State of New South Wales (Central Coast Local Health District) v Cook

DETERMINATION OF APPEAL PANEL
CITATION:	State of New South Wales (Central Coast Local Health District) v Cook [2022] NSWPICMP 445
APPELLANT:	State of New South Wales (Central Coast Local Health District)
RESPONDENT:	Shelley Louise Cook
Appeal Panel
MEMBER:	Deborah Moore
MEDICAL ASSESSOR:	Tommasino Mastroianni
MEDICAL ASSESSOR:	Brian Stephenson
DATE OF DECISION:	8 November 2022
CATCHWORDS:	wORKERS cOMPENSATION - Panel agreed that the MA erred in utilising an analogous condition of nerve damage where there was no evidence of such an injury; re-examination required because of conflicting medical evidence; re-examination confirmed the respondent had complex regional pain syndrome; Held – Medical Assessment Certificate revoked.

BACKGROUND TO THE APPLICATION TO APPEAL

On 4 July 2022 State of New South Wales (Central Coast Local Health District) (the appellant) lodged an Application to Appeal Against the Decision of a Medical Assessor. The medical dispute was assessed by Dr Tim Anderson, a Medical Assessor (MA), who issued a Medical Assessment Certificate (MAC) on 7 June 2022.
The appellant relies on the following grounds of appeal under s 327(3) of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act):
· the assessment was made on the basis of incorrect criteria, and
· the MAC contains a demonstrable error.
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 ground(s) of appeal on which the appeal is made.
The WorkCover Medical Assessment Guidelines 2006 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 the WorkCover Medical Assessment Guidelines 2006.
The assessment of permanent impairment is conducted in accordance with the NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4^th ed 1 April 2016 (the Guidelines) and the American Medical Association Guides to the Evaluation of Permanent Impairment, 5^th ed (AMA 5).

PRELIMINARY REVIEW

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.
As a result of that preliminary review, the Appeal Panel determined that the worker should undergo a further medical examination because we agreed that the MA erred in utilising an analogous condition of nerve damage where there was no evidence of such an injury.
The MA also erred in determining that because there is chronic pain, despite not meeting the diagnostic criteria for Chronic Regional pain Syndrome (CRPS), a whole person impairment assessment can be made to reflect chronic pain, contrary to the provisions of Table 17.1 of the Guidelines.

EVIDENCE

Documentary evidence

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

Further medical examination

Dr J Brian Stephenson of the Appeal Panel conducted an examination of the worker on
21 September 2022 and reported to the Appeal Panel on 12 October 2022.

SUBMISSIONS

Both parties made written submissions. They are not repeated in full, but have been considered by the Appeal Panel.
In summary, the appellant submits as follows:
(a)    the MA has taken an approach that because there is chronic pain, despite not meeting the diagnostic criteria for CRPS, a further whole person impairment assessment is warranted to reflect that chronic pain. The appellant submits that such an approach is erroneous;
(b)    the approach taken by the MA is inconsistent with the Guidelines;
(c)    this is because chronic pain by itself, without any other diagnosis, can only produce a rateable impairment when it amounts to CRPS for the purposes of the Guidelines;
(d)    the use of paragraph 1.23 of the Guidelines by the MA amounted to an error, as the condition for which the respondent was being assessed has been provisioned for in the AMA5 and the Guidelines, and
(e)     there was no diagnosed condition not covered by the Guidelines and AMA5.
In reply, the respondent submits that the appropriate course is for her to be re-examined, given the conflict in the medical evidence to which she has referred.

