YNCJ and Comcare (Compensation)
[2025] ARTA 1293
•7 August 2025
YNCJ and Comcare (Compensation) [2025] ARTA 1293 (7 August 2025)
Applicant/s: YNCJ
Respondent: Comcare
Tribunal Number: 2023/8393, 2024/2705
Tribunal:General Member M. Carey
Place:Perth
Date: 7 August 2025
Decision:
Application 2023/8393
The Tribunal sets aside the decision under review and in substitution decides:
1.The applicant is entitled to compensation pursuant to section 24 of the Safety, Rehabilitation and Compensation Act 1988 for permanent impairment resulting from the injury, ‘major depressive disorder and generalised anxiety disorder’, assessed at 25 percent in accordance with Table 5.1 of the approved Comcare guide (Edition 3.0).
2.The applicant is entitled to compensation pursuant to section 27 of the SRC Act, in the amounts calculated in:
a.Part A, by reference to the assessed 25 percent impairment; and
b.Part B, by reference to assessed scores set out below and tallying to 13.2/15 or 88 percent in accordance with Part 1, Division 2 of the approved Comcare guide (Edition 3.0).
i.Pain: 0
ii.Suffering: 4
iii.Mobility: 4
iv.Social relationships: 3
v.Recreation and Leisure: 5
vi.Other Loss: 2
vii.Loss of Expectation of Life: 0
3.The respondent shall pay the applicant’s reasonable disbursements in preparation of the matter.
Application 2024/2705
1.The Tribunal sets aside the decision under review and in substitution decides:
a.The applicant is entitled to compensation pursuant to section 16 of the Safety, Rehabilitation and Compensation Act 1988 for the cost of fish and krill oil as medical treatment for the left knee injury that is reasonable to obtain in all the circumstances.
2.The respondent shall pay the applicant’s reasonable disbursements in preparation of the matter.
.......................[SGD]...................................
General Member M. Carey
Catchwords
INJURY – consequential injury – psychological injury causally related to primary physical injury arising out of employment – diagnosis of major depressive disorder and general anxiety disorder – whether one injury or two – role of diagnostic manual DSM-5-TR or similar – whether diagnosis determines injury – single but distinct injury identified by evidence of its origin, nature and progress.
IMPAIRMENT – psychological injury resulting in impairment likely to continue indefinitely – major depressive disorder and generalised anxiety disorder – degree of impairment assessed by reference to approved Guide Edition 3.0 at 25 percent.
NON-ECONOMIC LOSS – assessment in accordance with approved Guide Edition 3.0 – whether pain results from psychological injury – whether effects too remote – reduction of life expectancy – acknowledged risk of suicide – reduction of life expectancy measured in years – estimate of 10 years – whether risk of suicide can be treated as more likely than not – evidence insufficient to identify number of years of loss of expectation of life.
MEDICAL TREATMENT – fish and krill oil – used to moderate pain and stiffness of compensable left knee injury – whether medical treatment in relation injury – therapeutic treatment under direction of medical practitioner.
Legislation
Administrative Review Tribunal Act 2024
Safety Rehabilitation and Compensation Act 1988Guide to the Assessment of the Degree of Permanent Impairment Edition 3.0
Cases
Canute v Comcare [2006] HCA 47; (2006) 226 CLR 535
Eaves v Blaenchlydach Colliery Company Limited [1909] 2 KB 73
Fellows v Military Rehabilitation and Compensation Commission [2009] HCA 38; (2009) 240 CLR 28
Heales and Comcare [2018] AATA 3788
Comcare v Mooi (1996) 69 FCR 439
Plumb v Comcare (1992) 39 FCR 236
Rana v Military Rehabilitation and Compensation Commission [2008] AATA 588; (2008) 48 AAT 385
Robson v Military Rehabilitation and Compensation Commission [2013] FCAFC 101; (2013) 214 FCR 1
Slattery v Comcare (1996) 70 FCR 131
William Purdon and Comcare [1997] AATA 466Secondary Materials
American Psychiatry Association, Diagnostic and Statistical Manual of Psychiatric Disorders. Fifth Edition (DSM-5)
American Psychiatry Association, Diagnostic and Statistical Manual of Psychiatric Disorders. Fifth Edition, Text Revision (DSM-5-TR)
Clinical Framework for the Delivery of Health Services published by WorkSafe and Transport Accident Commission of VictoriaStatement of Reasons
The applicant in these proceedings is named YNCJ, a pseudonym used because of an order made in the proceedings pursuant to section 70 of the Administrative Review Tribunal Act 2024 (ART Act).
The applicant is a Commonwealth public servant, employed since 2007 by Services Australia in the State of Western Australia. She remains an employee though she has not performed any duties since 30 November 2021.
On 6 December 2016, having transferred to the Perth Office of Services Australia only the day prior, she was seated at her workstation when suddenly the seat on her gas lift chair dropped, causing her to twist her left knee, thereby sustaining injury. Following investigation, it was discovered that she had sustained tears to the meniscus of the left knee and underwent arthroscopy on 7 February 2027. By reason of what was discovered during that procedure, the surgery was more complicated and YNCJ had a more prolonged and complex recovery.
Comcare accepted liability to pay compensation for the left knee injury pursuant to section 14 of the Safety Rehabilitation and Compensation Act 1988 (SRC Act) by determination dated 2 February 2017.[1]
[1] T5, 144-122.
What followed was the persistence of left knee disability, increasingly intractable pain and the development of a chronic pain syndrome as well as the development of a psychological condition, initially diagnosed as an adjustment disorder, but which deteriorated to the stage where YNCJ now suffers from major depressive disorder and generalised anxiety disorder. Liability for the psychiatric condition was the subject of a dispute before the former Administrative Appeals Tribunal. The decision in that case, YNCJ and Comcare (Compensation) [2019] AATA 4795, was made on 1 November 2019 and found liability to pay compensation pursuant to section 14 of the SRC Act ‘for the psychological conditions of Major Depressive Disorder Recurrent (moderate) and Generalised Anxiety Disorder, as diagnosed by Clinical Psychology Registrar Mary Roberts, which are secondary to the Applicant’s left knee injury’.[2]
[2] T86, 475.
After dealing for some years with these injuries, on 28 April 2023, YNCJ lodged claims for lump sum compensation for permanent impairment and non-economic loss resulting from the left knee injury and the consequential chronic pain syndrome, major depressive disorder and generalised anxiety disorder, pursuant to sections 24 and 27 of the SRC Act.[3] Decisions were made in those claims which were reviewed internally and then became the subject of review at the Tribunal. Applications for review of the decisions of Comcare in relation to the impairment to the left knee injury (Tribunal number 2024/4477) and chronic pain syndrome (Tribunal number 2024/4484) were resolved following written agreement of the parties as to the terms of a decision by pursuant to section 103 of the ART Act which was made on the first morning of the hearing of these matters.
[3] T115, 591-658.
Dispute – costs of fish and krill oil treatment
There was a further dispute concerning the denial of liability by Comcare pursuant to section 16 of the SRC Act to pay compensation for the cost of fish and krill oil. The applicant uses these oils to deal with the pain and stiffness caused by inflammation resulting from the left knee injury. That reviewable decision of 1 May 2024 (Tribunal number 2024/2705) proceeded to the hearing. This decision will set out reasons why the Comcare decision denying liability for the cost of treatment by way of fish and krill oil used is set aside.
Dispute – psychiatric impairment and non-economic loss
The remaining dispute concerning the liability to pay compensation for permanent impairment in respect of the consequential psychological condition (Tribunal number 2023/8393) was not resolved by consent.
There is a significant issue whether the psychiatric injury is a single injury of ‘major depressive disorder and generalised anxiety disorder’, as accepted by Comcare or whether there are two separate psychiatric injuries – major depressive disorder (MDD) on the one hand, and generalised anxiety disorder (GAD) on the other, as contended by YNCJ.
The assessment of the degree of impairment consequently is affected. Comcare originally determined the degree of impairment in respect of impairment for the psychiatric condition to be 15 percent in its primary determination dated 4 September 2023[4] assessed on Table 5.1 of the approved Comcare Guide, Edition 3.0 based on the original report and assessment of Dr Zeeva Cohen, consultant psychiatrist, dated 27 June 2023[5]. That was relevant to the quantification of the entitlement to lump sum compensation pursuant to section 24 of the SRC Act. That report was in contrast to the assessment of Dr Arief Mulyadi, which rated the impairment at 25 percent in a statement attached to the claim for lump sum compensation for the psychiatric injury.[6]
[4] T124, 712-721.
[5] T121, 680-693.
[6] T115, 652.
YNCJ also completed a non-economic loss questionnaire, relevant to the assessment of her entitlements pursuant to section 27 of the SRC Act. A summary of the scores asserted for the various elements from that questionnaire completed on 11 April 2023 in relation to ‘major depressive disorder and generalised anxiety disorder’ (T115, 637-658)
(a)Pain: 4
(b)Suffering: 4
(c)Mobility: 4
(d)Social Relationships: 3
(e)Recreation and leisure: 5
(f)Other Loss: 2
(g)Loss of Life Expectancy: Dr Mulyadi indicated ‘More than 10 years, less than 20 years’. In respect of his assessment of loss of life expectancy, Dr Mulyadi indicated a loss of 'more than 10 years, less than 20 years' at that stage and commented:[7]
~ 10 years. Patient is at regular risk of suicide. The patient has also admitted to occasional episodes of binge eating and binge alcohol drinking. This behaviour can lead to other co-morbidities such as cardiovascular disease and diabetes which can ultimately reduce patient's life expectancy.
[7] T115, 648.
Comcare’s determination dated 4 September 2023 assessed those elements rather differently:[8]
(a)Pain: 0
(b)Suffering: 4
(c)Mobility: 0
(d)Social Relationships: 3
(e)Recreation and leisure: 0
(f)Other Loss: 0
(g)Loss of Life Expectancy: 0
[8] T124, 712-721.
Comcare’s reviewable decision of 8 November 2023 affirmed its own determination in all respects.[9]
[9] T127, 750-757.
For the reasons outlined below the reviewable decision must be set aside. I have found that there is a single psychiatric injury, not two as contended by YNCJ. However, on the evidence, the assessment of the degree of impairment and non-economic loss made by Comcare is inadequate and a new assessment will be substituted.
Legislation
Where an employee suffers injury that results in death, incapacity for work or impairment, Comcare is liable to pay compensation pursuant to section 14(1) of the SRC Act:
14 Compensation for injuries
(1) Subject to this Part, Comcare is liable to pay compensation in accordance with this Act in respect of an injury suffered by an employee if the injury results in death, incapacity for work, or impairment.
The word ‘impairment’ is defined in subsection 4(1) of the SRC Act:
impairment means the loss, the loss of the use, or the damage or malfunction, of any part of the body or of any bodily system or function or part of such system or function.
The word ‘injury’ is defined in section 5A(1) of the SRC Act to include injury in the primary sense as well as disease and included the aggravation of injury or disease:
5A Definition of injury
(1) In this Act:
injury means:
(a) a disease suffered by an employee; or
(b) an injury (other than a disease) suffered by an employee, that is a physical or mental injury arising out of, or in the course of, the employee’s employment; or
(c) an aggravation of a physical or mental injury (other than a disease) suffered by an employee (whether or not that injury arose out of, or in the course of, the employee’s employment), that is an aggravation that arose out of, or in the course of, that employment;
but does not include a disease, injury or aggravation suffered as a result of reasonable administrative action taken in a reasonable manner in respect of the employee’s employment.
By section 16 of the SRC Act, Comcare is liable to pay compensation for the costs of medical treatment obtained ‘in relation to’ a compensable injury and the was ‘reasonable for the employee to obtain in the circumstances’:
16 Compensation in respect of medical expenses etc.
(1) Where an employee suffers an injury, Comcare is liable to pay, in respect of the cost of medical treatment obtained in relation to the injury (being treatment that it was reasonable for the employee to obtain in the circumstances), compensation of such amount as Comcare determines is appropriate to that medical treatment.
Medical treatment is defined in subsection 4(1) of the SRC Act and includes ‘(b) therapeutic treatment obtained at the direction of a legally qualified medical practitioner’. The expression ‘therapeutic treatment’ is given an inclusive definition in subsection 4(1) of the SRC Act:
therapeutic treatment includes an examination, test or analysis done for the purpose of diagnosing, or treatment given for the purpose of alleviating, an injury.
Where injury results in permanent impairment, compensation is payable pursuant to section 24 of the SRC Act.
24 Compensation for injuries resulting in permanent impairment
(1) Where an injury to an employee result in a permanent impairment, Comcare is liable to pay compensation to the employee in respect of the injury.
