dr Nathaniel said that in his experience, once a person becomes used to the taste of salt, they usually continue to consume it without reduction because of the common complaint that food becomes bland or tasteless. He said he had no text or other reference that he could point to where this phenomena has been published but said he was relying on his experience as a general practitioner.
With respect to the consumption of salt tablets in tropical climates, Dr Nathaniel acknowledged that when a person returns to a temperate climate the need for salt tablets is reduced. This is a result of a reduction in the excretion of sodium by sweating. Nonetheless, he said the "need" for salt was not necessarily reduced and may vary between persons.
Jeremy Hammond
Doctor Hammond is a specialist physician practising in cardiology. He provided a report at the request of the respondent on 1 May 2002.

Doctor Hammond had been given a number of documents prior to the preparation of his report and was familiar with the conclusions reached by Mr Tilbrook on behalf of Writeway. Upon the assumption that the deceased did consume 15 grams of salt per day during service, Dr Hammond said that he could not connect the blood pressure reading in 1945 of 130/90 to the Statement of Principles. He could not be satisfied that that reading alone was indicative that the deceased was then hypertensive. He said that blood pressure readings need to be repeated on two or three occasions before a diagnosis of hypertension could be made.
In reaching the conclusions that he did in his report, Dr Hammond, said he relied on Instrument No. 26 of 1999 - in preference to Instrument No. 32 of 2001. He did so because the former Instrument at factor 5(c) referred to the "accurate determination of hypertension", however the later Instrument referred to the "clinical onset" of hypertension. Dr Hammond said that he could find nothing in the papers made available to him of when the clinical onset occurred. He said that so far as "clinical onset" was concerned, the concept necessarily includes the "accurate determination" of hypertension, but also refers to a pattern of symptoms. It followed he said that the difference between "clinical onset" and the "accurate determination" of hypertension was the period of time between the determination of hypertension and the clinical onset of hypertension.
With respect to the definition of "salt supplement" as appears in the Hypertension Instruments, Dr Hammond said that he understood the concept to refer to the manner in which salt is ingested. Typically, he said, salt exists in foods that are consumed and is also added to foods that are consumed. In his experience, 8 to 12 grams of salt per day is typical in western diets.
With respect to the case on behalf of the applicant, that her husband had a high salt consumption during enlistment because of excessive sweating, Dr Hammond said that the patterns of salt intake are often established early in life and are associated with salt consumption within a family. He said that the consumption of between 8 and 12 grams of salt per day before enlistment would not be unreasonable. He had no knowledge of any journal or publication finding salt to be addictive, but when asked whether he expected salt consumption to reduce after the cessation of consuming salt tablets, Dr Hammond said the proposition was speculative.
In cross-examination, Dr Hammond said that the finding by Dr Nathaniel of fundus of the eyes (being thickening of arteries of the eyes) was consistent with pre-existing hypertension.
With respect to the consumption of salt by the deceased, Dr Hammond said that he could "not rule out the possibility of" the deceased consuming greater than 15 grams of salt per day. This was when he learnt of the evidence of Mrs Ross, as to her husband's consumption of salt.
With respect to his experience with patients where he has recommended reduction in salt consumption, Dr Hammond said that patients will often report that food tastes bland but for a period of 3 or 4 weeks only after salt reduction has commenced. He said that if persons are not advised to reduce salt consumption, in his experience, salt will continue to be consumed because of habit. He said that it was not possible to be definitive about a proposition, advanced in this application, that the deceased would have continued to consume salt in excess of 15 grams per day subsequent to service. The Tribunal needs to consider the applicant's salt consumption as a child.
When Mr Hammond learnt that the deceased was apparently hypertensive in the early 1960's (when he was in his early 40's), Dr Hammond said that that might have then been the onset of hypertension. As to the blood pressure reading in 1945 of 130/90, Dr Hammond said the deceased would have then been 28 years of age. In his experience, only 2% of the population would be hypertensive (at that age). Additionally, Dr Hammond queried the accuracy of the measurement of the blood pressure as recorded. It was also noted that the deceased had a blood pressure reading of 130/75 on entry to the Army in 1941. The witness said that the diastolic reading of 75 in 1941 could have been 80 and the systolic reading of 90 in 1945 could have been 85.
With respect to the clinical management of hypertension in the 1960's, Dr Hammond said the likely advice would have been to reduce salt consumption and the prescription of diuretics being either Chlotride or Aldomet. He said these medications would have increased the sodium excretion from the body but would not necessarily have increased the need by Mr Ross for salt.
Richard Byron Collins
Doctor Collins is a forensic pathologist, who provided two reports at the request of the applicant's solicitors on 12 February 2001 and 30 November 2001.
Doctor Collins agreed with the conclusions within the deceased's death certificate as having suffered a myocardial infarction. He noted that Dr Wong found the deceased suffered from exertional tightness of the chest, which he said was consistent with ischaemic heart disease. It was his opinion that hypertension may have been a factor in the development of ischaemic heart disease.
