DETERMINATION OF REVIEW PANEL	
	
CITATION:	Kallus-Lawson v Allianz Australia Insurance Limited [2023] NSWPICMP 684		
		
CLAIMANT:	Philippa Kallus-Lawson	
		
INSURER:	Allianz Australia Insurance Limited	
		
REVIEW Panel	 	
		
MEMBER:	Belinda Cassidy	
		
MEDICAL ASSESSOR:	Matthew Couch	
		
MEDICAL ASSESSOR:	Tai-Tak Wan	
		
DATE OF DECISION:	19 December 2023	
		
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accidents Compensation Act 1999; claimant’s application for review under section 63; assessment by Medical Assessor (MA) Cameron of 3% whole person impairment (WPI) combined with 4% assessment by MA Curtin led to a finding of WPI not greater than 10%; no challenge to MA Curtin’s assessment; claimant injured in accident on 23 May 2016; she was turning into a driveway when hit from behind by a truck at speed; claimant trapped in vehicle for over an hour and sustained multiple lower limb fractures and a head injury; insurer submitted no evidence of brain damage and claimant’s psychologist’s report records test results that suggested claimant was malingering, but psychologist never provided a final report; Panel requested report from a joint neuropsychologist to complete the testing; Panel also requested updated reports from treating surgeon regarding knee and ankle injuries; Held – parties obtained report from Dr Batchelor; Panel satisfied claimant did hit her head and satisfied requirements of clause 1.164 of the Guidelines; Panel not satisfied there was an assessable impairment of mental status and integrative functioning under clauses 1.166, 1.667 and Table 10; Panel also found no impairment of emotional or behavioural impairments in accordance with clause 1.170; Panel’s assessment of lower limb impairments considered primarily range of motion and table 64 of the Guides and sequelae from various fractures assessed WPI at 9%; when combined with MA Curtin’s 4% this resulted in a WPI of 13%; certificate of MA Cameron revoked.

DETERMINATIONS MADE:  	CERTIFICATE OF DETERMINATION
Issued under Part 3.4 of the Motor Accidents Compensation Act 1999
The Review Panel:
1.	Revokes the certificates issued by Medical Assessor Cameron on 8 July 2021 and 4 June 2022. 
2.	Taking into account the certificate of Medical Assessor Curtin dated 14 May 2022, certifies that the degree of permanent impairment resulting from the injuries sustained in the motor accident is greater than 10%.

STATEMENT OF REASONS
Introduction
1.	Phillipa Kallus-Lawson was involved in a motor accident on 23 May 2016. She was the driver of a car, indicating and slowing to turn into her driveway, when she was hit from behind by a truck travelling at speed. As a result of the impact, she lost control of her car which was propelled into a tree.
2.	Ms Kallus-Lawson was cut out of her car and airlifted to Liverpool Hospital sustaining serious lower limb injuries including fractures of both tibia, a right femur fracture, right foot fractures and related soft tissue injuries. She also says she sustained a head injury causing a nasal fracture and a brain injury.
3.	Ms Kallus-Lawson made a claim against Allianz, the insurer of the truck that hit her car. Allianz has admitted liability for the claim, which includes an admission that the insured driver was at fault and Ms Kallus-Lawson’s accident and injuries.
4.	A dispute about the claimant’s whole person impairment (WPI) has arisen in the claim and that dispute was referred to the Dispute Resolution Service (DRS) of the State Insurance Regulatory Authority (SIRA). Upon the abolition of the DRS and the establishment of the Personal Injury Commission (the Commission) that dispute became a matter for the Commission to determine.
5.	Three medical assessments were undertaken in order to determine the dispute as follows:
(a)	on 8 July 2021, Medical Assessor Cameron assessed the claimant’s head injury and lower limb injuries at 3% WPI;
(b)	on 14 February 2022, Medical Assessor Fukui assessed the claimant’s psychological or psychiatric injury at 8% WPI, and
(c)	on 14 May 2022, Medical Assessor Curtin assessed the claimant’s fractured nose and scarring at 4% WPI.
6.	On 4 June 2022, Medical Assessor Cameron issued a certificate combining the two physical injury assessments of WPI (his WPI of 3% and Medical Assessor Curtin’s of 4%) for a total WPI of 7% which is of course, not greater than 10%.
7.	As the claimant was disappointed with that result, she lodged an application seeking a review of Medical Assessor Cameron’s assessment. 
8.	A delegate of the President of the Commission determined on 1 September 2022 that there was reasonable cause to suspect a material error in Medical Assessor Cameron’s assessment and on 28 November 2022 the delegate convened this Panel.
9.	No application for review has been lodged in respect of Medical Assessor Curtin’s or Medical Assessor Fukui’s certificates.
Legislative framework
General
10.	Ms Kallus-Lawson’s claim and her entitlements to compensation are governed by the provisions of the Motor Accident Compensation Act 1999 (the MAC Act). Damages can be claimed and awarded for economic as well as non-economic losses resulting from the injuries, disabilities and impairments caused by a motor accident. 
11.	Damages for non-economic loss are provided for in Part 5.3 of the MAC Act with some limitations and restrictions. For example, non-economic loss damages are limited to a maximum amount in accordance with s 134 and entitlement to those damages is restricted by s 131 to persons who have a degree of permanent impairment resulting from the injuries sustained in the accident which is greater than 10%.
Permanent impairment assessment
12.	The degree of permanent impairment is assessed in accordance with the Motor Accident Permanent Impairment Guidelines (the Guidelines) which are largely based on the American Medical Association’s Guides to the Evaluation of Permanent Impairment, Fourth Edition (the AMA4 Guides).
13.	Due to the nature of the injuries sustained by the claimant that are the subject of this review, the following chapters of the AMA4 Guides are relevant:
(a)	chapter 3, the musculoskeletal system, and
(b)	chapter 4, the nervous system.
14.	The specific provisions in those chapters will be explained in the assessment section of these reasons.
Dispute Resolution
15.	If there is a dispute about the degree of the claimant’s permanent impairment, damages for non-economic loss cannot be awarded and disputes must be referred to a Medical Assessor for determination. 
16.	Part 3.4 of the MAC Act provides for medical assessments by the Commission, including provisions relevant to an original medical assessment such as Medical Assessors Cameron and Curtin’s, further medical assessments and the review of medical assessments by this Panel.
Assessment under review
17.	Medical Assessor Cameron acknowledges at [2] that he was referred the following injuries for assessment:
(a)	brain – cognitive injury, cognitive impairment; 
(b)	knee – ligament tears;
(c)	knee – fixation to femur with screws;
(d)	thigh – fracture to left tibia; 
(e)	foot – fracture of metatarsal and dislocation;
(f)	thigh – fracture to right femur, and
(g)	fracture to right tibia.
18.	Medical Assessor Cameron’s documents at [9] the history of the accident and at [10] recounts the symptoms experienced (as reported by Ms Kallus-Lawson) since the accident. The claimant remembered being trapped in her car and the helicopter ride to hospital. The Medical Assessor noted there was further orthopaedic surgery planned for late 2021 and that the screws in the claimant’s ankle needed to be removed.
19.	The claimant is reported at [12] to have the following current symptoms:
(a)	frequent headaches and fatigue;
(b)	difficulty sitting or standing for an extended period with significant right knee pain, and
(c)	upper and lower back pain.
20.	The claimant was working limited shifts and driving locally. She looked after her horses and rode her horses. Medical Assessor Cameron says at [13] the claimant is taking Pristiq and Gabapentin and is seeing Dr Bokey, psychiatrist; Dr Yu, pain specialist and her general practitioner (GP) Dr Hanbury.
21.	Medical Assessor Cameron records his examination findings at [14]:
(a)	the claimant was unsettled but comfortable sitting on the floor;
(b)	the claimant scored 20/30 on a cognitive assessment test which the Medical Assessor thought as unlikely to be valid as she would not be able to drive and work with that score;
(c)	there was a full range of motion in all planes of neck movement with no muscle spasm, guarding, dysmetria or non-verifiable radicular complaints;
(d)	range of motion of the shoulders was full, with pain at the extremes;
(e)	upper extremity joints were also full and there were no neurological abnormalities;
(f)	in her thoracic and lumbar spine, the claimant demonstrated mild and symmetrical range of motion with no spasm, guarding, dysmetria or radicular complaints;
(g)	there was a full range of motion in the hips;
(h)	there was a full range of motion in the knees with no crepitus or instability but some clicking in the right knee;
(i)	both ankles had a full range of motion, and
(j)	her right thigh circumference was 1cm less than the left but there were no differences elsewhere. Leg lengths were equal. There was an incomplete left common peroneal nerve palsy with impaired sensation without dysesthesia.