The word ‘permanent’ in relation to impairment, is defined in subsection 4(1) of the SRC Act:
permanent means likely to continue indefinitely.
The assessment of the level of permanent impairment must be conducted in accordance with the methods identified in subsections 24(3)-(6) of the SRC Act:
(3) Subject to this section, the amount of compensation payable to the employee is such amount, as is assessed by Comcare under subsection (4), being an amount not exceeding the maximum amount at the date of the assessment.
(4) The amount assessed by Comcare shall be an amount that is the same percentage of the maximum amount as the percentage determined by Comcare under subsection (5).
(5) Comcare shall determine the degree of permanent impairment of the employee resulting from an injury under the provisions of the approved Guide.
(6) The degree of permanent impairment shall be expressed as a percentage.
There is a threshold for the award of compensation established by subsection 24(7) of the SRC Act. Where the degree of impairment resulting from an injury, when assessed as a percentage, is less than 10 percent, no amount of compensation is payable pursuant to section 24 or 27 of the SRC Act (save for some exceptions relating to hearing loss, the loss of, or loss of use of, a finger or a toe or impairment constituted by the loss of the sense of taste or of smell).
The ‘approved Guide’ referred to is authorised by section 28 of the SRC Act as a written document which may be varied from time to time and is a legislative instrument approved by the relevant Minister. At the present time there is a Guide to the Assessment of the Degree of Permanent Impairment Edition 3.0 which commenced operation on 1 April 2023 (approved on 7 March 2023 and registered as F2023L00203) and which is the ‘approved Guide’ for the purposes of the present application.
In addition to the lump sum compensation payable pursuant to section 24, there is a further entitlement to compensation pursuant to section 27 of the SRC Act in respect of ‘non-economic loss.’
27 Compensation for non-economic loss
(1) Where an injury to an employee results in a permanent impairment and compensation is payable in respect of the injury under section 24, Comcare is liable to pay additional compensation in accordance with this section to the employee in respect of that injury for any non-economic loss suffered by the employee as a result of that injury or impairment.
(2) The amount of compensation is an amount assessed by Comcare under the formula:
($15,000 x A) + ($15,000 x B)
where:
A is the percentage finally determined by Comcare under section 24 to be the degree of permanent impairment of the employee; and
B is the percentage determined by Comcare under the approved Guide to be the degree of non-economic loss suffered by the employee.
The ‘maximum amount at the date of the assessment’ referred to in subsection 24(3) and set by subsection 24(9) of the SRC Act is $80,000. That amount and the amount of $15,000 for non-economic loss twice referred to in subsection 27(2) are subject to indexation in accordance with section 13 of the SRC Act.
Background
YNCJ first commenced employment with Services Australia on or about 19 November 2007. She worked on a full-time basis as a Service Officer (APS 3 Level) providing telephone service assistance to customers and, after gaining experience, she gave telephone assistance to other service providers. She was offered higher duties at the APS 4 level as a Program Support Officer in 2014 and by 30 May 2016 was promoted to a permanent position in that role. She delivered training for Service Officers and provided one-to-one support for Service Officers and handling customer complaints.
On 6 December 2016 she suffered her left knee injury when sitting at a pneumatic lift chair at work it suddenly dropped down and she twisted the left knee. By early 2017 she lodged a compensation claim for her left knee injury. Liability to pay compensation was accepted by Comcare on 3 February 2017.
On 7 February 2017, Mr Ian Skinner, her treating orthopaedic surgeon, performed a repair of the medial and lateral meniscal tears at the Fiona Stanley Hospital. The surgery was more extensive than originally planned, owing to the nature of the damage inspected upon the operation commencing. She was on crutches for some weeks following surgery and used a hinged knee brace for about six weeks.
In the period shortly after surgery, her treating general practitioner reported the development of psychological distress. In the certificate of 15 March 2017, he noted YNCJ needed a ‘few sessions with Psychologist – Help with stress associated with the impact of the knee injury to the patient’s professional and personal life’. On 28 April 2017, Dr Mulyadi, the treating general practitioner, noted in his clinical notes that his patient was consideration ‘lodging an application for a secondary injury - emotional and mental stress manifested by anxiety, stress, difficulty sleeping. and low mood --- due to the slow pace of rehabilitation / recovery and the effect of the injury to her personal and professional life.’[10]
[10] T31, 189.
Dr Mulyadi was also concerned about the degree of pain experienced following surgery. In a letter of 26 May 2017, he noted his patient ‘has been feeling very frustrated and anxious as she doesn’t seem to be progressing well in terms of her mobility and pain. Walking for only a short duration and distance can instantly give her pain and tightness (felt on the ITB region as well as on suprapatellar region).’[11] He also noted that she had allergies (or at lease adverse reactions) to Augmentin, an anti-biotic, Morphine and Oxycodone, analgesics which caused severe dizziness, nausea and migraine.
[11] T21, 152-153.
On 25 May 2017, Mr Skinner, the treating orthopaedic surgeon, wrote to the Hammond Park Family Practice stating:[12]
[YNCJ] continues to have knee pain. She has low back pain. She has a number of symptoms secondary to her knee and back pain.
[YNCJ] reports disturbance of sleep. As a result, headaches.
[YNCJ] reports that she can walk around a shopping centre no more than 300 m and she suffers from pseudo-locking of her knee which can set her back for a week. She reports swelling of the knee.
[YNCJ] has begun seeing a physiotherapist at Aubin Grove. Michael Oostryck has been seeing her. Michael believes that some of [YNCJ]’s pain arises from the patellofemoral joint/patellofemoral maltracking.
Today we’ve had a long discussion. I’ve advised [YNCJ] that there is no doubt that she has mechanical problems and that these need to be treated. I have advised her that it is my view that her anxiety about her symptoms is compounding the pain she notes. I believe that it would be of benefit for [YNCJ] and to spend some time with an Occupational Therapist who specialises in pain management. This would be to give [YNCJ] some techniques to reduce level of anxiety. She volunteered that she did not want to use medication for this and, I was not considering it in any case.
I think after the CT scan to quantify the patellofemoral maltracking it will be appropriate for the McConnell regime to be introduced. I advised [YNCJ] that the McConnell regime can be expected to increase her symptoms in the short term. We have a problem with analgesia in that [YNCJ] is unable to tolerate NSAIDs. She also has side effects to a number of analgesics. She has not had the Di-Gesic prescription filled as she is concerned about the possible side effect of suicidal ideation. She has proven quite sensitive to various analgesics. It may be necessary to consider an unusual analgesic for her.
[12] T25, 158.
The claims manager, Allianz Australia, wrote to YNCJ on 30 May 2017 stating that from information provided by her treaters, it appeared that there were secondary medical conditions and invited YNCJ to make a claim for compensation ‘to add a secondary condition to the above claim’.[13]
[13] T27, 162.
YNCJ accepted that invitation and made a further claim for ‘adjustment disorder’. On 8 September 2017, Comcare rejected liability in respect of 'somatic symptom disorder (somatization disorder) and adjustment disorder with mixed anxiety and depressed mood (adjustment disorder with mixed emotional features),' That decision was maintained following internal review in a reviewable decision dated 9 November 2017.[14] YNCJ sought review at the Administrative Appeals Tribunal.
[14] T39, 259.
YNCJ was referred to Ms Mary Roberts for psychological counselling which commenced on 6 November 2017. Ms Roberts has a particular speciality in pain management.
In a 6 February 2018 report, Ms Roberts noted a diagnosis of an ‘adjustment disorder with significant depression and anxiety secondary to her chronic pain together with clinical insomnia.’[15]
[15] T53, 341.
YNCJ’s psychological condition deteriorated and on 6 March 2018, her treating psychologist, Ms Mary Roberts, advised Dr Mulyadi that his patient met the criteria for ‘296.32 Major Depressive Disorder Recurrent (moderate) and 300.02 Generalised Anxiety Disorder, both of these are secondary to her chronic pain. She also displays signs of adjustment disorder and clinical insomnia.’[16]
[16] T54, 344.
Dr Yue Chong (Olivia) Lee, a consultant psychiatrist, examined YNCJ on behalf of the Department of Human Services, the employer, and reported on 6 September 2018: [17]
The diagnosis is adjustment disorder with anxiety and low mood secondary to chronic pain. Differential diagnosis of somatic symptom disorder with predominant pain … I have subsumed her preoccupation with somatic symptoms as part of the manifestation of anxiety, depression symptoms secondary to the development of chronic pain from her knee.’
[17] T67, 388.
About three years later, Dr Lee was again engaged by the Department of Human Services to examine YNCJ and reported on 30 August 2021, her diagnosis as ‘adjustment disorder secondary to chronic pain’ with the following qualification:[18]
The diagnosis can be construed as a chronic adjustment disorder because the stressor of the pain syndrome is chronic. Alternatively, it could be construed as a major depressive disorder with anxiety features or equally as a generalised anxiety disorder with major depressive features but all of these would be on a background of the previously noted rigidity in personality function - in being perfectionistic, preoccupied by rules and detail which have not been amenable to attempts at psychological treatment.
[18] T100, 525.
The diagnosis of major depressive disorder (MDD) and generalised anxiety disorder (GAD) first made by Ms Roberts was accepted by the Tribunal in its decision, YNCJ and Comcare (Compensation) [2019] AATA 4795 made on 1 November 2019 in accepting the liability pursuant to section 14 of the SRC Act.
On 21 November 2021, YNCJ was advised by her employer that she was not required to attend work with effect from 30 November 2021.
On 28 April 2023, YNCJ made claims for lump sum compensation for permanent impairment and non-economic loss for the following conditions:[19]
(1) Left knee injury (meniscal tears), dated and signed 30 March 2023;
(2) Chronic Pain Syndrome, dated and signed 4 April 2023; and
(3) Major Depressive Disorder and Generalised Anxiety Disorder, dated and signed 11 April 2023.
[19] T115, 591-658.
Evidence
The following documents were admitted into evidence:
A1 Non-economic loss statement by YNCJ dated 12 May 2025
A2 Joint report Dr Arief Mulyadi, treating general practitioner, and Mary Roberts, treating clinical psychologist, dated 30 October 2024
A3 Report of Mary Roberts dated 5 May 2025
A4 Report of Mary Roberts 15 May 2024
A5 Report of Mary Roberts 22 May 2024
A6 Fitness for duty report of Dr Olivia Chong, psychiatrist, dated 30 August 2021
A7 Article by Stonehouse et al, ‘Krill oil improved osteoarthritic knee pain’ American Journal of Clinical Nutrition’ 2022
A8 General Practitioner Progress Certificate 24 April 2025
A9 Email dated 6 May 2025 from Comcare, confirming date range of its prior acceptance of liability for the costs of treatment by Fish Oil and Krill Oil
R1 Supplementary report Dr Cohen 2 May 2024
R2 Supplementary report Dr Cohen 23 Sep 2024
R3 Supplementary report Dr Cohen 3 Apr 2025
R4 Supplementary report Dr Hardisty 29 July 2024 together with attached article, Laslett et al, ‘Krill oil for knee osteoarthritis: a randomised clinical trial’.
R5 Clinical notes upon which Dr Mulyadi and Ms Roberts were cross-examined, identified in Attachment A to this decision.
YNCJ
The applicant has provided extensive documentary evidence to a high standard for one unassisted by legal representation. She explained that such documentation did require much time to produce since the effect of her psychological injuries has caused her to slow down her mental processing, and that she was unable to give sustained attention to the production of such documents.
She opened her case with a written statement. In addition, a statement dated 12 May 2025 regarding non-economic loss was admitted into evidence as Exhibit A1 but only to the extent that it contained statements of fact from personal knowledge. I have treated similar statements by the applicant that are throughout the Tribunal documents, but particularly the extensive statement of 2 November 2023 for the benefit of her re-examination by Associate Professor Hardisty, as part of her evidence but, again, only to the extent that it contained statements of fact from personal knowledge.[20]
[20] 2024/2705 T128, 662-698.
For some years now her medical treatment consists of weekly counselling sessions of about one hour duration with Ms Mary Roberts and consultations with Dr Arief Mulyadi, her long standing general practitioner, approximately every five weeks. In addition, she has relied on a limited range of medications. She identified Melatonin, to assist with sleep; Magnesium; fish and krill oil for their anti-inflammatory properties; glucosamine; Fisiocrem, a topical pain reliever; and Voltaren Gel, a topical anti-inflammatory preparation.
In her evidence, YNCJ reported an intolerance to a wide range of pharmaceuticals, including psychotropic medication. The evidence is that beyond one experience of using Endep, she has not accepted any psychotropic medication. Endep is the marketing name of amitriptyline hydrochloride, a tricyclic anti-depressant which also has uses in assisting sleep. She reported that she suffered dizziness when she used that medication, and she discontinued using it. She had in the period after the injury also reported dizziness, as well as nausea and headaches, following use of strong analgesic medications such as Morphine and Oxycodone as noted above.