FINDINGS AND REASONS

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.
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.
Ms Cook was referred to the MA for assessment of whole person impairment (WPI) in respect of the “Left upper extremity; CRPS”.
The MA obtained the following history:
“Ms Cook related that she had been working on the Renal Ward. A lot of this was heavy and necessitated the lifting of heavy intravenous filled bags above shoulder height. She started developing pain in her left shoulder. She was referred to Specialist Orthopaedic Surgeon, Dr Jai Kumar. It was identified that there was a small supraspinatus tear and also tendinopathy. Unfortunately she developed a pain condition which was diagnosed at that stage as CRPS.
She was referred to Specialist Pain Management Physician, Dr Simon Tame. He treated her for CRPS which included stellate ganglion blocks. These only gave her limited benefit for about three months at a time and have not been continued.
Despite her condition, she has been able to rehabilitate back to work, although this is reduced.
Specialist Orthopaedic Surgeon, Dr Kumar has advised that it would not be appropriate to carry out a surgical procedure on the shoulder with this condition still in existence.”
The MA noted: “She is on quite extensive analgesic medication and also takes antidepressants”.
As regards present symptoms, the MA said:
“Pain in the left shoulder with reduced movement and power. There is a very unpleasant burning sensation radiating down the arm and equally unpleasant pins and needles in the digits. There have been occasions where there has been swelling and a colour change to purple and also increased sweating. She feels that the condition is gradually deteriorating. Cold climatic conditions make it feel worse and her sleep is disturbed.”
After documenting Ms Cook’s general health, work history and the impact of her injuries on her daily activities, the MA then set out his findings on physical examination as follows:
“She was in a lot of discomfort with her left arm and tended to hold it protectively.
Cervical Spine. There was no complaint of pain or tenderness in the neck. Movement was slightly reduced, particularly with lateral flexion towards the left.
Upper Limbs. There was slight swelling of the left hand and fingers and minimal alteration of colour, but I was unable to demonstrate any significant alteration of temperature and there was no sweating. No dysfunction of the nails was identified either. Sensation was reduced in the left hand and forearm in comparison with the right, although did not follow a peripheral or central distribution.
Movement of the elbows, wrists and all digits was virtually symmetrical.”
The only radiological material the MA had was an MRI of the left shoulder which revealed: “Small partial thickness supraspinatus tear and tendinopathy. No capsulitis identified”.
The MA summarised the injuries and diagnoses as follows:
“Ms Cook sustained a musculo-tendinous injury to her left shoulder which developed over a period of time in early September 2019. It was identified that she had tendinopathy and a small tear of the supraspinatus tendon. This further deteriorated to become a chronic pain condition. Earlier on this was diagnosed as CRPS and was treated by a pain management team along those lines.
At this assessment, although it was fairly obvious that she continues to have a chronic pain condition, this falls well short of the features necessary to unequivocally diagnose CRPS. Nevertheless, it was also fairly obvious that as well as the restriction of movement of the left shoulder, the condition of the left arm is still far from normal despite the absence of the full criteria for CRPS.
Ms Cook’s presentation was consistent.”
The MA assessed 20% WPI in respect of the “Left upper extremity (CRPS)”.
He then turned to consider the other medical opinions stating:
“Specialist Orthopaedic Surgeon, Dr Gregg Burrow in his report of 30/12/21 specifically advises that there was no alteration of temperature, sweating or nail growth, yet still diagnosed CRPS. With the greatest of respect, this is inappropriate and the criteria for CRPS have not been met in his description.
Specialist Pain Management Physician, Dr David Gorman in his report of 03/02/22 advises that there were no definitive signs of CRPS, with which I would agree. His whole person impairment is exclusively associated with reduced movement of the left shoulder, giving a final whole person impairment of 11%. With respect, I would suggest that there should still be a further assessment of the left forearm since it has been demonstrated (by all specialists who have assessed her) that it is still far from normal and therefore, there very reasonably is a need to fairly address this issue, hence my selection of an analogous system using sensory dysfunction of the median nerve below the mid-forearm.”
The appellant submits as follows:
(a)    there was a dispute in the medical evidence before the MA as to whether or not the respondent met the necessary diagnostic criteria set out in the Guidelines for a diagnosis of CRPS to be made for the purposes of assessing WPI;
(b)    Dr Gregg Burrow, orthopaedic surgeon considered the worker met the relevant diagnostic criteria for a diagnosis of CRPS, whereas Dr David Gorman, pain specialist, did not;
(c)    the MA concluded that “at this assessment, although it was fairly obvious that she continues to have a chronic pain condition, this falls well short of the features necessary to unequivocally diagnose CRPS”;
(d)    the MA notes he agrees with the report of Dr Gorman, stating: “Dr David Gorman in his report of 03/02/22 advises that there was no definitive signs of CRPS, with which I would agree”;
(e)    he also specifically disagreed with the opinion of Dr Burrow;