22.	Medical Assessor Cameron summarised the medical reports and noted Dr Zeman’s WPI assessment of 7%.
23.	Medical Assessor Cameron stated that the claimant sustained severe musculoskeletal injuries to her legs and impacts to her face and head but said, “there is no convincing information to show that Ms Kallus-Lawson has had a significant traumatic brain injury”. He did note there appeared to be psychological issues which the Panel notes have now been assessed by Medical Assessor Fukui.
24.	He assessed WPI as follows:
(a)	head injury and mild traumatic brain injury satisfying the criteria at cl 1.164 of the Guidelines and which attracted a 0% impairment;
(b)	right knee – abnormal range of motion method 0%;
(c)	left knee – soft tissue with peroneal nerve injury 1%;
(d)	left tibia fracture – 0%;
(e)	right tibia and fibula fracture – abnormal range of motion method – 0%, and
(f)	right femur – 2%.
Issues for determination
Claimant’s submissions
25.	The claimant argues that the assessment was wrong because Medical Assessor Cameron:
(a)	failed to assess the brain injury in accordance with the Guidelines, and
(b)	failed to evaluate or consider relevant evidence when assessing the brain injury.
26.	The thrust of the claimant’s argument is that the assessor failed to apply the Clinical Dementia Rating scale properly. The claimant notes there are six matters that required assessment, memory, orientation, judgment and problem solving, community affairs, home and hobbies and personal care and that she was assessed as having a 0 score for each “based on the clinical information and examination”.
27.	The claimant relies on her statement dated 15 July 2022 in which the claimant raises concerns about the assessment undertaken and says the assessor did not ask her questions about all of the six criteria.
28.	The claimant also says Medical Assessor Cameron’s assessment does not accord with the neuropsychological report of Ms Manns dated 6 April 2020 and the claimant says Medical Assessor Cameron has mis-stated the outcome of that assessment. The claimant notes cl 1.165 requires the results of psychometric testing to be taken into account and he has not done so.
Insurer’s submissions	
29.	The insurer refers to Ms Manns’ neuropsychological test and notes Ms Manns said the claimant did not apply consistent effort but that there could be cognitive impairment and denies that the Medical Assessor has misstated this outcome.
30.	The insurer also points to the test of memory malingering and that Ms Mann noted the claimant’s scores of 10 and 14 out of 50 and that it is extremely uncommon for individuals with true memory impairment to score lower than 45. She suggested a further review be done, but she has not done so.
31.	The insurer also submitted that Ms Manns did not use the Wechsler Memory Scale and the insurer raised other concerns about the qualifications of Ms Manns.
Procedural matters
32.	On 19 October 2022 the Panel met to discuss the Review and on 26 October 2022 the Panel reported to the parties.
33.	The Panel noted that of the six injuries assessed by Medical Assessor Cameron (brain, left and right knees, left thigh, foot and thigh) the submissions from the parties focussed exclusively on the assessment of the claimant’s head injury. The Panel requested an indication from the parties about whether the five injuries assessed in the lower limbs were in dispute or whether the parties agreed on the impairment percentages for those injuries.
34.	The Panel also noted the insurer’s submissions did not dispute that a head injury had actually occurred, and that this head injury could have led to a traumatic brain injury. The Panel suggested that the real issue in dispute between the parties was the extent of the claimant’s brain injury and any resultant cognitive impairment.
35.	In terms of the extent of the head/brain injury, the Panel noted that the claimant had neuropsychological testing administered by Ms Manns in April 2020. While Ms Manns noted (at page 23) a concern as to the validity and reliability of the claimant’s memory tests and recommended a review of all the evidence and (at page 24) a consideration of or closer look at memory function at a later time, no further report from Ms Manns or any other neuropsychologist has been provided. 
36.	As it was more than two years since Ms Manns’ assessment the Panel advised the parties the Panel would be assisted by an up-to-date neuropsychological assessment undertaking the additional tests recommended by Ms Manns. 
37.	The Panel requested up-to-date records and set a timetable for the provision of documents and submissions in response to the matters raised in the report.
38.	On 2 June 2023 the claimant provided further submissions requesting the Panel reassess all of the claimant’s orthopaedic injuries noting that since Medical Assessor Cameron’s assessment, the claimant had further treatment including right knee arthroscopic surgery in November 2022. An additional bundle of documents was provided by the claimant which included a number of documents including records from Dr Di Nallo in respect of lower limb issues up until March 2023. 
39.	On 14 June 2023 the insurer provided additional submissions pointing out issues with the claimant’s documentation and addressing the report of Associate Professor Batchelor. The insurer submitted at [26] “there is no reliable evidence on which to find that the Claimant is suffering from any cognitive impairment consequent upon the accident.” The insurer also submitted that the Panel could reassess the claimant’s right lower limb on the basis of additional treatment, but that it was unnecessary to assess the claimant’s left lower limb because there had been no additional treatment.
40.	On 15 June 2023 the Panel issued directions to the parties confirming receipt of the joint neuropsychological report from Dr Batchelor, the claimant’s and the insurer’s additional documents. The parties were advised of a medical examination scheduled for 23 October 2023.
41.	In the absence of any agreement between the parties concerning the lower limb injuries and resultant impairments and noting that the Panel is to undertake, in accordance with s 63(3A) “a new assessment of all the matters with which the medical assessment is concerned,” the Panel determined that all the claimant’s lower limb injuries should be reassessed in addition to the head injury.
42.	At the medical re-examination, Medical Assessors Wan and Couch examined both of the claimant’s lower limbs and all of her injuries. The claimant advised Medical Assessors Wan and Couch that she had further surgery to her right knee, but she was not clear on the detail of that surgery. In the light of this uncertainty, the Panel requested up to date records from Dr Di Nallo which were received on 22 November 2022 and considered.
43.	On 5 December 2022 the Panel asked the insurer whether it intended to provide any further submissions in respect of the lower limb injuries. The insurer responded saying:
“In the absence of information as to the extent to which any such assessment differs from that of Assessor Cameron, the insurer does not consider itself in a position to formulate any meaningful submission.  Put simply, on the information available, the insurer is not in a position to identify any area of contention.” 
44.	The Panel sent a further message to the parties confirming it is undertaking an assessment de novo of the following injuries:
(a)	right femur fracture and sequelae including muscle atrophy;
(b)	right tibia/fibula fracture (including the fracture of the medial femoral condyle caused during the recent surgery as identified in the additional material);
(c)	right knee joint;
(d)	right ankle dislocation injury which involves an assessment of both the ankle joint and the hindfoot joint and consideration of the additional material;
(e)	left tibia fracture, and
(f)	left knee injury including peroneal nerve injury and any resultant impairment to the left ankle, which also involves an assessment of both the ankle joint and the hindfoot joint.
45.	The Panel invited final submissions from the parties.
Insurer’s final response
46.	On 15 December the insurer provided submissions, summarising the medical evidence and the additional material from Dr Di Nallo and Dr Ballala. The insurer said:
“In the Insurer’s submission, the records which post-date Assessor Cameron’s assessment outlined above do not appear to suggest any material change to the lower limb ranges of motion and other physical findings on which Assessor Cameron based his WPI assessment. It is also noted that his findings appear largely consistent with the other medical evidence available.”
Review of the evidence
General observations
47.	There are over 2,000 pages of documents file by the parties in this matter. 
48.	There is no dispute that the claimant was seriously injured in the accident of 23 May 2016. There is also no issue with the treatment Ms Kallus-Lawson has received which has been appropriate and reasonable.
49.	The real issues in dispute between the parties is the nature of the head injury and any resultant brain damage, the current state of the claimant’s left and right legs and the permanent impairment arising from all injuries.