YNCJ told the Tribunal that following her injury and surgery, she resumed work and by 29 November 2021 she was working 20 hours per week from home. She was working at reduced hours as part of her rehabilitation return to work plan. Services Australia, through its human resources agents, advised her that she was no longer required to work from 30 November 2021. She stated that she was told that she would be retired on invalidity grounds. At this time, she was 42 years of age and sought legal assistance to intervene on her behalf. She told the Tribunal that any further moves toward invalidity retirement ceased and that she remains an employee of Services Australia and continues to receive weekly payments of compensation for incapacity for work at the rate of 75 percent of her normal weekly earnings.
YNCJ told the tribunal that she felt that she derived some benefit from use of fish and krill oils. She used fish oil for a period followed using krill oil. She did not use them together. She stated that she was conscious of the fact that krill oil was more expensive but that she shopped for these supplements with a careful eye for the lowest prices.
YNCJ gave evidence of how her psychiatric condition affected her daily living activity. Her depression has a severe impact on her capacity to engage in a range of ordinary activities, particularly self-care. She stated that she had ‘no will or motivation for anything’. She could go for days or a week without showering and could stay in her pyjamas for days on end. She was not motivated to cook or clean. She tended to binge eat, a cause of weight gain, which only made her feel excessively conscious of the way she looked. She was wholly reliant on her family to supervise her activity. Her mother would either cook her meals or help her make some basic dishes to be stored and used later, even to the extent of making sure she ate those meals. They would direct her to take showers and get into clothes and get out of the house, as well as direct her to maintain contact with her two remaining friends. Ms Mary Roberts, her treating psychologist, also directed her in these ways, setting her tasks to contact friends and visit them to maintain social contact. Ms Roberts apparently checked that those directions were followed and, if not, would follow up with further directions at their weekly counselling sessions.
YNCJ has a very limited lifestyle as a consequence of her injuries. She is conscious of her dependence upon her family and worries about her future when her parents die. She explained in her evidence that she had been in what she referred to as ‘dark places’ meaning, having suicidal thoughts. She relied upon family members talking to her to keep her from taking any active steps of physical self-harm. When giving this evidence, she was visibly upset, saying that it was hard to talk about such matters and plainly stated, ‘if it wasn’t for my parents, I wouldn’t be here today’.
At an earlier period, when she was recovering from surgery, she had a boyfriend who moved in with her to help her with day to day living. However, she stated that she no longer has that relationship and has been single and unattached for at least three years. She stated that her psychological condition has caused the loss of romantic relationships. She said that she perceived slights when no slight was intended and that she would become irrationally jealous, comparing herself to others. She stated that this pattern of behaviour developed following the injury. That pattern of behaviour, she admitted, drove people away from her, reinforcing her social isolation. As a poor compensating strategy, she turned to alcohol to overcome her social inhibitions to attempt romantic associations. The intended outcomes were not achieved but she would binge drink at times, causing hangovers, and she appeared to have a poor tolerance of alcohol.
All these psychological effects on her daily living activity, occurred on the background of chronic pain. Her entitlement to compensation for chronic pain as well as a specific entitlement to lump sum compensation for the secondary chronic pain syndrome, as a separate but causally related injury, has been recognised by Comcare. Some of the specific evidence relevant to the determination of this application, particularly in relation to YNCJ’s entitlement to non-economic loss compensation may be summarised from her 12 May 2025 statement in relation to non-economic loss (Exhibit A1).
In the statement she provided with her claim for impairment compensation she noted that she had been experiencing pain daily since her workplace injury. However, she is there referring to her chronic pain disorder but notes that depression and anxiety exacerbate that disorder. That said, the pain here referred to is that which relates to the separate injury for which an impairment lump sum is payable by consent decision made pursuant to section 103 of the ART Act immediately prior to this hearing.
YNCJ also stated she suffered from migraines and ocular migraines due to the ‘chronicity of my depression and anxiety’ as well as ‘muscle tension and gastrointestinal urgency followed by an upset stomach’.[21] In her evidence, she attributed intermittent attacks of pain to the effects of drinking too much alcohol, such as hangovers, as well as the stomach pain from binge eating. She claimed that in relation to generalised anxiety disorder, she had pain occurring most of the time that restricted activity and was resistant to treatment by way of recurring migraines.
[21] T115, 653.
This last evidence was the subject of cross-examination based on the clinical notes concerning the existence of migraines and their cause. In August 2018, YNCJ experienced visual symptoms, including blind spots and flashing lights, while driving. She pulled over and managed to get a lift to a hospital for treatment. She explained that she gets auras about 30 minutes prior to the onset of migraine headaches. At hospital she was given an MRI scan of the brain that only showed that she had a 2mm aneurism. That was a pre-existing pathology which has been under annual review and is stable. It was not thought to be relevant to any headaches or migraines. In discussion with the neurologist, she understood that the aneurism was not responsible for the symptoms and there was a history taken of stress from work following a recent workplace injury.
In respect of the claimed loss of life expectancy, YNCJ gave evidence of her fear for the loss of her parents upon whom she has a high degree of dependence for very basic activities of daily living. She had expressed her fear that with her parent’s death she would be faced with increased suicidal thoughts. In that respect, she related that she had contemplated suicide but that she would not do so because of the effect that would have on her family. She has contemplated suicide but in cross-examination, she states that she had so far made no physical attempt at suicide or other form of physical self-harm such as physical self-wounding.
In addition, YNCJ engaged in binge and comfort eating, again affecting her weight and poor self-image and reinforcing her sense of social isolation. It was the headaches following drinking binges and the stomach pain from binge eating that formed part of her claim that such pain was a consequence of her injury and ought to form an assessable part of her non-economic loss, over and above the claimed migraine headaches.
Dr Arief Mulyadi
Dr Mulyadi is YNCJ’s treating general practitioner since February 2017. She continues to be reviewed by him every five weeks. Dr Mulyadi completed the original assessment of impairment and non-economic loss questionnaire as we; as the joint report with Ms Mary Roberts on 3 October 2023[22] as well as the later, 30 October 2024 (Exhibit A2) joint report.
[22] T125,639-645.
In respect of the fish and krill oil dispute, Dr Mulyadi gave evidence that both types of oil have long chain Omega 3 polyunsaturated fatty acids with phospholipids that are credited with the ani-inflammatory effect. Hence, he told the Tribunal that fish and krill oil had the same function. He was not aware of the pattern of use whereby his patient used them in succession and not together and he had no evidence concerning the use of fish as opposed to krill oil. He accepted the beneficial anti-inflammatory effect of such substances from the general scientific literature such that the effect was temporary when used and required repeated application for the effect to be reproduced.
There was cross-examination concerning the relative merits of the opposing scientific papers by Stonehouse et al, ‘Krill oil improved osteoarthritic knee pain’ American Journal of Clinical Nutrition’ 2022 (Stonehouse article) (Exhibit A7) and that of Laslett et al, ‘Krill Oil for Knee Osteoarthritis, A Randomised Clinical Trial’ published in the Journal of the American Medical Association, 2024, No 331, page 1997 (Laslett article).[23] Part of the criticism relates to the later Laslett article’s criticism that the trial conducted could not bear out any particular effect from krill oil on pain and inflammation. That much was conceded on the reading of the papers from Dr Mulyadi though his answers also confirmed that the 4 gramme dosage of krill oil in the Stonehouse article did obtain such an effect. The later Laslett article did concede a possible explanation that the 2 gramme krill oil dosage that was the limit of its survey might be too small to obtain an effect. Dr Mulyadi made appropriate concessions on the differing aspects of the two scientific articles, but the Tribunal was left with little basis to form a conclusion about the value of the papers to the resolution to the question before it.
[23] The article was attached to the report dated 29 July 2024 of Dr Hardisty, received into evidence as Exhibit R4.
Dr Mulyadi also conceded in evidence that he diagnosed the adjustment disorder as early as March 2017 but altered the diagnosis of the psychiatric condition from adjustment disorder to MDD and GAD in March 2018 based on Ms Mary Roberts reports as the treating clinical psychologist. When asked in cross-examination about patients satisfying both diagnostic criteria for MDD and GAD but having only one condition, Dr Mulyadi answered by referring to the distinct criteria for the two diagnostic entities and therefore should be treated as distinct conditions.
The respondent put the following passage from the Preface of DSM-5 to suggest that it would be more appropriate to view YNCJ’s psychiatric condition as a single disorder: ‘Although DSM-5 remains a categorical classification of separate disorders, we recognize that mental disorders do not always fit completely within the boundaries of a single disorder. Some symptom domains, such as depression and anxiety, involve multiple diagnostic categories and may reflect common underlying vulnerabilities for a larger group of disorders.’ [24] Dr Mulyadi said he was not familiar with the Preface of DSM-5 but that agreed to the respondent’s suggestion that the diagnostic categories are ‘not fixed and immutable.’ He accepted that in this area of medicine he would defer to the psychologist and psychiatrist.
[24] DSM-5 page xli.
The respondent put the absence of sustained psychotropic medication as treatment for the condition as reasons for its deterioration. Dr Mulyadi his patient’s sensitivity to medications and he was aware of prior reactions, such as dizziness and nausea, to Endep (amitriptyline), an anti-biotic, Augmentin, morphine, non-steroidal anti-inflammatory drugs (NSAID) and to an iron infusion. He attributed the deterioration of the condition to the confounding factors with the associated chronic pain and lack of improvement in the original injury rather than the absence of psychotropic medications.
Exhibit A2 referred to dependence on alcohol using 2-4 standard drinks per day in the context of pain due to headaches from use of that alcohol. In answer to the proposition that 2-4 drinks would not be likely to produce a dependence, Dr Mulyadi said that the sensitivity of the person, in this case YNCJ, was a relevant consideration.
Dr Mulyadi in the 2023 joint report accepted there was a loss of life expectancy was based on his estimate of a loss of 10 years because there was no category for specifically 10 years (the choices being either 1-10 years or 10-20 years). That estimate was for what he considered an increased risk of suicide. He accepted that it was impossible to predict with certainty that any individual will suicide, and he acknowledged that his patient has, to date, not attempted suicide nor deliberately self-harmed. He agreed that the expression of an intent to suicide when her parents died, would not convert a risk of suicide to a probability of suicide.
One part of the assessment of loss of life expectancy by Dr Mulyadi was the possible effect of the binge eating on cardiovascular health, but he agreed that this was in the longer term and that there were no present signs of any cardiovascular disease, nor diabetes. Dr Mulyadi stated that his patient’s maladaptive behaviours in binge eating, eating sugary or fatty foods and increased use of alcohol, were to continue for another ten years into the future then the suggested risk of those cardiovascular disorders would be higher, and so would the risk of loss of life expectancy. However he agreed to the proposition put in cross-examination that at present, such a proposition was speculative.
Ms Mary Roberts
Ms Roberts has been YNCJ’s treating clinical psychologist since November 2017. At that stage, YNCJ was identified as suffering from an ‘adjustment disorder’, a diagnosis that Ms Roberts agreed with but that as the symptoms worsened, she identified that her patient’s symptoms met the criteria for MDD and GAD. In cross-examination, Ms Roberts stated that the diagnosis of adjustment disorder could no longer be maintained where MDD and GAD were present. She agreed that the new diagnosis was present at least from 20 March 2018.
Ms Roberts continues to see YNCJ for treatment on a weekly basis and she notes that over the years her patient’s condition has deteriorated. In that respect, she identified YNCJ’s report of panic attacks in most sessions currently. Her patient had become more dependent on alcohol and reported pain from hangover more frequently at sessions. Ms Roberts concluded the reports of hangover pain was from the abuse of alcohol the day prior to the session. She stated that the dependence on alcohol was a maladaptive response to the symptoms and that a hangover headache is not part of the diagnosis for MDD but it was a common co-morbid feature linked to MDD. Similarly, she considered the binge eating to be a maladaptive response to MDD, seeking a pleasurable ‘dopamine hit’ that leads to pain from bloating of the stomach. That effect was temporary, and she maintained that this was reflected in the rating given in the non-economic loss questionnaire report. Again, the maladaptive response is not part of the diagnosis of MDD but commonly reported to co-exist with that condition.