With respect to the basis of the application being a connection between salt consumption and hypertension, Dr Collins said that the finding in 1945 of blood pressure of 130/90 was consistent with hypertension. However, he doubted the accuracy of the reading and said that he expect more than one blood pressure reading in order to properly make a diagnosis of hypertension.
Conclusion & Reasons For Decision
During the hearing we learnt of a number of issues which were not previously known or which had not previously been explored.
Fundamentally, it was learnt that the late veteran had been under treatment for hypertension for many years prior to 1981. Prior to that year, it was believed that the nature of the deceased's treatment and illnesses could not be established because of the absence of records. This was because the notes of Dr Nathaniel, provided to the Tribunal, commenced in 1981. It became obvious, having heard the evidence from Mrs Ross and from Dr Nathaniel, that Mr Ross was treated for hypertension for many years before 1981. Dr Nathaniel noted the presence of arterial thickening upon fundus examination, which he said was indicative of hypertension "for quite some time". Mr Hammond agreed with this proposition. However - and probably more significantly - Mrs Ross estimated that her husband had been treated for hypertension for about 8-10 years, prior to him commencing employment in 1969 with a garage door manufacturer. She also recalled him being prescribed medication for hypertension. It follows, and we are satisfied as a fact, that the deceased had been diagnosed with and treated for hypertension from the early 1960's. It follows - and we are satisfied as a fact - that the "clinical onset" of hypertension was the early 1960's.
An issue as to the medication for hypertension also emerged during the hearing. Apparently, specific anti-hypertensive medication was not available until the 1970's. Prior to that time, persons - no less the late Mr Ross - were prescribed diuretics. Nonetheless, we are satisfied that prescription and consumption of medication of that type was the prevailing medical basis for treatment of hypertension. Thereafter, Mr Ross continued to be prescribed and consume hypertensive medication. It follows that the prescription of that medication amounts to "regular administration of anti-hypertensive therapy", as those words appear in paragraph 2 of Instrument No. 32 of 2001.
With respect to the condition of hypertension we are satisfied on the evidence of Dr Nathaniel and Dr Hammond that the blood pressure reading taken at discharge in 1945 cannot of itself be indicative of hypertension at that time. Indeed on the evidence of Dr Hammond, there is some doubt whether that reading was accurately determined. We are satisfied that hypertension is a condition which can only be reasonably diagnosed after a persons' blood pressure has been taken on a number of occasions and then found to be elevated. However, there is much to indicate from the clinical notes of Dr Nathaniel that the deceased was hypertensive after 1981. The blood pressure readings recorded - and which were taken every one or two months - consistently show an elevation of blood pressure. Nonetheless, we are satisfied that the prescription of anti-hypertensive medication from the early 1960's is an indicator also of hypertension. This is as a result of the deceased's blood pressure being regularly taken and, equally, regularly being found to be greater than the systolic and/or the diastolic levels as found at paragraph 2(b)(i) of Instrument No. 32 of 2001. Additionally, we are satisfied that the apparent condition of hypertension from the early 1960's, prevailing until the deceased's death in 1998 can be said to be "permanently elevated blood pressure", as those words appear in paragraph 2(b) of Instrument No. 32 of 2001.
Having made the above findings of fact, we are satisfied that Instrument No. 32 of 2001 is more appropriate to this application than Instrument No. 26 of 1999.
Both Instruments are identical as to the ingestion of salt supplements for a continuous period of at least 6 months. Instrument No. 32 of 2001, however, requires examination of the ingestion of salt supplements for "a continuous period of at least six months immediately before the clinical onset of hypertension". It follows that we are directed to enquire into the consumption of salt for a continuous period of 6 months immediately before the early 1960's.
By reason of the definition of "salt supplement" containing reference to salt added to food when cooking or eating or salt contained in salt tablets, we are (fortunately) not called upon to enquire into the level of salt already existing within food. As we understand the definition, we are only required to consider the salt that is "added to food when cooking or eating". In this enquiry - and upon the basis that there is no evidence of any consumption of salt tablets subsequent to discharge- we confine ourselves only to salt which was added to food when cooking or eating. We have used the word "fortunately" because the parties gave us no assistance – particularly, the applicant's representative who arguably had a duty to properly and competently advance the applicant's case - as to what constitutes 15 grams of salt. Having regard to the inquisitorial duty as a Tribunal of review, Associate Professor Maynard obtained samples of salt and caused them to be measured scientifically by reason of his position at the Victorian Institute of Forensic Pathology. Additionally, photographs were obtained of the samples with appropriate measurements, so as to give the parties an indication of the quantities. The parties were invited to make any further submissions having regard to those photographs, which were forwarded to them. The parties were also notified that the samples of salt were available for inspection at the Tribunal, should they prefer.
Mr Larkin responded to the above invitation. He noted that there is a reference in the Writeway report of serviceman being rationed up to 14 gms per day of salt. The quantity of 15 gms referred to in the Statement of Principles is only fractionally greater. Mr Purcell, on behalf of the respondent, submitted that the photographs depicted a 50mm x 20mm container of salt being half filled with 15 gms of salt. No further submission was made. Both representatives declined inspection of the photographed samples.