50.	The Panel is cognisant of the decision of Justice Basten in Rahman v Insurance Australia Ltd t/as NRMA Insurance said at [63]:
“The Court of Appeal has, on more than one occasion, remarked on the volume of material which is routinely provided to medical assessors under the Act and under workers’ compensation legislation ... Not only is there no general law principle requiring an assessor to refer in reasons accompanying a certificate to all the documentation to which he or she has had access, but rather, the function of the assessor is inconsistent with any such obligation. A judicial officer is not required to refer to each piece of evidence in a judgment determining the resolution of a dispute to which expert opinion is critical. As noted above, the function of the medical assessor is quite different. The assessor is not resolving a dispute between experts, but forming his or her expert opinion. The application of expertise permits (and indeed requires) the assessor to be discriminating as to that material which he or she considers significant and that which may be disregarded or given little weight. There is no requirement to identify material falling into the latter category, nor to justify its exclusion from consideration.”
51.	In the light of the comments above and because there is no issue with causation of injuries, the Panel does not intend to refer to each and every document filed in this matter. The Panel will extract some information from the material by way of background and provide detail on those documents consider relevant to the issues in dispute.
Claim form and claim documents
52.	The claim form is dated 24 June 2016. Ms Kallus-Lawson provides a history of the accident and notes she was admitted to hospital on the day of the accident and discharged two weeks later on 7 June 2016. The circumstances of the accident are provided and a list of injuries. The claimant said she had never made a previous claim and denied any previous relevant injuries or illnesses or conditions.
53.	She listed at [22] injuries to both her tibia, a right femur fracture, a foot fracture, ligament injury on the left side and nasal fracture.
Academic transcripts
54.	The claimant’s accident occurred the day before her 21st birthday. At the time she had not yet completed her tertiary studies.
55.	The claimant enrolled at the International College of Management in a Bachelor of Business Management in July 2013. She took leave of absence on 2 June 2015 and discontinued the course in September. She was readmitted in December 2015 but discontinued on 6 May 2016. She obtained a credit in one subject, four passes and three fails in others.
56.	Ms Kallus-Lawson enrolled in a Bachelor of Fashion and Business at the Holmes Institute in 2017 finishing her course in 2019. She obtained nine high distinctions, eight distinctions, five credits and four passes over the years 2017 to 2019.
Treating medical records and reports
Physical injuries and generally
57.	The ambulance report confirms the accident occurred on 23 May 2016 in the Southern Highlands. It was stated that a part of the car was compressing the claimant’s pelvis and legs and that the:
“Extraction extraordinarily complicated 100+ mins until extrication onto spine board achieved. In last 15 mins GCS began to fall even accounting for the Ketamine delivered.”
58.	The hospital records confirm the claimant’s various injuries and include a right ankle dislocation and a pre-orbital haematoma and a minor right shoulder abrasion. Operations were performed on 24 May 2016, 31 May 2016 and 2 June 2016. 
59.	The hospital records also suggest that after discharge, on 19 April 2017 the right femur screws were removed and on 7 February 2018 a loose body in the right knee was removed arthroscopically. 
60.	The file also includes records from Dr Ian Harris the treating orthopaedic surgeon detailing the injuries and procedures undertaken by him.
61.	The claimant’s GP notes have been provided from Dr Hanbury of Mittagong Medical Centre. These reveal pre-accident depression and glandular fever and the post-accident extensive treatment.
62.	The claimant provided a bundle of recent documents which included records from two orthopaedic surgeons (Dr Di Nallo and Dr Balalla) and a number of scans relevant to her right knee.
63.	The claimant consulted Dr Di Nallo in March 2021 due to irritation of the screws in the tibial nail and dislocation of the right patella. In June pain was coming from the patellofemoral joint and it was determined there was catching of soft tissues behind the knee and not dislocation and on 9 July 2021 he operated to remove the four tibial screws and a large bone fragment was removed from behind the patella.
64.	The claimant consulted Dr Balalla, orthopaedic surgeon during 2022. The claimant attended for ongoing right knee pain. The claimant had a normal gait and alignment. There was mild tenderness but full flexion and extension. The knee was stable, and her ligaments were normal on examination. After updated scans, Dr Balalla was of the view further surgery was likely.
65.	The claimant returned to Dr Di Nallo in August 2022 due to ongoing pain in her right knee and pain in both her ankles. Scans were undertaken (and which are summarised later in these reasons). On 23 November 2022 Dr Di Nallo operated on the right knee. He removed another loose fragment in the right knee fat pad and removed the locking screws of the right tibial nail and then the nail itself. He also removed the locking screws of the femoral nail and the nail itself. 
66.	During the course of this surgery a fracture of the medial femoral condyle occurred and as a result Dr Di Nallo advised the claimant that her rehabilitation would be slow. In his operation report of 23 November 2022, Dr Di Nallo described a difficult removal of the femoral nail, through the knee joint. This resulted in a fracture of the medial femoral condyle. Dr Di Nallo then fixed this new fracture with two 50mm 4/5 screws. On 17 January 2023 Ms Kallus-Lawson was seen with a range of motion that was equal to the contralateral uninjured joint and normal. 
67.	On 14 March 2023 the claimant was doing well but still had discomfort in the right knee and “clicking”. While her range of movement was normal there was discomfort arising from the Hoffa’s fat pad. Dr Di Nallo comments on the MRI findings including the increased tibial tuberosity to trochlear groove (TT-TG) distance and the increasing density in the Hoffa’s fat pad with tendinotic changes in the poles of the patella. He was contemplating further surgery to remove all the hardware if the claimant was still “not happy with her current situation.”
68.	Further documents were made available to the Panel on 22 November 2023 including letters from Dr Di Nallo dated 16 May, 22 September, 29 September, and 16 October 2023. In addition, there was an X-ray report of the left lower leg dated 28 September 2023, an MRI of the left ankle and an MRI MSK Tumour dated 17 October 2023. Dr Di Nallo saw the claimant again on 16 May 2023 and she reported “mild discomfort” in the right knee. There was clicking when moving her knee and difficulty squatting or kneeling. He records clicking when moving the joint on examination. He advised the claimant to continue physiotherapy and said that Ms Kallus-Lawson might need further surgery in 2024.
69.	On 22 September 2023 the claimant rang Dr Di Nallo reporting pain in her left lower leg and right knee pain. She reported no injury and no unusual activity, and she was seeing a new physiotherapist. The right knee was still sore but not as bad as before her previous surgery. He considered the claimant may have medial tibial stress syndrome but wanted to have 
X-rays and see her face to face. He did see her on 29 September 2023. On examination there was a lump on the medical aspect of her left distal tibia, which was quite painful to palpate. He said:
“I think that Phillipa suffers from medial tibial stress syndrome ... Examination demonstrates that she presents a mild varus alignement on her tibial angle. I think this may be due to her fracture. This type of shape of her tibia will predispose her to have increased pressures on the medial aspect of her tibia leading to the syndrome”. 
70.	He recommended stretching exercises and activity modification, with possible surgery if those failed.
71.	Dr Di Nallo reviewed the claimant on 16 October 2023, with the (unreported) MRI. He commented on a very thin layer of fluid on the medial aspect of the tibia, and on examination found marginal swelling in this area, and posterior tenderness. He recommended stretching, shockwave therapy, a review in two months, and again mentioned the possibility of surgery, “if everything fails”. 
72.	The subsequent MRI report commented on artefact from the tibial nail, no actual fracture of tibia or fibula, and suspicion of periosteal oedema over the distal tibia which was “concerning for Fredericson grade 1 medial tibial stress”.
Head injury and psychological injury
73.	The claimant’s treating psychiatrist from both before and after the accident was Dr Bokey and she has produced her records which include a number of letters to the claimant’s GP. The claimant relies on these. 
74.	The claimant was diagnosed in May 2015 with Major Depression in the context of physical illness (including tonsillitis and glandular fever) medication and further reviews were planned. By March 2016 the claimant was reported to be “doing extremely well socially and in her studies.”
75.	In a letter dated 27 June 2016, the claimant was said to be free from depression albeit with some down days and there was said to be a clear post-traumatic stress syndrome with nightmares, hyper-vigilance and flash-backs.