Ms Roberts reported that her patient’s reports of migraine headache were made in pretty much every session, and she adjusts the lighting during consultations and her patient can no longer drive because of the migraine effect, hence she now frequently resorts to telehealth consultations. In cross-examination, Ms Roberts accepted that the relationship was correlational, an association she made because there were no migraines experienced at the stage of when the condition was accepted as an adjustment disorder, but deteriorated as the clinical presentation was one of GAD. She related the muscle tension and anxiety as frequently associated with headaches, but she agreed that the mechanism was not well understood. She conceded that the migraine would be regarded as an independent disorder but one where the frequency and intensity of the attacks would be affected by GAD.
In answer to Dr Cohen’s evidence that it was not possible to identify a number of years by which life expectancy could be said to have been reduced, Ms Roberts stated that the suicide was a recognised risk factor, and she noted that there was a significant percentage of MDD sufferers who do go on to commit suicide. She stated that she had placed YNCJ’s risk at ‘high end of moderate’ and although there had been no previous attempts at suicide, her patient had disclosed that she thinks about suicide daily and has a major fear of the loss of her parents, upon whom, she was dependent for basic activities of daily living. She considered that upon the death of her parents her patient would move from the ‘high end of moderate’ to the high-risk category. The death of her parents would, Ms Roberts considered, have a double impact, firstly the grief at the loss, and secondly, the loss of the support. She has taken into consideration that her parents are the main source of social contact, they were among the very few people who come to YNCJ’s house, they are also among the very few people she feels safe enough to venture out of the house and drive to because of their proximity in terms of distance.
Dr Roberts, in cross-examination, conceded that more directed investigation of the headaches by a neurologist, it was suggested, would determine whether the migraines were a medically independent condition and that this had not been done in the case beyond what was presumed to have been the case following the first hospital presentation in 2018 and the taking of an MRI scan.
She agreed that in the original 2023 assessment no mention had been made to stomach pain or gut motility or binge eating but stated further that these features have become more prominent since then.
Asked about the loss of life expectancy score for an estimated loss of 10 years, there was reference to poor cardiovascular health but conceded that there was, at present, no evidence of poor cardiovascular health, coronary artery disease or hypertension present in her patient. Ms Roberts answered in response to the suggestion that such loss is at best, speculative, by saying that it was a feature that was observed as people aged.
She agreed in cross-examination, that there was no provision in DSM for the worsening of an adjustment disorder and that YNCJ’s condition had evolved from the adjustment disorder stage to the MDD and GAD. She also agreed that this evolution had the same cause. That said, she maintained that the symptom structure was different for MDD and GAD.
Dr Zeeva Cohen
Dr Cohen is a consultant psychiatrist engaged by Comcare in this case to examine YNCJ and prepare a report dated 27 June 2023 in respect of the assessment of the level of impairment.[25] Since that time, and following the commencement of the review and the provision of further documentary evidence and reports of the treating practitioners, Dr Cohen was able to provide supplementary reports dated 2 May 2024 (Exhibit R1), 23 September 2024 (Exhibit R2) and 3 April 2025 (Exhibit R 3).
[25] T121, 680-693.
In those supplementary reports, many disputed points were clarified. In the 2 May 2024 report (Exhibit R1) Dr Cohen noted the advantage that Ms Roberts and Dr Mulyadi had in making detailed observations over six and a half years which she was unable to obtain in a single hour’s session. Having had the benefit of the treaters detailed reports, Dr Cohen accepted that 25 percent was the correct assessment of the level of impairment according to Table 5.1 of the approved Comcare Guide. A further variation was made to the assessed non-economic loss assessment of Mobility in her 23 September 2024 report (Exhibit R2) to reflect a score of 4.
Asked whether YNCJ ought to continue with the weekly psychological treatment sessions with Ms Roberts, she stated ‘absolutely.’
Dr Cohen, in her 23 September 2024 (Exhibit R2), regarded that the headaches, migraines, or ocular migraines cannot be confidently said to be caused by MDD or GAD and no attribution could be made to those conditions in the absence of a neurological assessment.
Other loss answer clarified from the original report of 2023, which was scored at 5, a score not possible on the table provided in the approved Guide for this element of the assessment but she agreed that the score ought to be between 1 and 2: Moderate disadvantages.
As to the loss of expectancy of life no score was provided in the initial report and in her 23 September 2024 (Exhibit R2) report said that this was not possible to assess with any degree of accuracy. Dr Cohen accepted that YNCJ told her that she had moments of suicidal ideation but would not act on that because she was close to her family. She concluded in the original report that there was no current suicidal risk but following view of Dr Mulyadi and Ms Roberts reports she accepted that there was an accepted level of risk but cannot conclude from that there was any probability of suicide or probable loss of life expectancy.
Dr Cohen agreed that the relevant clinical criteria for MDD and GAD were present in YNCJ but qualified her response by stating that the DSM was not meant to be applied in a rigid fashion. She noted that people commonly present with both anxiety and depression, and she viewed these as the reverse side of the same coin. Adjustment disorder had both mood and anxiety components and there are similar components in post-traumatic stress disorder (PTSD). The DSM had no specific category for those patients falling between adjustment disorder and PTSD that encapsulates both anxiety and depressive symptoms. She stated that the DSM had no single expression of the psychiatric injury for which YNCJ was suffering. That did not alter her view that there was only one condition that developed
She did not agree that GAD and MDD were two different injuries because they are intertwined and not clinically separate. She emphasised that on her clinical experience that most people with MDD are anxious and people with GAD are also depressed. Her practice in diagnosis was to formulate diagnosis on presentation and mental state examination and matters other than DSM criteria. She stated that the DSM was primarily a communication tool enabling clinicians to share information about symptoms with a degree of common understanding. Dr Cohen noted that various editions of the manual change the categories point to the fact that DSM 5 makes a mood component part of the PTSD diagnosis which DSM IV did not. If she had a patient with predominant traumatisation and a depressive mood component she would diagnose a singular PTSD.
She agreed that someone might suffer from two distinct psychiatric disorders such as a psychosis or an eating disorder. Those would have two different treating approaches. But in the present case she stated that the two features co-exist and have a common treatment approach. With MDD and GAD are treated by anti-depressant medications because they treat both mood and anxiety and that is for all classes of psychotropic medication.
She said that all individuals present with variations of the features of mood disorder and anxiety and mentioned those suffering with an agitated depression, the agitation was an expression of anxiety and might well be serious enough to be a GAD.
Dr Hardisty
Dr Gerard Hardisty is a Clinical Associate Professor specialising in orthopaedic surgery with particular interest in knee, foot and ankle reconstructive surgery including arthroscopic and replacement surgery. He had provided his primary report on 3 November 2023, the same day he examined YNCJ.[26] There followed two further supplementary reports of 15 January 2024 and 23 February 2024.[27] The primary focus of those reports was directed to the issue of permanent impairment and non-economic loss resulting from the left knee injury and the chronic pain syndrome, issues that were resolved shortly before the hearing of the unresolved applications, including the issue of fish and krill oil treatment.
[26] 2024/2705 T129, 700-715.
[27] 2024/2705 T137, 752-753 and T140, 760-762.
His opinion concerning the left knee, relevant to the issue of treatment, was to note the stiffness, described as ‘restriction of flexion and pain in the medial side of her knee with pseudo-locking’. He also noted the existence of chronic pain, but he acknowledged he was not an expert in that area. He accepted that there would be limitations on the distances that YNCJ would be able to walk with her left knee injury.
He recorded the following about treatment: ‘Her current medical treatments have not improved her condition. She has stated she has been using magnesium, fish and krill oil, which are in my opinion, unlikely to be helping her condition. However, the magnesium has been noted to help with some cramps and pains, being nocturnal. The Fisiocrem and the Voltaren Osteo Gel would be helpful.’[28]
[28] 2024/2705 T129, 711.
Following the commencement of the review application, Dr Hardisty provided a further supplementary report, dated 29 July 2024, and attached a journal article by Laslet et al, ‘Krill Oil for Knee Osteoarthritis, A Randomised Clinical Trial’ published in the Journal of the American Medical Association, 2024, No 331, page 1997.[29] The authors of the article concluded that among people with knee osteoarthritis with significant knee pain and effusion synovitis on magnetic resonance imaging, a 2 gramme daily dose of krill oil supplementation did not improve knee pain over a 24 week period when compared to a placebo.
[29] The supplementary report dated 29 July 2024 of Dr Hardisty and the attached journal article were received into evidence as Exhibit R4.
Dr Hardisty described the study was greatly improved over the article presented by YNCJ from Stonehouse et al. It was well controlled and randomised. It excluded participants taking NSAID’s, a precaution not apparent in the Stonehouse study. Further, it was felt to be more objective in that outcomes were measured by MRI scanning to determine the effectiveness of the supplementation as opposed to relying on more subjective self-reporting. Some further evidence was given as to the independence of the Laslet article when compared to the Stonehouse et al study which was supported by Swisse Welness Pty Ltd, a major supplier of the supplement, and which disclosed that the ‘funding source, in collaboration with the research scientists, designed the trial and monitored its implementation, but had no influence over the analysis, reporting, and interpretation of the data.’
In answer to questions directed to the value of such supplements, Dr Hardisty stated in his 29 July 2024 supplementary report, at least in respect of fish oil: ‘The evidence which currently exists is low in regard to the treatment for osteoarthritis. Numerous studies have shown fish oil’s potential use in patients that cannot tolerate non-steroidal anti-inflammatory drugs due to side effects. It is therefore my opinion that fish oil would be of value to [YNCJ] given her intolerance to non-steroidal anti-inflammatory medication.’ He went on to state, based on his adoption of the report of Laslet et al, that “[YNCJ]’s condition has intermittent ongoing inflammation affecting her left knee and fish oil would help, but as stated above, krill oil would not.’
YNCJ suggested to Dr Hardisty that the Stonehouse paper favouring the benefit of krill oil, was based on a 4 gramme dosage, not the 2 gramme dosage used in the Laslet article. Dr Hardisty responded by making reference to the faults he perceived in the Stonehouse article in not properly excluding subjects using non-steroidal anti-inflammatory drugs (NSAID) and not having an objective outcome assessment.
The Tribunal put to Dr Hardisty the evidence received from the articles and the opinion of Dr Mulyadi, that the essential active ingredient of both fish and krill oils are the Omega 3 polyunsaturated fatty acids having anti-inflammatory effect to pose the question that since fish oil would help, there was little reason for suggesting that krill oil, with the same Omega 3 polyunsaturated fatty acids, would not have the same effect. Dr Hardisty made the concession that the effect would likely be the same, while not resiling from the general propositions he made concerning the value of the scientific papers.
Fish and krill oil treatment – 2024/2705
Submissions
The Comcare’s reviewable decision made on 1 May 2024 denies liability to pay compensation pursuant to section 16 of the SRC Act for the cost of both fish and krill oils used to reduce inflammation and manage pain from the left knee injury on the grounds that it was ‘not reasonable to obtain in the circumstances.’
YNCJ submitted that payments for these treatments had been accepted in the past and that given her intolerance of most prescription medication, and non-steroidal anti-inflammatory drugs (NSAIDs) in particular, it was reasonable to use these methods of treatment, recommended by her general practitioner in his report of 2 March 2024, as giving measurable benefit in reducing inflammation and thereby obtaining better control of symptoms. Comcare first accepted liability for the cost of fish oil on 1 September 2017 and for krill oil on 17 February 2023.[30]
[30] Exhibit A9, an email from Comcare dated 6 May 2025 confirming the date range of acceptance of the costs of fish and krill oil.
In response to the report of Dr Hardisty who advised Comcare that the oils were unlikely to help the condition of the left knee and referred to a journal article to support that view, YNCJ presented a journal article by Stonehouse et al, ‘Krill oil improved osteoarthritic knee pain in adults with mild to moderate knee osteoarthritis: a 6-month multicentre, randomized, double-blind, placebo-controlled trial’ published in the American Journal of Clinical Nutrition in 2022 that was said to support the proposition that ingestion of 4 grammes of krill oil per day resulted in ‘modest improvements in knee pain, stiffness and physical function in adults with mild to moderate knee OA [osteoarthritis]’.[31]
[31] Exhibit A7, American Journal of Clinical Nutrition, 2022; No. 116; page 672.
Comcare’s submissions somewhat modified the position expressed in the reviewable decision. In his final supplementary report, Dr Hardisty did accept that ‘fish oil would be of value to [YNCJ] given her intolerance of anti-inflammatory medication.’ However, the value of krill oil was disputed based on the Laslet et all scientific paper that was produced by Dr Hardisty. Comcare urged the affirmation of the decision to deny both fish and krill oil relying on those arguments raised in its Statement of Facts Issue and Contentions on matter 2024/2705 dated 17 April 2025. That submission derived from the decisions in Re Aylett and Comcare [2001] AATA 739; Re Rope and Comcare [2018] AATA 42 (“Rope No. 3”) and the Clinical Framework for the Delivery of Health Services published by WorkSafe Victoria in conjunction with the Transport Accident Commission of Victoria (the Clinical Framework). The essential submission was that the claims treatment was not reasonable for YNCJ to obtain in the circumstances. It would only be reasonable, in Comcare’s submission, where the benefits are substantial and the cost is low, where the treatment’s effectiveness results in measurable benefits, it is of limited duration and is consistent with the principles set out in the Clinical Framework.