Some visual appreciation of the quantity of salt is important in order to comprehend the evidence of Mrs Ross, as to the consumption by her husband of salt. It is trite to say that unless the deceased did ingest at least 15 grams of salt per day on average for a continuous period of six months, before the clinical onset, the application will fail.
Mrs Ross said in evidence that her husband liberally applied salt to food that she cooked at breakfast and at his evening meal. She also applied salt to sandwiches and salads that she made for his lunch. Additionally, she added salt to water when preparing vegetables for the evening meal.
In order to find as a fact whether the late Mr Ross ingested at least 15 grams of salt - as added to food when cooking or eating - we can do no more than to have regard to the evidence of Mrs Ross. We must translate the quantities that Mr Ross did apply to his food and the quantities that she applied when cooking food into the samples, which Associate Professor Maynard prepared. Additionally, we will attempt this exercise by reference to the evidence of Mrs Ross as to the size of the salt shaker, the number of times that it was shaken by her husband to release salt onto his food, the frequency of her filling the salt shaker and the frequency of her purchasing salt. Doing the best that we can in these unusual circumstances we are satisfied as a fact that the deceased did ingest at least 15 grams of salt supplements per day. We find that consumption at this rate did occur within the six month period prior to the clinical onset of hypertension being the early 1960's. This is because Mrs Ross said that she cooked all meals after her husband was discharged and his use of salt did not vary.
With respect to whether there is a connection between the consumption of salt and the deceased's service we note the evidence of Dr Hammond that in his experience the "pattern of salt intake" is set early in a persons life and enquiries should be made as to salt consumed within the family home. Additionally, he thought that the typical Western diet involved the consumption of between 8 and 12 grams of salt per day. It followed, on this evidence, that the applicant could not demonstrate a connection between her husband's ingestion of 15 grams of salt per day and his service.
We do not share that view. Mrs Ross was asked to talk about what she observed of her husband's salt consumption within his family when they both resided in Bendigo. Whilst she said that she and her husband together did not have many meals at his parents' home, she said that she did not take any notice of the salt that he then consumed. She did say, however, that when her husband was on leave from the army she noticed that he "well and truly used" salt. We think that it is significant that some 60 years after these events occurred, Mrs Ross is able to recall the use of salt by her husband when he was on leave from the army, but could not recall anything extraordinary about his use of salt within the family home prior to his enlistment. We think this is important because if there had been heavy salt consumption by her husband within the family home the observation by her of his salt consumption during discharge would not have been as significant. It follows, in our view, that her late husband had acquired a taste for salt by reason of his army service, as his consumption evidences during leave. Thereafter, it appears, that he developed a lifelong habit of use. We had no evidence presented that the consumption of salt was in any way addictive, but on balance it appears that salt Mr Ross used salt by reason of his preference for it to enhance taste. We find that had its origin in and related to service. It also appears that the deceased did know about the risk of salt consumption. Mrs Ross told us that she frequently commented to him about the quantities of salt that he consumed. Equally, he apparently also ignored her advice. Additionally, Dr Nathaniel said that whilst he had no specific note, he frequently advised patients who suffered from hypertension to reduce their salt consumption. As a fact, we are satisfied this advice was given.
On balance, therefore, we are satisfied that prior to enlistment, the deceased probably did consume salt, but in modest quantities. As a result of his service, he acquired a habit of use that continued after discharge as a civilian. It follows that, on the balance of probabilities, we are satisfied that there is a connection between the circumstances of the deceased's service and his ingestion of 15 grams of salt per day. This averaged for a continuous period of at least six months immediately before the clinical onset of hypertension.
Having regard to the Instruments with respect to ischaemic heart disease, we are satisfied that the deceased did suffer from the presence of hypertension before the clinical onset of ischaemic heart disease (factor 5(a)) in Instrument No. 39 of 1999 and Instrument No 81 of 1998).
Upon the evidence of Dr Byron Collins, Dr Nathaniel and Dr Hammond, we are satisfied that a connection exists between ischaemic heart disease and the fatal infarct suffered by the late Mr Ross.
We are satisfied that the applicable templates of all of the relevant Instruments are satisfied and a connection between service and death does exist.
Insofar as the applications under review are concerned, with the acceptance of hypertension and the claim brought by Mrs Ross for pension by reason of the death of Mr Ross arising out of his myocardial infarction, we are satisfied that those decisions should be set aside. In substitution, decisions will be made that hypertension is war-caused and the circumstances of death are war-caused. The remaining parts of the decisions under review should otherwise be affirmed.

I certify that the 73 preceding paragraphs are a true copy of the reasons for the decision herein of Mr J. Handley, Senior Member
Signed:         Katherine Navarro..........................
  Associate
Date of Hearing  7 May 2002
Date of Decision  21 June 2002
Counsel for the Applicant        Mr Larkin
Solicitor for the Applicant         De Marchi & Associates
Counsel for the Respondent    Mr Purcell
Solicitor for the Respondent    Department of Veterans' Affairs