(f)    the MA has taken an approach that because there is chronic pain, despite not meeting the diagnostic criteria for CRPS, a further WPI assessment is warranted to reflect that chronic pain. Such an approach is erroneous;
(g)    the approach taken by the MA is inconsistent with the Guidelines. The Guidelines expressly exclude Chapter 18 of the AMA5 on pain for the reasons set out in paragraph 17.3. Those include, among others, because pain is a subjective experience, it cannot be measured and no objective assessment can be made and tools to measure pain are based on self-reports and may be inherently unreliable;
(h)    the exception to this approach is that a diagnosis of CRPS for the purposes of a WPI assessment can be made if the relevant criteria, which incorporate objective elements, as set out in Table 17.1 of the Guidelines are satisfied;
(i)    the approach taken by the MA is contrary to the explicit direction of the Guidelines when dealing with chronic pain. This is because chronic pain by itself, without any other diagnosis, can only produce a rateable impairment when it amounts to CRPS for the purposes of the Guidelines;
(j)    the way in which the MA made a further assessment of the respondent’s chronic pain in her upper left extremity was to apply paragraph 1.23 of the Guidelines, an approach not open to him;
(k)    paragraph 1.23 cannot be engaged where the relevant condition being assessed is already covered in the Guidelines. It applies, by its own terms, to “unlisted condition[s]”. Its purpose is to ensure that the discovery of new medical conditions can be assessed even if there is no express provision made for their assessment in AMA5;
(l)    in this case, the Guidelines and AMA5 do make provision for the condition for which the respondent had been diagnosed by her treating specialists, namely, CRPS. It is just that for the purposes of assessing any WPI as a result of that condition, the MA found she did not meet the relevant diagnostic criteria set out in the Guidelines for there to be a rateable impairment;
(m)     in this case, the only diagnosis made by the MA was a musculo-tendinous injury to the left shoulder and a chronic pain condition diagnosed by the respondent’s treating specialists as CRPS. The worker’s left shoulder condition was the subject of assessment, for which there was rateable impairment. The only other diagnosis, being the CRPS, was a condition that was covered by the Guidelines and AMA5, and
(n)    in other words, there was no diagnosed condition not covered by the Guidelines and AMA5.
The respondent submits as follows:
(a)    the appellant’s submissions ignore the scope of the amended referral. The amended referral provides the body systems for assessment as relate to the date of injury 6 September 2019 as follows: “Body part/s referred: Left upper extremity, Chronic Regional Pain Syndrome (left upper extremity)”;
(b)    Medical Assessor Anderson was not confined by the amended referral to assess the left shoulder only. Indeed, over and above the left shoulder injury/condition and associated rateable impairment he assessed, he opined that there was a further condition/injury affecting other areas of the left upper extremity and proceeded to assess a rateable impairment of those additional upper extremity areas that did not fit within the other sections of the Guidelines. Accordingly, MA Anderson correctly applied paragraph 1.23 of the Guidelines to rate the impairment of the other areas of the left upper extremity;
(c)    it is clear from a consideration of the material before the MA that the respondent’s impairments to her left upper extremity (not merely the shoulder) were amply sufficient to justify an assessment of WPI in accordance with the amended referral;
(d)    it was not open to the MA to limit his assessment of WPI to the respondent’s injured left shoulder alone, without providing sufficient reasons for imposing such a limitation;
(e)    if the MA had failed to consider the injury/condition affecting the balance of the respondent’s left upper extremity (leaving aside the shoulder) and rate the obvious impairment in accordance with the Guidelines, this would have amounted to an error, and
(f)    the appellant’s contention that the MA’s application of the Guidelines amounts to an error, is misplaced.
The respondent then added:
(a)    if the MAP is against the respondent on the above then the following is submitted;
(b)    the appellant seeks the MAP revoke the MAC and “…in its place, the respondent should be assessed at 11% WPI, in accordance with the opinion of Dr David Gorman”;
(c)    the relief sought by the appellant calls for acceptance of the assessment of
Dr Gorman which expressly excludes the diagnosis of CRPS but also then relying on the findings of the examination as conducted by Dr Gorman. The approach is problematic when considering the above and the date of the assessment conducted by Dr Gorman (3 February 2022);
(d)    the appellant’s submissions do not address why the approach suggested might be appropriate;
(e)    further to the above, the submissions advanced by the appellant ignore the clinical findings made by the MA:
(i)slight swelling of the left hand and fingers;
(ii)minimal alteration of colour;
(iii)sensation reduced in the left hand and forearm in comparison with right although same did not follow a peripheral or central distribution, and
(iv)reduced range of left shoulder range of motion when compared to the right.
(f)    when compared to the findings of Dr Gorman on 3 February 2022 there are differences including Dr Gorman not finding alteration of colour or swelling;