Consideration
From an early stage of the left knee injury there was evidence of her complaints to Mr Ian Skinner, an orthopaedic surgeon, who reported on 25 May 2017 that he had no doubts as to the mechanical problems of the left knee, with pseudo-locking and inflammation with pain, as well as YNCJ’s intolerance of NSAIDs and sensitivity to analgesics.[32] As early as 14 December 2017, Dr Phillip Meyerkort, a consultant occupational physician, noting YNCJ’s reported intolerance of prescribed medication, recommended various supplements that could be ‘utilised in a similar way to prescribed medications, however with less side effects’ and included fish oil among those supplements.[33]
[32] 2024/2705 T25.
[33] 2024/2705 T50.
I accept that YNCJ has an intolerance to a large range of prescription medications, and I rely on her self-reporting and the close and consistent review of her treating general practitioner, Dr Mulyadi. There have been recorded reactions to a wide range of differing medications and treatments and I accept that there is a genuine sensitivity to medication. I would not expect such a person, suffering from the multiple conditions affecting her left knee, chronic pain, anxiety and depression, to have to try all possible medications in exhaustive fashion. I do not say that as the adoption of some ‘patient autonomy’ principle, valuable as that might be, but on the acceptance of the evidence to sensitivity to the range of medications she has tried.
I also accept there is some efficacy among sufferers of osteoarthritic symptoms (post-traumatic or otherwise) from fish oil in reducing inflammation, stiffness and pain which is beneficial and therapeutic for those sufferers with intolerance of NSAID medications. I accept the evidence that it is the Omega 3 polyunsaturated fatty acids that are the operative substances responsible for those benefits.
That being so, and the concession from Dr Hardisty that krill oil has the same operative substances found in fish oil, leads me to the conclusion that both have the same therapeutic effect on a person such as YNCJ and both are therefore treatments ‘in relation to’ the left knee injury.
The only other question is whether these oils are treatment that is reasonable to obtain in the circumstances. One aspect of that question is whether there may be alternative therapies better adapted to the purpose. Most medical practitioners would recommend simply NSAID therapy to deal with inflammation, stiffness and pain in a case of traumatic osteoarthritis. In the present case given the finding I have made about YNCJ’s intolerance to NSAID’s, recognised from as early as late 2017 during her rehabilitation following surgery, it is reasonable to seek out alternative therapies in her case.
As to the applicability of the Clinical Framework, it is not a document of general application, and I adopt the caution expressed by the Tribunal in Heales and Comcare [2018] AATA 3788: The Clinical Framework is not a formal policy of Comcare obliging decision makers to give it due weight unless there are good reasons for not following it. It is directed at clinicians in formulating treatment plans but not decision makers weighing the reasonableness of particular expenses in any individual case. It assumes a short-term approach leading to self-management in all circumstances.
In the case before me, given the admitted permanence of the injury, the likelihood of treatment for a limited duration is not realistic. Further, the particular situation of intolerance to other forms of treatment puts YNCJ in a particular category not addressed in the Clinical Framework. If YNCJ’s treatment does not conform to the Clinical Framework, given those considerations of permanence and intolerance to ordinary pharmaceuticals, that is no reason for not treating her with therapeutic substitutes.
Another aspect of this question is the cost of such therapy. There was no specific evidence as to the costs of fish and krill oil other than to note the latter is likely more expensive. The question of cost was not pressed and Comcare submitted that it was not a significant consideration in the present case. Considering that this aspect was not part of Comcare’s decision making, and that it had for some years accepted the costs of such supplements without questioning their cost, I accept that the cost of the supplements is no barrier to the acceptance of this mode of treatment.
Accordingly, the reviewable decision is set aside and in substitution, a new decision will be made in substitution to allow recovery of the cost of fish and krill oil pursuant to section 16 of the SRC Act.
Psychiatric impairment assessment – 2024-8393
Submissions
YNCJ has been assessed for separate entitlements to lump sum compensation for permanent impairment and non-economic loss for both the left knee and the chronic pain syndrome. That assessment was made by agreement shortly prior to the commencement of the present hearing. I note that the assessments were both made as for separate injuries, notwithstanding that the chronic regional pain syndrome was a secondary condition, causally related to the left knee injury that was sustained on 3 December 2016.
The significant issue in the proceedings relates to the question whether the major depressive disorder and generalised anxiety disorder are one or two injuries. The applicant, referring to the language used in the 1 November 2019 decision of the former AAT, asserted that it had been clearly found there were two separate injuries and that the ART ought to be bound by such findings. The summary of the Tribunals findings in 2019 were:[34]
158. In summary, for the reasons set out above, the Tribunal finds that:
(a) the appropriate diagnoses for the Applicant’s Psychological Conditions are major depressive disorder recurrent (moderate) and generalised anxiety disorder, as diagnosed by Ms Roberts;
(b) the Applicant’s Psychological Conditions constitute a disease which was contributed to, to a significant degree, by her knee injury and therefore the Applicant’s employment; and
(c) s 7(7) of the SRC Act does not apply because the Applicant did not make a wilful and false representation (or representations) in her Health Status Assessment Form.
[34] YNCJ and Comcare (Compensation) [2019] AATA 4795, [158], Senior Member Dr M Evans.
The respondent submitted that the question of two injuries was not part of the argued case before the earlier Tribunal and a reading of the decision at paragraph 115 (the ‘Psychological Conditions best accord with the definition of “disease” [because they] … meet the definition of an “ailment”’ [emphasising the singular]) and paragraph 127 of the reasons for decision (‘… the Tribunal finds that the Applicant’s Psychological Conditions amount to a disease …’) favour the conclusion that the accepted injury was singular.
Consideration - Impairment from one psychiatric injury or two
The central issue in this case is whether there is one psychiatric injury, that is, a major depressive disorder and generalised anxiety disorder, or are there two distinct injuries, a major depressive disorder and a separate generalised anxiety disorder?
The decision concerning two injuries is not determined by the words used in deciding the 2019 Tribunal review of the liability for the psychiatric injury. The principal issue in the 2019 AAT dispute was whether there was such a mental condition outside the bounds of normal mental function that was causally related to the 2016 left knee injury. The diagnoses were accepted by reason of the evidence of the causal association of the physical injury and the consequential psychiatric reaction, but there is no particular discussion or contention concerning whether there are two psychiatric injuries or one. The Tribunal’s articulation of the issues to be considered at paragraph 36 of the decision did not stray beyond the employment connection between ‘the Applicant’s condition (or conditions) and whether it is an “injury”,’ within the meaning of the SRC Act.
The argument that I am bound to assume there are two injuries by virtue of the decision made in 2019 would be an application of the doctrine of issue estoppel, that is, once a judgement is given between parties on an issue of fact or law, it is a once and for all disposition of those matters so that it cannot be raised again between the same parties (or their privies).[35] However, the Tribunal deals with a stream of administrative decision making that is dependent upon evidence and facts found at particular points of time in order to determine statutory rights. In relation to injury compensation, claims for particular benefits depend upon facts that are to be considered at the time when the claim falls to be determined. A full discussion as to the inappropriateness of the doctrine of issue estoppel in administrative review is articulated in the decision of Deputy President Fogie in Rana v Military Rehabilitation and Compensation Commission [2008] AATA 588; (2008) 48 AAT 385 and I am guided by the reasons expressed there. Further, for reasons stated by the Full Federal Court in Plumb v Comcare (1992) 39 FCR 236, decisions on particular matters dealt with by the AAT in 2019 cannot bind me to make particular findings relevant to the present dispute before me.
[35] Blair v Curran (1939) 62 CLR 464 at 531-532, Dixon J.
Injury and its consequences
While the SRC Act refers to liability for ‘an injury’, the High Court in Canute v Comcare [2006] HCA 47; (2006) 226 CLR 535) (Canute) noted that the definition ‘is expressed in terms of the resultant effect of an incident or ailment upon the employee’s body’ and that ‘disease’ and ‘physical or mental’ injuries are referred to disjunctively, the SRC Act contemplates that an employee may suffer more than one injury.[36]
[36] [2006] HCA 47; (2006) 226 CLR 535 at 540 [10]. The High Court was referring to the definition of ‘injury’ in section 4(1) of the SRC Act at the times relevant to the case which now appears in subsection 5A(1) and to subsection 24(1) of the SRC Act.
Obviously, a traumatic blow, fall or collision may cause wounds, fractures or internal damage to many sites of the body and also traumatic nervous shock. All such consequences would be regarded as injuries, either physical or mental, arising out of or in the course of employment.
Then there is the case of an injury which has such serious, long-term consequences that it may result in effects that are so different in nature and effect on the body or mind, that the complications ought to be regarded as a separate injury. A familiar case is the physical injury arising from some accident or incident that also has ‘mental or nervous, or hysterical’ effects.
Where the physical effects of injury have ceased but the employee ‘has not wholly recovered from the nervous effects of the accident’, which themselves render the employee incapacitated for work, the liability to pay compensation continues (Eaves v Blaenchlydach Colliery Company Limited [1909] 2 KB 73,75 Cozens-Hardy MR) (Eaves).[37] The persistence of ‘nervous effects’ beyond the cessation of physical effects of primary injury, in various cases since Eaves, has justified treating those effects as a separate injury that has a life of its own, not dependent upon the persistence of the initiating physical injury.
[37] [1909] 2 KB 73 at 75 per Cozens-Hardy MR. Eaves was a case of a colliery worker arising under the Workman’s Compensation Act 1906 (UK). The employee suffered a physical injury from the fall of a large heavy stone on his foot, an injury by accident both arising out of and in the course of his employment. He was paid compensation until his physical injury recovered but the evidence accepted showed that along with the physical injury, he had developed a ‘traumatic neurasthenia’ which was held to be ‘a real complaint, and that it had affected [his] mental condition and destroyed his will power.’ The Court of Appeal held that it was not sufficient, in terminating liability for payments, to only show the cessation of the physical effects but all the consequential nervous and mental effects.
In this case, there are several injuries and impairments under consideration. The left knee injury was suffered by accidental traumatic incident on 6 December 2016. However, the subsequent injuries, chronic pain syndrome, MDD and GAD evolved later because of the experience of that injury. It is common to speak of the primary injury and the consequential injuries, though I accept that the High Court in Canute pointed out that those qualifiers are not legal categories and that the SRC Act speaks exclusively in terms of ‘an injury’.[38]
[38] Canute (2006) 226 CLR 535 at 547 [34].
That said, in the settled proceedings, the left knee injury has been assessed as resulting in a particular impairment distinct from the chronic pain syndrome which has been treated as a distinct injury and hence the resulting impairment was separately assessed. We now come to the psychiatric consequences of the 2016 injury. Comcare accepted there was a distinct psychiatric injury but as a single injury requiring a single assessment of the impairment; YNCJ says MDD and GAD are separate injuries.
For most purposes, such as determining the liability for the cost of medical treatment or for weekly payments of compensation, it is unnecessary to first determine whether the consequential condition is a distinct injury. It is sufficient that there is evidence to demonstrate the consequential condition’s causal relationship with the primary injury to determine whether specific treatment is ‘in relation to’ that injury, or incapacity for work ‘results from’ that injury.
It is uncontroversial in this case, that impairment ‘results from’ the left leg injury, the chronic pain syndrome or the major depressive disorder and generalised anxiety disorder. Comcare accepts that this is so based on the evidence. Comcare further accepted that the chronic pain disorder was properly regarded as a separate, though consequential, injury to the left leg, for the purposes of assessment of lump sum compensation for permanent impairment and non-economic loss. Immediately prior to the commencement of the hearing, both those disputed applications were resolved by consent order pursuant to section 103 of the ART Act with the payment of separate amounts for impairment to the left leg and the chronic regional pain syndrome.
Comcare also regards the major depressive disorder and generalised anxiety disorder as a distinct injury that results from the primary left knee injury due to the pain, limitation of movement, and consequential impacts on the social and emotional life of YNCJ. While the primary left knee continues, the psychological injury has a distinct life of its own. Comcare accepts and I agree with its assessment that the psychiatric condition or conditions of MDD and GAD ought to be seen as an injury or injuries, distinct from the left knee injury and the chronic pain disorder.