76.	In September 2016 Dr Bokey reported the claimant’s mood was variable, she had returned to horse riding but was still having post-traumatic stress symptoms. It was also noted “the greatest threat to her well-being will be the often protracted nature of the ligation/insurance process a victim of a MVA endures.”
77.	In November 2016 Dr Bokey was worried the claimant might relapse into depression and on 1 June 2017 she reported this had occurred. Ms Kallus-Lawson’s mood deteriorated in February 2018 in the light of further surgery being needed. 
78.	On 15 May 2018 the claimant was reviewed on an urgent basis due to a significant deterioration in her mood which Dr Bokey considered may have been triggered by the contents of a report from one of the insurer’s rehabilitation providers. Dr Bokey referred the claimant for admission to St Vincent’s private hospital for treatment.
79.	On 13 November 2018 the claimant was reported to be coming out of her depression and medication was assisting her nightmares. On 18 December 2018, after the claimant had started her first job post-accident, the claimant was said to struggle with some cognitive functions and was forgetful. A “patchy short-term memory” was mentioned in February 2019 along with continued post-traumatic stress disorder symptoms when driving.
80.	On 7 July 2019 Dr Bokey referred the claimant to Professor Sachdev “concerned about her persistent complaint of memory problems.” On 1 August 2019 Dr Bokey wrote apparently to the claimant’s course provider seeking special dispensation for her upcoming exams.
81.	In a letter to Dr Bokey dated 10 September 2019, Professor Sachdev, neuropsychiatrist, stated that the claimant complained of cognitive difficulty and mood problems (in addition to her physical symptoms from her lower limb fractures). Her friends and noticed her repeating herself and she had difficulty with exams. She was worried about her creative side and focussed on the business side of her course.
82.	Professor Sachdev had a history of the claimant’s pre-accident depression, recovery and relapse after the accident. Ms Kallus-Lawson did not report any significant symptoms of depression. He noted the development of symptoms of post-traumatic stress disorder. Ms Kallus Lawson had no focal neurological signs on examination.
83.	The claimant scored 28/30 in the Montreal Cognitive Assessment (MoCA) test. He notes Ms Kallus-Lawson was slow in completing tasks. He expressed the view that:
“The assessment suggested … that she has problems with attention and possibly frontal executive function which is likely affecting her memory as well. A formal neuropsychological evaluation is therefore necessay.” 
84.	Dr Bokey reported in October 2019 that the, “protracted and gruelling legal process … is becoming a chronic trauma which puts her at risk of deterioration in well-being unless there is a speeding resolution.”
85.	Ms Carol Manns completed a “Neuropsychological Assessment Report” dated 6 April 2020, after an interview with Ms Kallus-Lawson on 16 March 2020. Ms Manns noted the claimant was diagnosed with depression in 2014, and glandular fever in February 2015. Ms Manns administered a number of psychometric tests, including the Test of Memory Malingering (TOMM). The claimant scored very low (10 and 14 out of 50 in two trials of this test. Ms Manns stated that:
“It is extremely uncommon for individuals with true memory impairment to score lower than 45”. 
86.	Ms Manns also reported that Ms Kallus-Lawson’s general cognitive abilities, verbal comprehension and perceptual reasoning abilities were all in the low average range. Ms Manns stated:
“[T]he results of the WMI, VI and PSI subtest scores, BADS subtest score on Rule Shift Card, and the Zoo Map test support the idea that Mss Lawson may have cognitive deficits (frontal lobe damage) as a result of a traumatic brain injury that is impacting on her executive functions, which is also supported by her self-report measure. The level of injury is unclear as premorbid functioning was not assessed, however, the reported that she was completing a Tertiary degree in business and was performing well until the accident and once she returned back to university in 2017, she began to struggle with her studies. She has since completed her degree and graduated November 2019.” 
87.	Ms Mann recommended continue psychotherapy and dialectical behaviour therapy.
88.	On 6 August 2020 Dr Bokey noted the results of the neuropsychological assessment and observed that while the claimant was free of depression stress was causing insomnia which was not responding to treatment. A report dated 2 February 2021 is in similar terms. There are no up to date records from Dr Bokey.
Joint neuropsychological report
89.	The parties obtained a joint report from Associated Professor Dr Jennifer Batchelor dated 11 May 2023 following an examination on 26 April 2023. In her executive summary of her report at [1] she found:
(a)	the claimant sustained a mild traumatic brain injury as a result of the car accident;
(b)	her neuropsychological assessment revealed definite evidence of suboptimal performance indicating “Ms Kallus-Lawson was deliberately attempting to exaggerate impairment on test of recent memory”, and
(c)	this invalidated the quantification of the nature or degree of any genuine cognitive impairment. Dr Batchelor considered it was possible “she suffers cognitive dysfunction secondary to psychiatric disorder.”
90.	Dr Bachelor appears to have received all the relevant reports which she has reviewed at [4]. 
91.	Dr Bachelor took a thorough history from the claimant at [5]. The claimant’s therapy dog was with her for the examination. Ms Kallus-Lawson reported she was not as bubbly as she was before and that her memory was not great and that she suffers from chronic pain. She said she had down days once a fortnight and slept for 12 hours a day. 
92.	The claimant’s mother supported the claimant’s history of poor memory and personality or mood change.
93.	Dr Bachelor had not administered a full standard set of psychometric tests normally done for a brain injury medico-legal assessment, because she found definite evidence of suboptimal performance. 
94.	The results of Dr Batchelor’s test included the following comments:
(a)	TOMM – results of 21 and 23 out of 50 and came to the conclusion that this was evidence “of a deliberate attempt to score poorly”; 
(b)	word choice test “her result provided additional, unequivocal evidence of purposeful test failure”;
(c)	California Verbal Learning test- second Edition: “that test provides further indication of a deliberate attempt to enact or exaggerate memory disorder", and
(d)	the Validity-10 Scale embedded in the Neurobehavioral symptom Inventory "Her responses on that scale indicated that in addition to exaggerating memory impairment she was likely overstating the symptomatology experienced on a subject level."
95.	Dr Batchelor was of the view that the results did not provide a true indication of the claimant’s actual level of ability noting the claimant was able to provide information on interview and complete a tertiary degree.
96.	Dr Batchelor said at [6] that in her opinion it was likely that the claimant sustained a mild traumatic injury in the accident. She noted that the claimant’s Glasgow Coma Scale (GCS) was 14 at the scene (possibly under the influence of opioid and ketamine), post traumatic amnesia was not formally measured but was likely to be four days based on the history from the claimant. She also noted the claimant’s brain scans were normal.
97.	Because of the invalid test results, Dr Batchelor expressed the view that “the traumatic brain injury … was not of sufficient severity to result in ongoing cognitive impairment.” Dr Batchelor did state that it is possible any cognitive impairment was secondary to the psychological conditions.
Medico-legal reports 
98.	There are no medico-legal reports in the bundle of documents relied upon by the claimant although there are extensive records and documents form the claimant’s treating health practitioners.
99.	The Panel also observes that the parties have in recent years appeared focussed on the claimant’s head injury. There is therefore no orthopaedic medico-legal reports from the insurer since 2021 and none which take into account the last two years of records from 
Dr Di Nallo.
100.	In a report addressed to the insurer and dated 13 October 2017, Dr Zeman, rehabilitation consultant, stated he assessed the claimant on 3 October 2017 at the request of the insurer. He diagnosed: 
(a)	nasal fracture with deviation;
(b)	right orbital bruising now resolved;
(c)	fractured right femur internally fixed and now healed;
(d)	fractured left tibia and fibula internally fixed and now healed;
(e)	left lateral collateral ligament tear repaired now healed;
(f)	left superficial peroneal nerve palsy with near complete recovery;
(g)	fractured right tibia internally fixed and now healed;
(h)	soft tissue injuries to right ankle and foot now healed;
(i)	prior depression with relapse after accident, and
(j)	reported anxiety and post-traumatic stress disorder.
101.	He suggested the claimant’s fractured nose could be improved with surgery and that the scarring on her leg could be improved. 
102.	He expressed the opinion that the claimant was medically fit for normal duties and for her previous work. However psychological issues and behavioural reactions would limit that. In an addendum to that report, he assessed a total of 5% WPI resulting from the lower limbs fractures and superficial peroneal nerve palsy.