(g)    the conclusion/opinion of Dr Gorman regarding the respondent/worker’s appropriate diagnosis of “adhesive capsulitis” is inconsistent with the objective radiological findings in the MRI scan conducted on 4 March 2022. The conclusion of Dr Gorman is one that is not supported by any other clinical specialist and is specifically and unambiguously excluded on radiological investigations;
(h)    even the respondent has identified this blatant error in Dr Gorman’s opinion/conclusion in her statement dated 14 April 2022. At paragraph 17 [she] states: “For an abundance of clarity, I must emphasise that I have never received any diagnosis of adhesive capsulitis and of course, I have never been treated for that either”. At paragraph 23 [she] states: “On 4 March 2022, I underwent further MRI imaging of the left shoulder. The report unambiguously and definitively states: “No capsulitis present”. At paragraph 24 [she] states: “On 24 March 2022, I had a further consult with Dr Kumar. It is apparent that the MRI images specifically exclude any possibility of ‘adhesive capsulitis’. Dr Kumar’s report of 24 March 2022 actually refers to my ‘quite profound CRPS’;
(i)    the appellant is asking the MAP to revoke the MAC and prefer the flawed and erroneous opinion of Dr Gorman;
(j)    there is no dispute that the respondent/worker suffers (or at least has suffered) from CRPS;
(k)    various medical specialists have diagnosed CRPS in the left upper extremity;
(l)    as peculiar to the particular condition of CRPS, the objective criteria must also be satisfied when assessing the degree of permanent impairment on the date of the assessment, and
(m)     the respondent submits that, rather than dismissing the appeal the appropriate relief is for a Member of the MAP to properly re-examine the respondent pursuant to s 328(2A) of the 1998 Act.
The Panel agreed with some of the appellant’s submissions which we noted in our preliminary review referred to above.
Equally we considered that, given the conflicting medical opinions, it was appropriate for the respondent to be re-examined.
Dr J Brian Stephenson conducted the re-examination on 21 September 2022 and reported to the Panel on 12 October 2022.
He reported as follows:
“1. The worker's medical history, where it differs from previous records.
The claimant Shelley Cook was Enrolled Nurse in Renal Unit/Ward of Gosford Hospital. During the period with daily employment duties and the nature and conditions of her employment encompassing 6 September 2019 to 12 September 2019, a significant amount of repetitive bending, twisting, manual handling and lifting of awkward heavy stock (bags/packets of dialysis fluid), loading/unloading on/off trolleys and lifting and hooking up on various equipment apparatus. There was the development of significant pain in left upper extremity and cervical spine.
This is a situation where complex regional pain syndrome is diagnosed based on the following facts and findings.
Dr Simon Tame, Pain Specialist, diagnosed neuropathic left arm pain, responding well to intermittent stellate ganglion blocks. She had to receive a further series of stellate ganglion blocks early the following year in his report of 17 September 2021. Sought approval of this series of three left-sided stellate ganglion blocks combined with pulsed radiofrequency neurotomy treatment under x-ray guidance in early 2022.
Diagnosis: CRPS-1. The reference is to page 80, clause 17 of Evaluation of Permanent Impairment arising from chronic pain where there must be a requisite number of symptoms and physical signs, reference page 81, table 17-11, SIRA Guidelines.
On page 80, for CRPS to be present for assessment:
·    The diagnosis is to be confirmed by criteria table 17.1.
·    The diagnosis has been present for at least one year; to ensure accuracy in the diagnosis and to permit adequate time to achieve maximum medical improvement. That requirement has been met as from the workplace injury statement. It is confirmed it was related to nature and condition of employment now three years ago from 6 September 2019 to 12 September 2019.
·    The diagnosis has been verified by more than one examining physician. In fact, it has been a diagnosis by three examining physicians.
1. Dr Simon Tame.
2. Dr Greggory Burrow, orthopaedic surgeon, on 3 December 2021, who advised Ms Cook’s shoulder pathology by way of a partial or small tear of the rotator cuff, has been complicated by a Chronic Regional Pain Syndrome (CRPS). Her treatment to date has been appropriate by way of non-operative, but she has marked ongoing symptoms and disabilities.
Applying the requirements of CRPS required for the WorkCover Guidelines at left upper extremity, Dr Greggory Burrow noted the diagnosis has been made by
Dr Kumar, Orthopaedic surgeon, at page 4 of Dr Burrow’s report under the heading Chronic Pain Syndrome but referring to “September 2020, Dr Kumar diagnosed (CRPS) and recommended a referral to a pain team. This has been done with referral to Dr Simon Tame.
Findings on clinical examination.
a. CRPS-1:
Shelley Cook advised she started nursing in 2001 as an Enrolled Nurse. The claimant in her statement falling on 14 April 2022 noted as I mentioned above that Dr Greggory Burrow diagnosed CRPS-1 as did rheumatologist Dr Stephen Potter. The history from the claimant is that she sustained a significant tear in left shoulder and came under the care of Dr Jai Kumar, Orthopaedic Surgeon, as she developed severe neuropathic pain with limited range of motion in left upper extremity.
On 29 September 2020, she noted Dr Simon Tame confirmed the unequivocal CRPS diagnosis. For treatment, Shelley Cook has been having physiotherapy for left shoulder.
Reference to page 80, chapter-17 for evaluation of permanent impairment arises from chronic pain, complex regional pain syndrome type 1, for the purpose of assessment:
·    A diagnosis should be confirmed by criterion table 17.1, page 81, where the diagnosis should have been present for at least one year (ensure accuracy of the diagnosis and to permit adequate time to achieve maximum medical improvement).