However, Comcare sees the major depressive disorder (MDD) and generalised anxiety disorder (GAD) as a singular disorder and not two individual injuries, one being the major depressive disorder and the other, generalised anxiety disorder. YNCJ asserts the two diagnostic entities are two injuries, distinct from each other, and ought to be assessed independently.
Impairment assessment requires determination of single or multiple injuries
The question of whether a diagnostic entity, causally related to an injury, amounts to a separate injury, is a necessary consideration when considering the assessment of permanent impairment for the purposes of compensation. That is so because of the provisions of subsections 24(5) and (6) of the SRC Act. The degree of impairment must be expressed as a percentage and the degree of permanent impairment resulting from ‘an injury’ must be determined under the provisions of the approved Guide.
The approved Guide, Safety, Rehabilitation and Compensation Act 1988 – Guide to the Assessment of the Degree of Permanent Impairment Edition 3.0,[39] adopts a ‘whole person impairment’ concept by which the degree of impairment is expressed as a percentage. That concept is not one that appears in the SRC Act. It allows 0% assessment of the degree of impairment in some circumstances. The approved Guide also adopts an algorithm to allow the combination of multiple impairments resulting from an injury such that no matter how many impairments as assessed, the final combined value cannot exceed 100 percent. The method required the addition of the highest assessed percentage impairment with the next highest percentage assessment by the following formula:
A + B (1 – A) = combined value of A and B
[39] This is a legislative instrument made under section 28 of the SRC Act and commenced on 1 April 2023. It was entered into the Federal Register of Legislation as F2023L00203.
The next highest value, should there be one, is then combined with the result, and so on to give the final combined value. This is more conveniently expressed as a chart sourced from the American Medical Association’s Guide to the Assessment of Permanent Impairment, Edition 5 (AMA5).
Take the case of a ruptured intervertebral disc of the lower lumbar spine which extrudes into the surrounding tissues and impinges the nerves exiting the spine termed radiculopathy. Typically, there is impairment of the lower back and impairment of lower limb function from sciatica or foot drop caused by damage or malfunction of the nerves impinged by the prolapse at the intervertebral disc. There would be two relevant impairments from a single injury. In such a case, assuming the degree of permanent impairment was such as to rate assessment according to the approved Guide, each assessment would be then combined to give a final assessment of the degree of impairment resulting from ‘an injury’. The low back impairment, for example, may be assessed as a 12 percent impairment by the approved Guide, and the secondary lower limb impairment might be assessed as a 10 percent impairment. When combined according to the algorithm in the combined values table in the Guide, the assessed degree of impairment, on the ‘whole person impairment’ method equals 21 percent, not 22 percent as would be achieved by simple arithmetic.
Now take the case of a low back injury resulting in impairment entitling the employee to lump sum compensation at 12 percent with a secondary psychiatric condition that developed at a later stage. In Canute, referred to above, the employee of the Department of Defence sustained injury to his back in the course of employment which resulted in permanent impairment for which he was entitled to lump sum compensation in respect of an assessed – a final assessment - as 12 percent whole person impairment for about two years following the onset of the injury. A further two years later, he lodged a claim for impairment compensation for ‘adjustment disorder with anxious and depressed mood’. This later claim was denied by Comcare on the grounds that following a final assessment, he was obliged by operation of subsection 25(4) of the SRC Act to show an increase of the degree of impairment of 10 percent. Since the approved Guide assesses multiple impairments by the ‘whole person impairment’ method described above, the combination of values came out at 21 percent and this result did not satisfy the rule in subsection 25(4) for a necessary increase of 10 percent following the earlier ‘final’ assessment.
The employee was obliged to argue, on appeal, that his ‘adjustment disorder with anxious and depressed mood’ was ‘an injury’ in its own right, separate and distinct from the low back injury. In that manner, there was a separate injury that was assessed at 10 percent, sufficiently high to escape the threshold impairment barrier, to achieve an award of compensation.
In Canute the High Court stated that ‘injury’ is not used ‘in a global sense to describe the general condition of the employee following an incident’.[40] Further, the Court identified fault in the decision-making process was the assumption that multiple impairments arose from the same physical injury and that the Tribunal at first instance had treated the concept of ‘injury’ as co-extensive with the workplace incident. The High Court ruled that this was not consistent with the definition of ‘injury’ in the SRC Act allowing from multiple injuries to arise from any incident or accident.[41]
[40] Canute (2006) 226 CLR 535 [10], Gummow A-CJ, Kirby, Callinan, Heydon and Crennan JJ.
[41] Ibid (2006) 226 CLR 535 at 544 [23].
Before the High Court, Comcare accepted that the adjustment disorder was a ‘secondary’ or ‘consequential injury’ that was distinct from, though causally related to the ‘primary’ low back injury. The High Court favoured the dissenting judgement of Gyles J in the Full Federal Court that since the ‘adjustment disorder with anxious and depressed mood’ was a separate injury and had ‘nothing to do with the impairments previously assessed’ then the restriction imposed by subsection 25(4) of the SRC Act did not apply. The High Court further stated that while the approved Guide adopted a ‘whole person impairment’ approach to the assessment of the degree of impairment, that could only be applicable for permanent impairments resulting from each ‘injury’ and cannot deny the applicability of section 24 to something that corresponds to the legislative definition of ‘injury’.[42] Hence, given Comcare’s concession before the High Court, that the adjustment disorder in that case was a separate injury, the employee was entitled to recover compensation for the resulting permanent impairment without reference to section 25(4) of the SRC Act.
[42] Ibid (2006) 226 CLR 535 548 [36]-[37].
One important fact needs to be remembered about the series of cases leading to the High Court’s decision in Canute. No Tribunal with jurisdiction to make a decision concerning the existence of two injuries ever did so. While Hill J in the Federal Court at first instance set aside the Tribunal’s decision requiring the case to be reheard on the question as to whether two injuries existed, the parties went directly to the Full Court and then the High Court where Comcare made its concession that there were two injuries, without apparent explanation. Canute is not the key authority on the question of how to determine whether the present psychological condition is one injury or two, though it does explain why such a question is a necessary one to answer.
The answer to the question whether GAD and MDD should be regarded as a single psychiatric injury, or two separate injuries is vital step in the context of making the assessment of impairment in accordance with subsections 24(5) and (6) of the SRC Act.
YNCJ referred me to two later cases before the High Court, Fellows v Military Rehabilitation and Compensation Commission [2009] HCA 38; (2009) 240 CLR 28 (Fellowes) and Robson v Military Rehabilitation and Compensation Commission [2013] FCAFC 101; (2013) 214 FCR 1 (Robson). Both are cases dealing with the impairment benefit provided by section 24 of the SRC Act.
Robyn Fellows was a serving member of the Australian Army when she suffered injury to her left knee in 1986. In 1987, she suffered another injury to the right knee. Both injuries resulted in impairment, not of the range of movement of the joint, but some functional loss of difficulty with steps and grades as distinct from distances. The approved Guide under which her impairments were assessed was an earlier iteration of the current Guide Edition 3.0. It provided for assessment of function impairment being ‘difficulty with steps and grades’ resulting from injury. In 2007 she was found to be entitled to compensation for an assessed degree of impairment of 10 percent of the left knee, matching the descriptor on the relevant table of the Guide providing 10 percent rating ‘Can rise to standing position and walk BUT has difficulty with grades and steps.’ Shortly after that determination, the Commission determined that there was no entitlement to impairment compensation for the right knee injury because Ms Fellows had been compensated for 10 percent of the whole person. The approved Guide’s Principles of Assessment referred to ‘Combined Impairments’ and stated that ‘Where two or more injuries give rise to the same impairment a single rating only should be given.’ The Tribunal upheld the Commission’s approach and on appeal to the Full Court of the Federal Court there was no alteration since the approved Guide appeared to explicitly block that approach. While there had been impairment resulting from the second, 1987 right knee injury, and Ms Fellows was ‘at least somewhat worse off’ after the second injury, the result was determined by making allowance for the existing 10 percent impairment from the first, 1986 left knee injury. The High Court disagreed and pointed out that in its decision in Canute, it was stated that ‘recourse to the criteria and methodologies set out in the Guide is only necessary once the key statutory criterion of the occurrence of ‘an injury’ (which resulted in at least one permanent impairment) has been fulfilled.’[43] In the event, the Tribunal’s decision denying recovery for the second 1987 right knee injury was assessing the impairment by reference to the pre-existing capacity of the particular applicant, that is, the applicant who already had a 10 percent functional impairment. Given the rejection of the ‘whole person impairment’ concept in cases of multiple injuries, and the Guide’s own statement that the percentage assessments are a ‘percentage value of the capacity of a normal healthy person’ the references in the Guide to ‘whole person impairment’ did not ‘direct attention to the effect of an injury or disease on a particular individual. On the contrary, the effect to be assessed is by reference to the functional capacities of a normal healthy person.’[44] The Court stated, ‘The text of the Guide is therefore to be construed as providing that the whole person impairment to which it directs attention requires comparison with the “functional [capacities] of a normal healthy person” rather than the capacities of the particular applicant as they existed immediately before the injury in question. The reference to two injuries causing the “same impairment” requires attention to the particular identified effect on bodily parts, systems or functions that is said to have resulted from the two injuries.’[45] The decision was therefore overturned, and Ms Fellows was entitled to lump sum compensation pursuant to sections 24 and 27 of the SRC Act based on the degree of impairment of 10 percent for the right knee.
[43] Ibid (2006) 226 CLR 535 at 542 [15].
[44] Fellows (2009) 240 CLR 28 at 37 [24].
[45] Fellows (2009) 240 CLR 28 at 38 [26].
The decision rightly reinforces the need for separate injuries to be assessed separately for the impairment effects from the injuries without reference to ‘whole person impairment’ concept to determine what may or may not be assessed. In Fellowes there was no dispute as to the existence of two quite separate injuries.
In Robson again, there had been three separate psychological injuries sustained by the Army member over the course of service. Firstly, post-traumatic stress disorder arose from service as part of the UN Peacekeeping Force in Rwanda between August 1994 and February 1995. Secondly, Mr Robson suffered fractures to both ankles, pelvis and coccyx and a duodenal haematoma in a parachuting accident in February 2004. Because of those injuries, he developed a mental injury which both exacerbated his existing PTSD and also caused a major depressive disorder. In the review of his impairment applications the former AAT accepted the applicant’s contentions concerning the three psychiatric injuries – the PTSD, the major depressive disorder and the aggravation of PTSD. It should be noted that the compensation legislation treats the aggravation of an existing disorder as a separate injury. It is possible to suffer an aggravation of PTSD in a separate accident and be entitled to compensation for the second aggravation injury regardless of whether a continuing liability exists for the earlier PTSD (see Slattery v Comcare (1996) 70 FCR 131).
The Full Court held that the AAT had erred in giving a single impairment assessment for the three psychiatric injuries and awarding an impairment lump sum for the first PTSD injury alone. Of the MDD following the parachute accident the Court noted that it was ‘a separate injury in both its origins and in its clinical manifestations, even though there are some features of the condition which are shared with PTSD.’ The expert medical evidence accepted that PTSD and MDD were clinically separate conditions.[46] The AAT had determined that the aggravation of PTSD following the parachute accident was a separate injury and the Court held that the decision of the High Court in Fellows applied to the assessment of that injury: ‘where the same impairment was alleged, the matter had to be judged by reference to the “particular identified effect” of each injury.’[47]
[46] Robson (2013) 214 FCR 1 at 6 [25]-[26]; Cowdroy, Buchannan and Katzmann JJ.
[47] Robson (2013) 214 FCR 1 at 9 [34].
The conclusion reached by the Court in Robson was the application of the statute to facts already determined on the evidence, and not challenged, concerning the existence of separate injuries. The AAT in Robson and Military Rehabilitation and Compensation Commission [2012] AATA 809 had determined the separate injuries by analysing the evidence concerning the incidents of injury and the clinical manifestations that developed, particularly following the parachute accident. The first psychiatric injury was PTSD from Rwanda service which long predated the parachute accident. The medical evidence before the Tribunal accepted there were two distinct psychiatric conditions manifested, this resulted in permanent impairment: PTSD, first manifesting itself in 1995 and MDD which was accepted for compensation in 2006. The MDD resulted from the parachute accident and was considered ‘secondary to physical injuries.’[48] One of the medical expert’s evidence concerning differing clinical manifestations were described in the AAT decision as ‘in the case of PTSD, arousal, preoccupation, and the easy triggering of flashbacks, and in the case of MDD, helplessness, hopelessness, difficulty concentrating, and suicidal thoughts.’[49] That same doctor had considered that the assessment of impairment should be global but in cross-examination agreed that the clinical records of the applicant did suggest an aggravation of the existing PTSD as a result of the parachuting accident.[50] The other expert witness identified an aggravation of the PTSD after the parachute accident and gave separate assessment of the PTSD and its aggravation.[51] Guided by the evidence, the AAT concluded that there was a further injury, aggravation of PTSD, following the parachute accident in 2004, and the worsening of that condition persisted.[52]
[48] Robson and Military Rehabilitation and Compensation Commission [2012] AATA 809 [26] R P Handley, Deputy President, Dr W Isles, Member.