103.	In a further report dated 17 February 2021 following an examination on 9 February 2021, Dr Zeman recorded the claimant’s score of 28/30 in a Mini-Mental State examination (mini-mental). He noted that the claimant stopped her university course for several months before the accident apparently because of a relapse of major depression. Dr Zeman noted other stressors in the claimant’s life including her mother’s illness, the death of a horse, a relationship breakdown and eviction from their property. Dr Zeman noted however the claimant was able to travel and was working and had continued her studies.
104.	Dr Zeman expressed the view Ms Kallus-Lawson did not have a significant frontal lobe injury and that her cognitive problems may be due to depression or the effects of medication. He considered her physical injuries from the accident had resolved. He discussed the treatment and disabilities, but he did not assess WPI.
105.	The insurer has obtained two reports from Dr Newlyn, psychiatrist. In the first dated 1 November 2017, he diagnosed a major depressive disorder and post-traumatic stress disorder both in partial remission and assessed WPI at 0%. He considered she did not need further treatment.
106.	In his second report dated 1 February 2021, Dr Newlyn diagnosed persistent depressive disorder and post-traumatic stress disorder (both in remission) and a mild neurocognitive disorder from a traumatic brain injury with behavioural disturbance. He assessed WPI at 2%.
107.	The insurer also relies on a report from Dr Noll, orthopaedic surgeon dated 30 July 2018. The claimant complained of persistent pain in her right knee and a stiff right ankle. She also had a generalised dull ache in her left leg. He considered these would “gradually settle with the passage of time” and although he indicated the claimant’s injuries were stable for the purposes of assessing impairment, no impairment assessment has been provided.
108.	The insurer relies on a report from Dr Horsley dated 15 February 2021. While he records that all of the claimant’s injuries have healed, he notes ongoing symptoms including her right knee giving way with dislocation and cracking. She also reported a dull ache in both legs down to the ankle as well as pain on both her ankles. He assessed WPI at 5%.
Other assessments
109.	Medical Assessor Fukui assessed the claimant’s WPI arising out of a psychiatric or psychological injury in a certificate dated 14 February 2022. 
110.	Medical Assessor Fukui noted the claimant had completed her course with special consideration from university and her psychiatrist. The claimant had been working in retails but was asked to do further hours which she could not do. The claimant was still working at McDonalds. She was able to care for herself.
111.	Medical Assessor Fukui refers at [17] to the clinical notes of Dr Bokey, the report of Professor Sachdev and the neuropsychological assessment of Dr Manns.
112.	She diagnosed at [18] that Mr Kallus-Lawson had developed a major depressive disorder and post-traumatic stress disorder which had improved with treatment, but which had left some residual symptoms. She stated the claimant’s physical symptoms had “a significant impact on her social and occupational function.”
113.	At [19] the Medical Assessor acknowledged the claimant’s previous condition but said her current major depressive disorder and post-traumatic stress disorder were causally related to the accident.
114.	The degree of WPI was assessed at [22] as having a 6% WPI with [24] an additional 2% for the effect of treatment. There was with no apportionment for pre-existing impairment at [23] on the basis “she was independent and functioning well as a student and working part-time before the subject accident.”
115.	Medical Assessor Mason assessed a dispute about treatment for the claimant’s psychological injuries issuing a certificate on 26 July 2023. The disputed treatment was for consultations with a psychiatrist every six weeks for the remainder of the claimant’s life expectancy.
116.	Medical Assessor Mason also found a major depressive disorder post-traumatic stress disorder and that “a mild traumatic brain injury” was sustained as a consequence of the accident. He found a pre-existing condition. While he found a need for some continuing consultations with a psychiatrist for up to five years, he did not consider treatment every six weeks for the remainder of her life was reasonable or necessary.
117.	Medical Assessor Home assessed a dispute about a number of treatment modalities finding that future analgesia for the remainder of the claimant’s life related to the injuries caused by the accident as was monthly physiotherapy for the next 12 months and were reasonable and necessary in the circumstances. 
118.	All other treatment including consultations with an occupational therapist, naturopath, pain specialist, pain management, vocational rehabilitation were not related to the injuries caused by the accident and not reasonable and necessary. In addition, he found a proposed transfer tub bench, mattress lifter, Thermomix, height adjustable kitchen stool, shower handrail and a Dyson cordless vacuum cleaner every six months from the date of assessment were not related to the injuries and not reasonable and necessary.
Re-examination findings
119.	Ms Kallus-Lawson attended a re-examination with Medical Assessors Couch and Wan on 23 October 2023 at Fairfield.
120.	The claimant’s mother assisted with some of the history-taking although the claimant answered the majority of the questions. The assessment, including history taking, cognitive functions assessment and physical examination was completed in about two hours.
121.	The claimant is currently 28 years of age. The accident occurred seven years ago, just before the claimant turned 21.
History as given by the injured person
Pre-accident medical and social history
122.	Ms Kallus-Lawson works three hours per day, four days a week teaching horse riding and also horse riding herself. She reported no major difficulty in doing her current job, also she said her balance “was not as good as before the subject motor vehicle accident.” She said she was a university student at the time of the accident, and also worked part-time in McDonalds. 
123.	Ms Kallus-Lawson denied any previous accidents, injuries or other relevant physical conditions before the accident. 
124.	There is no known history of allergy.
125.	Ms Kallus-Lawson was born in Australia. 
126.	She said her high school academic performance was average. Her best subject was design and technology, and the worst subject was science. She obtained a university entrance score of 55. She said she studied a Bachelor degree of business in 2014, but did not think she completed any units in 2015. She said she delayed the course because of glandular fever. She then changed courses in 2017 completing a Bachelor degree in Business and Fashion in November 2019.
127.	At the time of the accident, she lived with her mother on a 12 acre property. She still lives with her mother in a single storey house with two steps. Her parents are separated she has some half siblings who are not living with her.
128.	She is a non-smoker and social drinker.
129.	She drives an automatic car with power steering.
130.	She has good friends and meets them regularly.
History of the Motor Accident (from the claimant)
131.	Ms Kallus-Lawson said at about 3.00pm on 23 May 2016, she was driving home after finishing her shift at McDonalds. She was wearing her seatbelt, and there was a headrest in her car seat. While she was driving along the Illawarra Highway, near Moss Vale, she slowed down to a speed of 20 kmph (in a 100 kmph zone) to turn into her own driveway. Her car was hit by a truck from behind, and then hit a tree. The airbag deployed in the collision, and she was trapped in the car until released by the fire brigade. She believed she was unconscious for few minutes. The last thing she could remember before the collision, was that she saw the truck coming from behind. 
132.	The next thing she remembered after coming to was that she was trapped in the car and could not move her legs. She recalled that she was airlifted to Liverpool Hospital. She understands her car was written off.
133.	The medical members of the Panel note that this suggests the claimant’s retrograde amnesia was in term of seconds, and the anterograde amnesia was in term of minutes. There was no evidence suggesting significant post-traumatic amnesia (PTA). The Panel noted that Dr Batchelor concluded that the claimant sustained a mild traumatic brain injury and said:
“The description of the post-injury interval … indicates that she suffered a brief period of dense amnesia immediately following the accident, subsequently regained connected recall at the scene of the event, and then became amnesic following administration of ketamine. She was intubated at the scene and was extubated until after she had undergone multiple surgeries. The information … suggested that post-extubation she was able to record events in memory … post-traumatic amnesia of less than 24 hours…”
History of symptoms and treatment hollowing the motor accident 
134.	Ms Kallus-Lawson said she had pain all over the body after the collision. She believed she sustained the following injuries from the accident:
(a)	head injury;
(b)	fractured nose;
(c)	injuries to both legs (fractured right tibia and left tibia, fracture right femur);
(d)	right knee injury;
(e)	left knee injury (anterior cruciate ligament tear);
(f)	ankles injury (fractured metatarsals and dislocation), and
(g)	post-traumatic stress disorder and depression.
135.	Ms Kallus-Lawson had two operations while she was in the hospital, including the open reduction and internal fixation of the multiple fractures of the left and right lower limbs while in Liverpool Hospital, and then discharged home. She could not remember seeing a brain injury specialist while she was a patient there and did not attend a rehabilitation hospital.