I note that has been achieved as date of injury was in September 2019 due to nature and condition of employment encompassing 6 to 12 September 2019.
·    The diagnosis has been verified by more than one examining physicians. That has been achieved. Dr Simon Tame, pain specialist; Dr Stephen Potter, consultant rheumatologist; and Dr Gregory Burrow, orthopaedic surgeon.
·    Other possible diagnoses have been excluded.
·    CRPS-1 states as follows: Applying the diagnostic criteria for CRPS type-1 table 17.1. Referencing table 17.1: 1) Continuing pain which is disproportionate to any causal event. 2) Must report at least one symptom in each of the following four categories:
o   Sensory: Reports hyperesthesia and also allodynia.
o   Vasomotor: Reports skin colour changes and skin colour asymmetry. She advised the right arm goes purplish blue and is cooler.
o   Sudomotor/oedema: Reports oedema and/or sweating increase or decrease and/or sweating asymmetry. She reports sweating in the left palm and oedema with ongoing “puffy around the knuckles”.
o   Reports decreased range of joint motion in the fingers of the left hand and in the three larger joints of left upper extremity namely shoulder, elbow and wrists. She reports motor dysfunction, not being able to hold a coffee cup in the left hand and also she drops things with the left hand. In addition, she reports tremor in left upper extremity. She reports trophic changes in the nails of the left hand, which she has now applied false nails.
Must display at least one sign at the time of evaluation in all of the following four categories:
·    Sensory: There is evidence of hyperalgesia to pinprick using the Neurotip device and also allodynia to light touch with an obvious withdrawal of the hand.
·    Vasomotor: There is evidence of temperature asymmetry and also asymmetric skin colour changes with the left hand turning to purplish blue, with dependency of the left upper extremity.
·    Sudomotor/oedema: There is evidence of oedema in the left hand specifically around the knuckles area. There is evidence of decreased active joint range of motion and also motor dysfunction with tremor, left hand. Therefore, there is motor/trophic dysfunction with tremor, left hand and/or trophic changes in nails of left hand.
·    Motor/trophic: There is evidence of decreased active joint range of joint motion of the three large joints of the left upper extremity as well as all the fingers of the left hand.
Referencing restriction in range of motion in three large joints of right upper extremity, AMA 5, Chapter 16, full range of motion of the opposite unaffected/uninjured right upper extremity.
Large joints of the left upper extremity, reference AMA5, reference page 467 to 469, figure 16-28 and figure 16-31
Elbow: Page 472 to 474, figure 16-34 to figure 16-37.
Shoulder: Page 476 to 479, figure 16-40 to figure 16-46.
The above impairment assessment range from figure 16-1b, upper extremity impairment evaluation record part 2 wrist, elbow and shoulder, page 437 AMA5. The three large joint values entered on figure 16-1b gaining 14% upper extremity wrist, 7% upper extremity elbow and 22% upper extremity shoulder. These regional impairments are combined with a combination of higher to lower value, that is 22, 14 with 7 which is subsequently combined with the hand value, which is expectedly the highest entry on the figure 16-1b chart.
On examination of the left hand restriction, second to fifth fingers flexion 30°, extension 0 at MP joint.
At PIP joints, 2 to 5, flexion 60°, extension 0.
DIP joints, 2 to 5, flexion 30° and extension 0.
These values are entered on figure 16-1a, upper extremity impairment evaluation record part-1 hand, left.
For thumb abnormal motion 18% which is recorded on the final column of Figure 16-1a. The total digital impairment was therefore 18% which converts on the conversion table page 438 to 439 of AMA5. 18% of thumb equals 7% hand. For the four fingers, a combination of 25 with 21 with 12 gains 48% for digit. For index and middle fingers, 48% digit equals 10% hand. For ring and little finger, 48% digit equals 5% hand.
That combines with the pain figure reference AMA5 page 482, table 16-10 where I assess Grade 3. Grade 3 is distorted superficial tactile sensibility (diminished light touch and 2-point discrimination with some abnormal sensation, also a pain that interferes with some activities. The maximum sensory deficit is chosen CRPS-1 and that is 60% sensory deficit. The value of each of the four fingers, as I noted, gains 48% abnormal motion and that combines with 18% abnormal motion for left thumb. A combination of 48 with 18 gains 57% upper extremity. That combines with sensory deficit of 60% upper extremity. 60 with 57 gains a total upper extremity value of 83%.
The impairment for the upper extremity impairment evaluation record part-1 at page 436, AMA5 has been completed and the total hand impairment is added for thumb and the four digits; that being the addition of 7 + 10 + 10 + 5 + 5. That gives 37% hand impairment which equates to 33% upper extremity which is then combined with 22% upper extremity for the left shoulder, 14% for the wrist and 7% for the elbow. The total combined value is 58% upper extremity which combines with a pain assessment namely page 482, table 16-10, description of sensory deficit or pain. That final range of motion loss for left upper extremity of 58% combines with 60% sensory deficit.
That combines as 58% upper extremity with 60% that achieves 83% which converts to 50 % WPI.
There is no deductible proportion in the absence of previous injury, condition or abnormality.
Conclusion: There is a 50% whole person impairment for the left upper extremity CRPS-1.”