[49] Ibid [37].
[50] Ibid [38].
[51] Ibid [27].
[52] Ibid [51].
In effect, the Tribunal identified a primary traumatic injury of PTSD in 1995 as well as in the aggravation of PTSD following the 2004 parachute accident, both independent injuries, and the MDD as a clinically distinct psychiatric condition developing as a secondary injury to the experience of the physical injuries in the 2004 parachute accident.
The finding of psychiatric injury, particularly where the manifestation is secondary to some other physical injury must look to its manifestation, its relationship to the initiating injury, and its clinical development to determine its nature.
It is not an analysis that is dictated by diagnostic categories. It is well to consider that in compensation law, the finding of injury is not dependent upon the existence of a diagnosis. The Federal Court in Comcare v Mooi (1996) 69 FCR 439 (Mooi) accepted that while it was essential that before a mental injury was accepted for compensation it was necessary that there be a ‘condition that is outside the boundaries of normal mental functioning and behaviour’, that is a ‘clinically significant’ condition, that might be shown even though the ‘condition cannot be identified with the label of a recognised medical condition.’[53] In the experience of workers compensation disputes, ‘[n]othing is more common than that medical diagnoses change and evolve, or are or become various.’ (Abrahams v Comcare (2006) 93 ALD 147) (Abrahams).[54]
[53] Mooi (1996) 69 FCR 439 at 443-444 per Drummond J.
[54] Abrahams (2006) 93 ALD 147 at 153 [21] per Madgwick J.
The applicant’s argument in favour of the finding of two separate injures of MDD and GAD rests on the report of her treating Clinical Psychologist, Ms Mary Roberts, particularly the report of 5 May 2025 (Exhibit A3), which summarised the applicant’s submission concerning separate injuries and identifies the importance of diagnosis to that argument:
▪ [YNCJ] has “separate diagnoses” of (1) MDD, and (2) GAD.
▪ [YNCJ]’s GAD is a separate injury to her MDD.
▪ GAD is not an alternate diagnosis of MDD / MDD is not an alternate diagnosis of GAD.
▪ MDD and GAD are independent mental health conditions. They are recognised as distinct (separate and different) psychological injuries, each defined by its own set of diagnostic criteria in the DSM-5 (please see attached DSM-5 criteria). They result in separate changes of the microstructure of the white matter of the brain (Yu et al, 2025). There cognitive profiles are different (Hendriks et al 2014). As well as having separate impacts on function.
▪ While they may co-exist, they can also exist separate from each other (Blanco et al, 2014).
It may well be accepted that there are separate diagnoses, and one is not an alternative diagnosis for the other. It can also be accepted that MDD and GAD can exist as independent mental health conditions and while they frequently co-exist, they can exist separately to each other. Dr Cohen, as noted in the 5 May 2025 report, agreed with the last proposition. I also accept that it is possible to suffer MDD and GAD as separate injuries for the purposes of compensation in the SRC Act. However, the fact that DSM-V-TR classifies MDD and GAD as separate clinical entities does not determine the outcome in the present case.
The DSM is an exercise in nosology, that branch of medical science concerned with the classification of disease. Dr Cohen agreed in her evidence that psychiatric disorders are classified by grouping symptoms and not by ‘pathogenesis’, a method of classification that identifies disease by identification of the biological agent (bacterial, fungal, viral and the like) responsible for the genesis of diseases in an otherwise healthy body. Psychiatry, by and large, does not have such a body of information to identify cause and effect and so disorders are identified by their effects, grouping characteristic symptoms together.
The DSM authors are aware of this fact, and this also accounts for the revision process to improve identification of distinct disorders over time. ‘Neurasthenia’ was a diagnosis that was generally characterized by weakness, fatigue, lack of stamina, and exhaustion. It was included in the DSM until 1980 when it was discontinued. It is now classified as a chronic fatigue syndrome or a somatoform disorder such as Somatic Symptom Disorder, a diagnostic entity in DSM-5. It was a ‘traumatic neurasthenia’ that was the recognised consequential injury in Eaves referred to above. It should be recognised that in this process the diagnoses may change but the disorder remains the same. Hence, the DSM’s categories do not ultimately determine the issue.
The authors, in the Introduction to the DSM-5-TR, provide several statements to give context and sounds a caution to be taken in a too simplistic use of the manual:
(a)At page 14:
It should be noted that the definition of mental disorder was developed for clinical, public health, and research purposes. Additional information is usually required beyond that contained in the DSM-5 diagnostic criteria in order to make legal judgments on such issues as criminal responsibility, eligibility for disability compensation, and competency (see “Cautionary Statement for Forensic Use of DSM-5” at the conclusion of Section I).
…
Structural problems rooted in the categorical design of DSM have emerged in both clinical practice and research. Relevant evidence of such problems includes high rates of comorbidity among disorders, symptom heterogeneity within disorders, and the substantial need for other specified and unspecified diagnoses to classify the substantial number of clinical presentations that do not meet criteria for any of the specific DSM disorders.
At pages 14-15:
There is broad recognition that a too-rigid categorical system does not capture clinical experience or important scientific observations. The results of numerous studies of comorbidity and disease transmission in families, including twin studies and molecular genetic studies, make strong arguments for what many astute clinicians have long observed: the boundaries between many disorder “categories” are more fluid over the life course than has been recognized, and many symptoms that make up the essential features of a particular disorder may occur, at varying levels of severity, in many other disorders.
A dimensional approach classifies clinical presentations on the basis of quantification of attributes rather than the assignment to categories and works best in describing phenomena that are distributed continuously and that do not have clear boundaries. Although dimensional systems increase reliability and communicate more clinical information (because they report clinical attributes that might be subthreshold in a categorical system), they also have serious limitations, and thus far, they have been less useful than categorical systems in clinical practice. Numerical dimensional descriptions are much less familiar and vivid than are the category names of mental disorders. Moreover, as yet there is no agreement on the choice of the optimal dimensions to be used for classification purposes. Nonetheless, with the increasing research on, and familiarity with, dimensional systems and the establishment of clinically meaningful cut points to guide treatment decisions, greater acceptance of dimensional approaches both as a method of conveying clinical information and as a research tool is eventually likely.
For reasons of both clinical utility and compatibility with the categorical ICD classification required for coding, DSM-5 continues to be a primarily categorical classification with dimensional elements that divides mental disorders into types based on criteria sets with defining features. Despite the categorical framework, it is important to recognize that in DSM-5 there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder.
(b)At page 15:
Given that psychiatric pathologies are not reliably discrete with sharp boundaries from one another, clinicians need to shift their approach to assessment and look beyond the prototypical presentations that neatly coincide with DSM categories.
(c)At page 23:
The specific diagnostic criteria included in DSM-5 are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a rigid cookbook fashion.
The respondent, in submissions, brought to my attention an earlier decision of the former AAT, William Purdon and Comcare [1997] AATA 466 where similar cautious approach was adopted.[55]
[55] [1997] AATA 466 [12] MD Allen, Senior Member and MEC Thorpe, Member.
Dr Cohen’s supplementary report of 3 April 2025 (Exhibit R3) reflects this cautious approach consistent with the ones spelled out in the introductory parts of the DSM manual. In answer to a question concerning the relationship between MDD and GAD she wrote:
The DSM is a classification system based on the descriptive groupings of symptoms however in clinical practice, it is a somewhat reductionist and artificial way of conceptualising psychological illness. Generally speaking, I can comment that the relationship between major depressive disorder and generalised anxiety disorder is that they frequently co-exist and represent a person’s particular symptomatic response to a major stressor. The DSM does not take into account a holistic perspective of the underlying personality, emotional resources, aetiology and a person’s coping response style. In clinical practice most psychiatric conditions present with varying levels of anxiety, and defences against such, as anxiety symptoms are generally speaking an expression of a person’s overwhelming inability to cope with a particular stressor.
Dr Cohen assessed the disorder as a single disorder even though she recognised the application of both diagnostic criteria. It is an approach that identifies the MDD and GAD as a single consequential injury.
There may be cases where the appearance of MDD and GAD emerge as separate injuries, but in this case, given the development and course of the psychiatric symptoms, I find that there is a single psychiatric injury that is distinct from the initiating left knee injury and the consequential chronic pain disorder. It is an injury that entitles YNCJ to compensation and is likely to continue indefinitely. However, the injury, though it may go by the combined diagnosis of MDD and GAD, is a single injury by reason of its causation and development.
The history of the present disorder shows an evolution from an ‘adjustment disorder’ with features of anxiety and depression but which deteriorated over time so that now it satisfies the diagnostic criteria for MDD and GAD. That evolution is noted in the background history above and I have had reference to the following further evidence:
(a)Dr Brendan Jansen, a consultant psychiatrist engaged by Comcare examined YNCJ on 20 July 2017 and reported on 28 July 2017 his conclusion that she presented with features consistent with an ‘an adjustment disorder with mixed anxiety and depressed mood and that the anxiety symptoms are largely related to the post-trauma symptomatology and any dysphoric symptoms related to the grief over the delayed recovery from her physical condition.’[56] In forming his view, he referred to an earlier note made on 13 June 2017 by an occupational therapist, Ms Jacinta Bell, stating in relation to YNCJ: “There are some significant psychosocial factors that are likely to lead to poor return-to-work outcomes if they are not addressed."[57]
(b)Ms Mary Roberts, the treating psychologist, reported to Dr Mulyadi on 6 February 2018, following an initial five sessions of individual therapy, that she assessed YNCJ as displaying ‘signs of adjustment disorder with significant depression and anxiety secondary to her chronic pain together with clinical insomnia.’[58]
(c)In the following month, Ms Roberts reported on 6 March 2018 that her patient ‘meets the DSM’s criteria for 296.32 Major Depressive Disorder Recurrent (moderate) and 300.02 Generalised Anxiety Disorder, both of these are secondary to her chronic pain. She also displays signs of adjustment disorder and clinical insomnia.’[59]
(d)Dr Yue Chong (Olivia) Lee, a consultant psychiatrist, examined YNCJ on behalf of the Department of Human Services, the employer, and reported on 6 September 2018, ‘The diagnosis is adjustment disorder with anxiety and low mood secondary to chronic pain. Differential diagnosis of somatic symptom disorder with predominant pain … I have subsumed her preoccupation with somatic symptoms as part of the manifestation of anxiety, depression symptoms secondary to the development of chronic pain from her knee.’[60]
(e)Dr Yue Chong (Olivia) Lee again examined YNCJ on behalf of the Department of Human Services, the employer, and reported on 30 August 2021. YNCJ has ceased work and Dr Lee formed the view that her condition was, by then, such that she would be unable to work her formerly restricted duties for limited hours and that would be the case for the foreseeable future. In respect of the diagnosis at that assessment she wrote: ‘The diagnosis can be construed as a chronic adjustment disorder because the stressor of the pain syndrome is chronic. Alternatively, it could be construed as a major depressive disorder with anxiety features or equally as a generalised anxiety disorder with major depressive features, but all of these would be on a background of the previously noted rigidity in personality function - in being perfectionistic, preoccupied by rules and detail which have not been amenable to attempts at psychological treatment.’[61]
(f)On 9 November 2022, Ms Roberts advised Dr Mulyadi: ‘[YNCJ] was initially diagnosed with an adjustment disorder secondary to her left knee injury and with time her mental health deteriorated as the significant impacts of her workplace injury on all areas of her life confirmed to be permanent. On 6th March 2018, [YNCJ]’s diagnosis changed to Major Depressive Disorder and Generalised Anxiety Disorder secondary to her left knee injury. Medical evidence shows that [YNCJ]’s left knee injury has reached maximum medical improvement and has left her with permanent physical impairments. Her secondary psychological conditions MDD and GAD have been present since March 2018 and have stabilised at this level indefinitely. This level of depression and anxiety since March 2018 has become [YNCJ]’s norm now. She has shown variability in that her psychological conditions which have deteriorated when psychological supports were removed and when there was a significant change in her employment conditions that were outside of medical recommendations. This is likely to occur again in the future if she has similar experiences.’[62]
(g)Dr Zeeva Cohen examined YNCJ at the request of Comcare on 16 June 2023 and reported on 27 June 2023 that the ‘current diagnosis is most consistent with major depressive disorder and generalised anxiety disorder.’[63]
[56] T34, 226.