136.	She could not remember doing memory tests (such as post traumatic amnesia testing) while she was in the hospital. However, she recalled seeing two neuropsychologists sometime after the accident but could not give more details.
137.	She was seen by physiotherapists, who initially visited her home twice a week for two weeks after discharge, then she attended the physiotherapy clinic for six months.
138.	She was seen by a psychologist from 2016 to 2020, but this treatment has now stopped. She was seen by a psychiatrist, Dr Bokey once every six weeks, and she understands the diagnosis was depression and anxiety.
139.	She was seen by an occupational therapist between 2016 and 2021, but she did not feel this was helpful. She was seen by a vocational rehabilitation service (with an occupational therapist) regarding a return to work from 2016 to 2021 but did not find this useful.
140.	She had the rod in her right femur and right tibia removed about a year after the accident because of pain in the femur. The screws in her right and left ankles were removed in 2020. Dr Di Nallo (a lower limb surgeon) performed other surgery more recently, but she could not give further details about what was done. 
141.	She said she has seen a pain specialist and a plastic surgeon but could not give further details.
142.	Ms Kallus-Lawson denied any subsequent injuries.
Current symptoms 
143.	Ms Kallus-Lawson’s current complaints are as follows:
(a)	pain (a constant dull ache) in both legs, from the hips downward, which she rates at 8/10 on the visual analogue scale (VAS);
(b)	pain in the right knee at 6/10 on the VAS. This is a constant pain which varies in intensity. It is relieved by “shock therapy” physiotherapy and reduced by taking paracetamol;
(c)	she notices swelling in the left leg from time to time;
(d)	low back pain at 5/10 on the VAS. This is a constant dull ache and is relieved by lying down and flat;
(e)	intermittent pain in the left shin at 7/10 on the VAS, and
(f)	pain in lower sternum at 5/10 on the VAS. This is a constant dull ache. The Panel notes there was no fracture in the sternum according to the records.
144.	Ms Kallus-Lawson reports that her sleep is poor because she has “too much to think of”, due to both early waking and late sleeping. She does not take sleeping pills.
145.	She complaints that her memory is not good, especially recently. For example, she may forget what she was told the day before and she has to write a shopping list before she goes to shopping. However, she has no problem in her work, and can remember the lessons and appointments. She does not use any memory aids. She does not get lost. Although she drives regularly, she uses an in-car navigation system. She said she finished her Bachelor degree in 2019 although she got a lot of help from the college. 
146.	When asked about any change in personality after the subject motor vehicle accident, the claimant said she is not as happy as before. Her mother agreed with this. The Panel noted that the claimant had history of depression before the accident. The Panel also noted that in the neuropsychological report, Dr Batchelor reported that the claimant’s mother described, “… a significant change in her daughter’s mood following that event, such that on some days she did not even want to get out of bed…”
147.	The claimant said she has constipation occasionally, but no problems with bladder function.
148.	She said at most she can sit for 10 minutes, stand for 10 minutes and walk for 25 minutes. She can drive for 1.5 hours. The Medical Assessors noticed that she sat for 1.5 hours during the interview without any difficulty.
149.	Ms Kallus-Lawson said she was independent in personal hygiene care and most activities of daily living. She sometimes helps her mother with the housework. She does not go to the gym frequently but does exercise at home. 
Current and proposed treatment
150.	Ms Kallus-Lawson stated that she takes the following medication:
(a)	Panadol or Panadol osteo, two tablets as necessary;
(b)	Nurofen, one or two tablets as necessary;
(c)	she was prescribed Endone for short periods after her surgeries;
(d)	Pristiq 100mg daily (antidepressant);
(e)	iron tablets, one tablet per day;
(f)	Roaccutane, 10mg twice a week (for acne);
(g)	Voltaren (anti-inflammatory) two to three tablets a day, and
(h)	Topical physio cream or Voltaren cream.
151.	She no longer has psychological counselling, but she sees her psychiatrist once every six weeks. She is still having physiotherapy and seeing her treating orthopaedic surgeon.
Findings on clinical examination
General
152.	At the examination on 23 October 2023 Ms Kallus-Lawson was orientated in terms of where she was and the purpose of the assessment. She was alert. She said she was 173cm tall, and weighed 61kg, which gave a body mass index of 20.4. which is in the normal range. 
153.	She walked independently without a walking aid in a normal symmetrical gait. She could walk on tiptoes, on heels, and in tandem (heel-toes) way. She had no problem in squatting but complained of pain in the hips and the knees. She could dress and undress independently. She could get on and off the examination couch independently.
154.	She is right-handed.
155.	All the measurements recorded in these reasons are of active movements measured using a goniometer:
Head
156.	Examination of the head showed no conspicuous scars, swellings, or deformities.
157.	Smell sensation was normal. Visual fields tested by confrontation were normal on both eyes. There was no nystagmus or diplopia found. Pupils were equal and reactive. Visual acuity was grossly normal. There was no gross hearing loss. 
158.	There were no other motor or sensory deficits in the face and head. The cranial nerves were intact. There was no difficulty in communication, both in expression and comprehension throughout the examination. There were no cerebellar signs found. Romberg test was normal.
Mental state screening
159.	Ms Kallus-Lawson scored 29/30 in the Folstein mini mental test. She lost one point in orientation (date). She scored 3/5 in the serial 7 test but score 5/5 in reverse spelling test, so she still got a full score in the attention and calculation item. 
160.	She became quite emotional while doing the orientation item of the mini-mental, and the assessment was paused until she settled and was comfortable for the examination to continue.
161.	She had no problem in copying figures including three-dimensional cubes. She had no problem in alternating sequences. She drew a clock showing the current time quick and well. Regarding written arithmetic tests, she got the correct answer for addition and subtraction, but got the wrong answer for multiplication. She refused to try division, saying that she would not be able to do it. She gave good answers when asked to explain some common proverbs. She gave good answers when asked for three differences but gave only one answer when asked for three similarities between apple and orange.
162.	The Medical Assessors found no evidence of cognitive impairment detected clinically in the mental state screening tests. The slight difficulty in orientation (date) was within normal limits. The arithmetic test results most likely reflected her usual ability, work experience, or inadequate effort. Abstract thinking and executive function were within normal limits. Clinically there was no evidence of cognitive impairment from the accident. However it is well known mental status screening may not detect subtle change in mild traumatic brain injury, and a comprehensive neuropsychological clarifies the situation. Therefore, the reports of the neuropsychologists are important.
Upper extremities
163.	Examination of the upper limbs showed no gross muscle wasting. Measurements of mid-arm circumference and mid-forearm circumferences were equal on both sides. Muscle power was normal in both upper limbs, both above and below the elbow. Reflexes were normal and symmetrical, and sensation was normal.
164.	Examination of the shoulders showed tenderness in both trapezius muscle regions. No crepitation was found on moving shoulders. Active movements of both shoulders were normal in all directions.
165.	Examination of the elbows showed no tenderness or swelling. Active movements of the elbows were symmetrical and within normal limits.
166.	Examination of the wrists and hands showed no deformity or swelling. Active movements of the wrists, hands and fingers were all symmetrical and within normal limits.
Lower extremities
167.	Examination of the lower limbs showed no gross muscle wasting. Measurement of mid-thigh circumference showed the right side was one centimetre smaller than the left. The mid-calf circumference and the ankle circumference were equal on both sides. The leg lengths were equal on both sides. 
168.	There was no obvious rotational deformity in either of the lower limbs. 
169.	There was a well healed scar about 20cm long on the lateral aspect of the left knee, which was nontender. There was a nontender well healed scar, about 10cm long, over the right patella, and a smaller scar, about 4cm long on the lateral aspect of the right knee. The Panel notes that scarring has been assessed by Medical Assessor Curtin. 
170.	Muscle power was normal and symmetrical, both proximally and distally. Reflexes were normal and symmetrical on both lower limbs. There was some sensory change over the skin graft area.
171.	There was mild subjective impairment to touch and pain to the lateral aspect of the left leg with no dysesthesia or allodynia (assessed as grade 2), consistent with the distribution of the left superficial peroneal nerve, but otherwise sensation was normal in the lower limbs.