The appellant submitted that there was no or insufficient evidence before the MA for a diagnosis of CRPS.
However, as the appellant correctly pointed out:
“In this case, the Guidelines and AMA5 do make provision for the condition for which the respondent had been diagnosed by her treating specialists, namely, CRPS. It is just that for the purposes of assessing any WPI as a result of that condition, the MA found she did not meet the relevant diagnostic criteria set out in the Guidelines for there to be a rateable impairment.”
The Panel agrees with the findings and assessment of Dr Stephenson. It is also consistent with the opinions of Ms Cook’s treating specialists, Dr Kumar and Dr Tame.
Dr Gorman concluded that there were no definitive signs of CRPS.
The MA agreed, but qualified his opinion with the following comment:
“[Dr Gorman’s] whole person impairment is exclusively associated with reduced movement of the left shoulder, giving a final whole person impairment of 11%.
With respect, I would suggest that there should still be a further assessment of the left forearm since it has been demonstrated (by all specialists who have assessed her) that it is still far from normal (our emphasis) and therefore, there very reasonably is a need to fairly address this issue…”
In short, even the MA conceded that there were, at the time of his assessment, some signs of CRPS.
Re-examination by the Panel has confirmed this.
For these reasons, the Appeal Panel has determined that the MAC issued on 7 June 2022 should be revoked, and a new MAC should be issued. The new certificate is attached to this statement of reasons.

PERSONAL INJURY COMMISSION

APPEAL PANEL

MEDICAL ASSESSMENT CERTIFICATE

Injuries received after 1 January 2002

Matter Number:	W2377/22
Applicant:	Shelley Louise Cook
Respondent:	State of New South Wales (Central Coast Local Health District)

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

The Appeal Panel revokes the Medical Assessment Certificate of Dr Tim Anderson 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 WorkCover Guides	Chapter, page, paragraph, figure and table numbers in AMA 5 Guides	% WPI	Proportion of permanent impairment due to pre-existing injury, abnormality or condition	Sub-total/s % WPI (after any deductions in column 6)
1.Left upper extremity-CRPS	06/09/19	Page 80-81 Para. 17.5 Table 17.1	50%	N/A	50%
2.
Total % WPI (the Combined Table values of all sub-totals)					50%

[2022] NSWPICMP 445

8 November 2022