[57] T43, 223.
[58] T53, 341.
[59] T54, 343.
[60] T67, 388.
[61] T100, 525.
[62] T111, 573.
[63] T121, 688.
The evidence shows the development of symptoms of a psychological reaction in YNCJ to the pain and disability resulting from the physical injury that started as an adjustment disorder with features of both anxiety and depression but over time, deteriorated. The mixture of anxiety and depression has been a characteristic feature since the diagnosis of adjustment disorder was made as early as 2017. Given the DSM-5 note about the presence of anxiety and depression across a range of ‘multiple diagnostic categories’ and the related cautions of that manual I have looked to the common causation of the disorder in the continuing and unrelenting pain and disability following her knee injury and I prefer, in this case, the analogy of Dr Cohen seeing anxiety and depression being ‘two sides of the same coin’ or twin features of a single continuing injury. Doubtless, YNCJ’s intolerance of psychotropic and other medications, has not been able to arrest the deterioration in her condition but it has come to the stage where it has deteriorated to MDD and GAD. However, the development of this disorder tends to confirm a singular psychiatric condition, certainly distinct from the physical injury and the chronic pain syndrome, but one injury with features of both anxiety and depression.
I accept the opinion of Dr Cohen in this regard and find that there is a single psychiatric injury that results in impairment that is likely to continue indefinitely.
Consideration – Assessment of impairment
The reviewable decision accepted Dr Cohen’s opinion in her 27 June 2023 report that the impairment was assessed at 15 percent in accordance with Table 5.1 of the approved Comcare Guide 3.0.[64] However, in Dr Cohen’s supplementary report of 2 May 2024 (Exhibit R1), she altered her assessment after considering the joint reports of Dr Mulyadi and Ms Roberts dated 3 October 2023 (Exhibit A2), and accepted that ‘they have been [YNCJ]’s treating providers of six and half years’ a vantage point that she did not have in terms of assessing ‘marked disturbances in thinking, definite disturbances in behaviour’ and altered her assessment to 25 percent in accordance with the relevant Table 5.1 in the Guide.
[64] T121, 691.
Ms Roberts and Dr Mulyadi, proceeding from the view that there were two separate diagnoses and two separate injuries, were able to present their separate assessment of the degree of impairment in their joint report of 30 October 2024 (Exhibit A2). In doing so, they carefully attracted separate assessments of the level of impairment by reference to the diagnostic criteria and identifiable behavioural effects of the diagnosis: in the case of MDD, reference to the problems of alcohol dependence, binge eating and poor personal hygiene, self-care and domestic care and avoidance of leaving her house; in the case of MDD, by reference to cognitive distortions and behaviours such as compulsions, controlling behaviour, dependence on alcohol, avoidance of leaving the hours and impairment of interpersonal capacities. There is a degree of overlap although the witnesses have been careful in associating the elements of the assessment with each diagnosis to come to 25 percent in each case of MDD and GAD. However, that view still proceeded from the assumption of separate injury because of the separate diagnoses.
I did not find either Ms Roberts and Dr Mulyadi to be advocates or even zealous advocates for their patient and therefore reject that their opinions were to be discounted for that reason. Their detailed reports, particularly the joint report of 3 October 2023 (Exhibit A2) was influential in the assessment of the degree of impairment as Dr Cohen recognised. The conclusion that there are two injuries and not one is, for the reasons outlined above, not accepted. Had I found two injuries, I would, like Dr Cohen, have no difficulty in accepting the accuracy of their assessments as to the degree of impairment.
Having found a single psychiatric injury, I assess the degree of impairment as 25 percent in accordance with Table 5.1 of the approved Comcare Guide Edition 3.0 pursuant to section 24 of the SRC Act. That assessment also settles the Part A of the non-economic loss assessment pursuant to section 27 of the SRC Act.
Consideration - Assessment of non-economic loss
There are only a few areas of disagreement between the parties in respect to the Part B assessment of non-economic loss pursuant to section 27 of the SRC Act.
The assessment of non-economic loss in one where specific categories of loss, pain suffering etc, are measured in accordance with criteria and weighted by the assignment of a score. The individual scores are then further weighted and a final score out of 15 is converted to a percentage. A table of those scores for comparison will show:
Loss
Comcare decision
Applicant
evidence[65]
Dr Cohen
Pain
0
2 or 4
-
Suffering
4
4
4
Mobility
0
4
4[66]
Social Relationships
3
3
3
Recreation and Leisure
0
5
5
Other Loss
0
2
1-2[67]
Loss of Life Expectancy
0
2
-
[65] Taken from the joint report of Ms Roberts and Dr Mulyadi of 30 October 2024 ((Exhibit A2).
[66] This assessment was made in the 23 September 2024 supplementary report of Dr Cohen (Exhibit R 2). The scores were otherwise remarked upon by Dr Cohen in her report of 16 June 2023 (T121).
[67] This is based on Dr Cohen’s evidence in the hearing that the score of 1 was not enough and 2 was too high.
At the end of evidence, Comcare conceded the scores for Suffering (4), Mobility (4), Social Relationships (3), Recreation and Leisure (5).In respect of the score for Other Loss, given Dr Cohen’s expression in evidence that such a score would, in her opinion, be ‘between 1 or 2’, Comcare accepted the score of (2). Having reviewed the evidence, I accept those as correct scores to be applied to YNCJ’s assessment.
That leaves the two disputed areas: Pain, and Loss of Life Expectancy.
The case for the applicant in respect of pain score is built on the following elements derived from the treaters joint report (Exhibit A2):
(a)As a consequence of her MDD and GDD, YNCJ has developed a dependence on alcohol, a ‘maladaptive strategy’ to deal with depression. Her bouts of alcohol use result in hangover with headaches as a prominent feature.
(b)YNCJ also over eats with an attraction to high fat and high sugar food items, another maladaptive response to depression. She experiences stomach pain from binge eating.
(c)The evidence of the treaters was to the effect that there was ‘frequent headaches and migraines’ triggered by the psychiatric disorder and Dr Mulyadi had expressed an opinion that ‘there are no other causes for her migraines’.
(d)There was also ‘anxiety related stomach pain. Anxiety and stress can alter the motility of the gut, which is the movement of food through the digestive system and out of the body.’ It was hypothesised that the gut is sensitive to anxiety and stress ‘due to the gut-brain connection. Anxiety causes the body to release certain chemicals and hormones, disrupting the digestive process.’
(e)The doctors concluded that the pain score of 4 ‘accurately describes the pain [YNCJ] experiences from frequent disabling migraines due to Generalised Anxiety Disorder’.
The clinical notes relating to migraines that were the subject of cross-examination show that on August 2018, YNCJ experienced visual symptoms, including blind spots and flashing lights, while driving followed by presentation at hospital where she was given an MRI scan. On consulting with Dr Mulyadi shortly after, YNCJ the onset of migraine headache. The following month TNCJ reported another episode of blurred vision and flashes but on report to Dr Mulyadi, no associated headache was noted.[68]
[68] Clinical notes Dr Mulyadi 2 September 2018.
It was on 23 September 2018 that Dr Mulyadi noted ‘recurrent migraine’ as a presenting complaint, associated with ‘nausea – occasional blurred vision’. He noted that day that YNCJ has seen two doctors at another clinic, the Hammond Park Family Practice, and she reported that she was ‘diagnosed with Migraine attributed to stress’. At that time, YNCJ wanted to know is anything else could explain the migraine other than stress.[69] A similar view was expressed to Dr Mulyadi by YNCJ on 26 November 2018, that stress was worsening her sleep and ‘in return gives her migraine.’[70]
[69] Clinical notes Dr Mulyadi 23 September 2018.
[70] Clinical notes Dr Mulyadi 26 November 2018
Beyond that initial collection of episodes in 2018, here is little mention of migraines thereafter in the clinical notes until 12 October 2023, at about the time when the assessment of impairment was being made, when YNCJ told Dr Muyladi she had ongoing sleeping issues and ‘has been having migraines + cognitive issues which she attributed to not sleeping enough’.
The picture depicted in the clinical notes is not one of ‘frequent disabling migraines’ as described by Dr Mulyadi and Ms Roberts in the joint report of 30 October 2024 (Exhibit A2) as being worthy of a score of 4 which equates to ‘Pain occurring most of the time. Restrictions on activity. Resistant to treatment’.
However, the primary objection to accepting this score is that there is no good evidence that there are migraines that are due to the psychiatric condition as opposed to being idiopathic migraine. No referral has been made to a neurologist for any specialist consideration of the headaches and their cause. Dr Mulyadi does not have particular expertise in the diagnosis of migraine headaches sufficient to answer any question concerning their aetiology, whether idiopathic or secondary to the psychiatric condition. Dr Zeeva Cohen did not proffer any opinion in this regard, accepting the limitation on giving opinion beyond her expertise.
I do not accept headaches associated with hangover or stomach pain due to overeating to be pain that is due to the psychiatric injury as opposed to maladaptive behaviour in response to that ailment. The experience of this type of pain is too remote to be a pain due to the injury. A maladaptive response to injury is not itself the injury. Accordingly, I assess the correct pain score as ‘0’.
The other contested issue is the possible loss of expectation of life that is posed by the risk of suicide due to the injury. This element of the assessment requires an estimate of the loss in terms of years from a score of 0 (Loss of life expectancy of less than one year) to 3 (loss of 20 years or greater). Dr Mulyadi and Ms Roberts in the joint report of 30 October 2024 (Exhibit A2) assessed this at a score of 2 (Loss of 10 years to less than 20 years).
The loss score of 2 arises from the MDD and the risk of suicide. The evidence supports that YNCJ has experienced suicidal ideation, and she is restricted in social contact, and she is dependent on her parents for direction and supervision in self-care, washing and changing clothes, feeding and preparing food. She has, as reported by the treaters ‘ruminating thoughts about losing her parents in the future, which has triggered an increase in panic attacks and sleepless nights and suicidal ideation.’ She sees her parents as a protective factor in keeping her alive, such is the dependence on her parents given her social isolation and the impact of her injuries on her activities of daily living. All this evidence is accepted.
However, the loss of expectation of life is not the same as the presence of suicidal ideation or even the risk of suicide. In other types of injury, such as the devastatingly aggressive asbestos related cancer, mesothelioma, there is good epidemiological evidence of mortality capable of determining the loss of expectation of life in years. In this case however, the evidence taken at its highest shows a ‘risk’ of suicide. There is some evidence of lower life expectancy for sufferers for major depressive disorder but not in any way that can give such definite evidence of death from suicide or from other cause.
There is no sound basis for converting a risk of suicide to a definite loss of expectation of life in terms of years. I do not accept the assessment of a loss of expectation of 10 to 20 years or any other definite number of years. Accordingly, I find the correct score for this element of the assessment is ‘0’.
In the outcome, the Comcare decision of 8 November 2023 must be set aside and replaced by a decision finding a whole person impairment of 25 percent pursuant to section 24 of the SRC Act by reference to Table 5.1 of the approved Comcare Guide Edition 3.0. Further, the relevant scores for the non-economic loss assessment: Pain: 0, Suffering: 4, Mobility: 4, Social relationships: 3, Recreation and Leisure: 5, Other Loss: 2, Loss of Expectation of Life: 0.
Dated: 7 August 2025
Date(s) of hearing: 19, 20 and 21 May 2025
Appearances:
Applicant: Self-represented
Respondent Counsel: Brendan Kelly
Respondent Solicitor: Moray & Agnew, Perth
ATTACHMENT A
Clinical Notes arranged by date, admitted into evidence as the subject of cross-examination of witnesses:
16 June 2017 Referral to Dr Mondello (T30)
20 June 2017 Patient Health Summary printed (T31)
From documents produced under Summons by Whitford Medical Centre, clinical notes dated:
5 February 2018 (Tender Bundle S3 p 591)
26 February 2018 (Tender Bundle S3 p 592)
23 September 2018 (Tender Bundle S3 p 617)
13 April 2018 (Tender Bundle S3 p 611)
2 September 2018 (Tender Bundle S3 p 614)
18 June 2018 (Tender Bundle S3 p 606)
26 November 2018 (Tender Bundle S3 p 624)
11 June 2021 ((Tender Bundle S3 p 681)
28 February 2023 [‘High Sensitivity CRP (serum) test results – 1.88mg/L (average risk for cardiovascular disease prediction = >1mg/L and <3mg/L)’] (Tender Bundle S3 p 776)
27 September 2023 (Tender Bundle S3 p 713)
12 October 2023 (Tender Bundle S3 p 714)
27 February 2024 Patient Health summary print date (Tender Bundle S3 p 590)
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