172.	Examination of the hips showed no deformity or swelling. There was no tenderness over the hip regions. The test of flexion, abduction and external rotation (FABER test) was reduced on both sides. Active movements of the hips were symmetrical and within normal limits.
Hip 	Flexion	Extension	Abduction	Adduction	Internal Rotation	External rotation	
Normal	110-120	10 - 15	30 - 50	30 - 50	30 - 40	40 - 60	
Right 	120	20	50	40	30	60	
Left	120	20	50	40	30	60	
173.	Examination of the knees showed no deformity, swelling or effusion. There was no crepitation or click on moving the knees. There was mild tenderness behind the patella when the patella was pressed on both sides. There was no excessive antero-posterior or medio-lateral laxity of both knees suggesting the cruciate and collateral ligaments were intact. McMurray’s test was normal on both knees, suggesting the menisci were intact. There was mild restriction in flexion of the right knee when compared with the left knee, but both were within normal limits (and attract no impairment percentage).
Knee 	Flexion	Extension	
Normal	135	0	
Right 	140	0	
Left 	150	0	
174.	Examination of the ankles showed no deformity or swelling. Active movements of the left ankle were mildly restricted in hindfoot inversion and eversion when compared with the right. This is likely resulting from the injury to the peroneal nerve. The right ankle was also mildly restricted in eversion and likely resulting from the dislocation injury noted in the hospital records.
Ankle 	Ankle motion
Plantar flexion	Ankle motion
Dorsiflexion	Hindfoot motion
Inversion	Hindfoot motion
Eversion	
Normal	40	20	30	20	
Right	40	20	30	10	
Left	40	20	20	10	
Chest and abdomen
175.	Examination of the chest showed that there was some tenderness over the sternum. However, there was no crepitation found on breathing, with no significant “steps” or mass of sternum to suggest nonhealing fractures.
176.	Examination of the abdomen was unremarkable.
Consistency of Presentation
177.	In general, the clinical presentations were consistent with the complaints and there was no inconsistency demonstrated within the examination (on repetition of movements or when considering informal observation and formal examination).
Relevant imaging studies and other investigations
178.	The claimant did not bring any X-ray films or reports to the assessment.
179.	The Medical Assessors reviewed the reports of the following imaging studies performed at Liverpool Hospital on 23 May 2016, the day of the accident:
(a)	X-ray left foot showed no fractures or acute injury;
(b)	CT scan of the right foot showed “several small fractures of the right foot”. The most severe of these was said to involve the calcaneus and cuboid, with “calcaneocuboidal joint space widening and subluxation”. The factures at the base of the second metatarsal and the medial cuneiform raised concern for Lisfranc ligament injury. “However no evidence of subluxation of the Lisfranc.”
(c)	X-ray tibia and femur, showed displaced fractures with overlap at the mid-shafts of the right tibia and fibula. There was no disruption to the right ankle mortise. There was a displaced fracture with overlap at the mid-shaft of the left tibia and a further non-displaced fracture through the distal third of the tibia. There was a mildly displaced fracture at the left fibular head. No disruption to the left ankle mortise;
(d)	X-ray chest showed the patient was intubated but there was nothing to suggest pneumothorax or pleural effusion and no rib fractures were seen; 
(e)	X-ray pelvis, showed there was no widening of the pubic symphysis or sacroiliac joints. The visualised pelvic ring appeared intact, and the hip joint congruence was maintained. No displaced fractures were seen;
(f)	X-ray bilateral femur from the day of the accident showed a displaced mid-shaft fracture of the right femur with marked overlap of the fractured shaft fragments. The right hip joint congruence was maintained. The visualised left femur was intact. Alignment at the left knee joint was maintained. The left fibular head apophysis was incompletely fused;
(g)	CT facial bones showed displaced nasal bone fractures were noted. There was moderate deviation of the nose- to the left. There was a right frontal/peri orbital soft tissue haematoma, with no evidence of orbital wall fractures. No post septal orbital haematomas were identified. The globes were intact. There were minimally displaced subtle fractures involving the medial walls of both maxillary sinuses. There is possibly a fracture involving the bony nasal septum, with blood noted within both maxillary sinuses;
(h)	CT chest, abdomen and pelvis, showed pulmonary contusions, worse on the right but was no pneumothorax, thoracic or lumbar spinal fractures or other abnormality, and
(i)	CT brain and cervical spine – showed no intracranial haemorrhage or skull fractures. A right frontal scalp haematoma was noted. No acute cervical spinal injuries were seen.
180.	The Medical Assessors also reviewed the following additional imaging studies performed after the claimant’s discharge from hospital:
(a)	X-ray right femur, right lower leg, left knee, left lower leg and CT facial bones of 11 August 2016, taken at Highlands X-ray, – 2.5 months after the accident these show a K-nail in the right femur was in situ and in good alignment with good periosteal reaction, but bony healing was still incomplete. The right tibial fracture was in good alignment with bony healing and the right knee joint was normal.
For the left knee, there was internal fixation of a proximal fibula fracture with good bony healing. There was internal fixation of the tibia with two fractures, both showing good alignment and bony healing.
CT facial bones showed an undisplaced nasal bone fracture, polyps and impacted wisdom teeth.
(b)	X-ray right femur and both lower legs of 13 February 2017, taken at Highlands 
X-ray. showed on the right side an intra-medullary nail in the tibia with a long screw in the proximal fibula. Alignment was anatomical. There is no evidence of implant loosening. No fracture line was seen through the tibia or fibula.
(c)	MRI right knee of 10 July 2017, taken at Highlands X-ray – showed intact menisci, cruciate ligaments and collateral ligaments but an uncertain issue in the fat pad in the patella-femoral region.
181.	An X-ray taken at Castlereagh Imaging on 6 June 2022 showed:
(a)	right side – “HPA 1 degree varus, SPA 6 degrees varus”, weight bearing line 42 percent;
(b)	left side – “HPA 6 degrees varus, SPA 2 degrees”, weight bearing line 31 percent;
(c)	pelvic tilt 7mm (right over left);
(d)	normal sacroiliac joints, hips, pubic symphysis and lumbar spine, and
(e)	right femoral nail and tibial nails in situ and left femur screw with a normal appearance, and
(f)	normal knees and ankles.
182.	An MRI of the claimant’s right and left ankles was undertaken on 19 September 2022 at the request of Dr Di Nallo. This showed on the right normal alignment but small full thickness cartilage loss in the inferior calcaneocuboid joint and possible nodular synovitis. On the left there was a small ganglion cyst in the posterior ankle joint.
183.	An X-ray was performed of the claimant’s right knee at the request of Dr Di Nallo on 12 January 2023. This showed the absence of the hardware in the femur and tibia. There was a “hazy density obscuring the margins of the patellar tendon suspicious for patellar tendinosis.” The subsequent MRI of the right knee done on 13 March 2023, to “assess TT-TG distance” showed all ligaments and meniscus intact and no loss of articular cartilage. The TT-TG distance was measured as increased and at 20mm. 
184.	The Panel also notes an X-ray of 28 September 2023 showing residual hardware through the left lower leg which is “held in near anatomical alignment.” An MRI of 17 October 2023 noted “suspicion of periosteal oedema involving the left tibia … concerning for Fredericson grade 1 medial tibial stress.”
CONSIDERATION OF THE ISSUES
Does the claimant have a head injury and resultant impairment?
Head injury assessment general
185.	The central nervous system including the brain is assessed in accordance with Chapter 4 of the AMA4 Guides and clauses 1.160-1.176 of the Guidelines.
186.	Clause 1.160 provides for the following categories of impairment resulting from head and brain injury:
(a)	aphasia and communication disturbances (section 4.1a of AMA4 Guides);
(b)	permanent disturbances in level of consciousness and awareness (section 4.1d of AMA4 Guides) such as a coma;
(c)	disturbances of mental status and integrative functioning (section 4.1b of AMA4 Guides), and
(d)	emotional or behavioural disturbances (section 4.1c of AMA 4).
187.	The medical members of the Panel note Ms Kallus-Lawson showed no difficulty with comprehension or communication therefore section 4.1a of the AMA 4 Guides is not relevant to this assessment. Bearing in mind the nature of her injury and current complaints, section 4.1d of AMA4 Guides is also not relevant to her impairment assessment.
188.	Clause 1.164 of the Guidelines provides that in order for there to be an assessment of mental status impairment (section 4.1b) and emotional and behavioural impairment (section 4.1c), there must be:
(a)	evidence of a “significant impact to the head”, and
(b)	one or more significant, medically verified abnormalities such as an abnormal Glasgow Coma Scale (GCS) score, post-traumatic amnesia (PTA) or brain imaging abnormality.
189.	There is no dispute that Ms Kallus-Lawson fractured her nose and that no other fractures of the skull were revealed by the imaging. The claimant’s fractured nose does indicate there was a “significant impact” to her head in the accident. 
190.	The Panel notes that the medical and other records indicate:
(a)	the claimant’s GCS was 14 at the scene (normal is 15) and GCS later deteriorated which was likely secondary to medication (Ketamine) rather than the effect of the head injury;
(b)	PTA was not formally measured at the hospital. The claimant reported a brief period of amnesia immediately following the accident, subsequent recall at scene of the accident and was then amnesic following the administration of ketamine. Dr Batchelor assessed the PTA was less than 24 hours;
(c)	brain imaging was normal, and
(d)	from the history given by claimant at the re-examination and from the review of the records there was very brief retrograde amnesia (probably in terms of seconds) and brief anterograde amnesia (in terms of minutes).
191.	The Panel is satisfied on the basis of the initial GCS reading and the estimate of PTA that the claimant satisfies the preconditions set out in cl 1.164 of the Guidelines.
Psychometric testing
192.	The Panel notes that cl 1.165 of the Guidelines requires psychometric testing to be taken into consideration. Psychometric testing is a comprehensive set of cognitive and psychological tests usually performed by the neuropsychologist.
193.	She scored 29/30 in Folstein Mini Mental test (MMSE) administered by the Medical members of the Panel. She lost one point in orientation (saying the date was 20 October instead of the correct answer 23 October). She had no problem in copying figures including 3-dimensional cubes. She had no problem in alternating sequences. She drew a clock showing the current time quick and well. Regarding written arithmetic tests. She got the correct answer for addition and subtraction but got the wrong answer for multiplication. She refused to try division, saying that she would not be able to do it. She gave good answers when asked to explain some common proverbs. She gave good answers when asked for three differences but could only one answer when asked for three similarities between apple and orange.
194.	In summary, apart from difficulty in orientation (date), doing multiplication and division, and some difficulty naming the similarity between apple and orange, there was no indication of significant clinical cognitive impairment. 
195.	The slight difficulty in orientation (date) was within normal limits. The arithmetic test results most likely reflected her usual ability, work experience, or inadequate effort. Abstract thinking and executive function were within normal limits. 
196.	The panel also noted that:
(a)	the cognitive assessment test done by Professor Sachdev in September 2019 was normal (28/30);
(b)	the mini-mental assessment done by Dr Zeman in February 2021 was normal (28/30);
(c)	a cognitive assessment done by Medical Assessor Cameron in July 2021 showed a score of 20/30. However, Medical Assessor Cameron found no convincing information to show that the claimant had a significant traumatic brain injury. Using the Clinical Dementia Rating (CDR) scale, he assessed 0% WPI. He also assessed 0% WPI for emotional and behavioural functioning due to brain injury, and
(d)	the claimant had been diagnosed with depression in 2015 and had difficulty with her tertiary studies in 2014 -2015 likely caused by her depression but that she returned to study after the accident in 2017 and finished her degree is 2019.
197.	It is the clinical judgment of the medical members of the Panel that neuropsychological assessment, which uses valid standardised tests is more accurate in assessing brain injury, especially mild traumatic brain injury, than the mental screening tests administered by a number of the examiners, including this Panel. However, administering neuropsychological testing takes a considerable amount of time and is not appropriate for Medical Assessors to conduct within the context of an impairment assessment. The medical members of the Panel have before them the claimant’s neuropsychologist, Ms Manna’s report and the joint expert report of Associate Professor Dr Batchelor. 
198.	The Panel has carefully considered the tests they have administered and their results and in the light of the findings below in respect of the degree of WPI resulting from the claimant’s head injury does not intend to engage further with the claimant’s results.
Impairment of mental status and integrative functioning
199.	Clause 1.166 of the Guidelines provides that an assessment of mental status and integrative functioning must be done using the clinical dementia rating (CDR) tool provided for in Table 9 of the Guidelines.
200.	Table 9 provides for six categories of function:
(a)	memory;
(b)	orientation;
(c)	judgment and problem solving; 
(d)	community affairs;
(e)	home and hobbies, and 
(f)	personal care.
201.	For each of the above there are five impairment levels, with a descriptor for each and a corresponding score:
(a)	no impairment (0);
(b)	questionable impairment (0.5);
(c)	mild impairment (1);
(d)	moderate impairment (2), and
(e)	severe impairment (3).
202.	Clause 1.667 provides that the cognitive function for each of the six functions must be scored independently.
203.	In Ms Kallus-Lawson’s case, it is the clinical judgment of the medical members of the Panel that impairment as a result of her head injury (and not any psychological or other physical impairment) should be assessed as follows:
(a)	memory score will be questionable – although the claimant complains of a memory problem, it is not confirmed by the mini-mental tests and neuropsychological assessment. The score is therefore 0.5;
(b)	orientation score is questionable – she is fully oriented except for slight difficulty with date relationships. The score is therefore 0.5;
(c)	judgment and problem-solving score is 0 as Ms Kallus-Lawson has returned to study with impressive results (albeit with help) and has completed her degree;
(d)	community affairs score – as she functions independently in her job, shopping and social groups in the context of her head injury and her score is therefore 0;
(e)	her home and hobbies score is assessed on the basis she is not impaired as her life at home, horse-riding hobbies and intellectual interests were well maintained and have not been affected by her head injury – the score is therefore 0, and
(f)	Ms Kallus-Lawson’s personal care score is also 0, as she is fully capable of caring for herself in terms of feeding, bathing, dressing and so on in the context of her head injury.
204.	Clause 1.167 states that the memory score is the primary score, and all other categories are secondary scores and that:
(a)	if three or more secondary scores are the same as the memory score then the overall rating score is that of the memory score;
(b)	if three or more secondary scores attract a score more or less than the primary score then the overall rating score is the majority of secondary categories, however
(i)	if three of the secondary scores are less than (and only two more than) the memory score in which case the overall rating score is the memory score or
(ii)	if two of the secondary scores are more than, and two are less than, and one the same as the memory score then the overall rating score is the memory score. 
205.	In Ms Kallus-Lawson’s case her primary (memory) score is 0.5 as is one of her secondary scores (orientation). Three other secondary scores are 0. Therefore, in accordance with paragraph 189(b) above, Ms Kallus-Lawson’s overall score is 0 (the majority of the secondary categories) and she does not therefore have an impairment that can be measured in accordance with Table 10. Even if her memory score was assessed as 1 on the basis of valid neuropsychological tests, her overall score would remain at 0, that is no assessable impairment.
Emotional or behavioural disturbances
206.	Section 4.1c of the AMA4 Guides acknowledges that an injured person’s head injury may result in neurological impairment to mood and behaviour which may have psychiatric features as well. The Panel must be careful to consider the impairment attributable to the head injury only. 
207.	Clause 1.170 of the Guidelines provides that Table 3 at page 142 of the AMA4 Guides must be used. 
208.	Table 3 provides four categories of impairment:
(a)	mild limitation of daily social and interpersonal functioning (WPI of 0-14%);
(b)	moderate limitation of some but not all social and interpersonal daily living functions (WPI of 15-19%);
(c)	severe limitation impeding useful action in almost all social and interpersonal daily functions (WPI of 30-49%), and
(d)	severe limitation of all daily functions requiring total dependence on another person (WPI of 50-70%).
209.	The history given by the claimant to the Medical Assessors is that she has a group of friends and goes out with them. She has a good relationship with her family. The Panel is not therefore satisfied that there is any limitation of daily social and interpersonal functioning and therefore no emotional or behavioural impairments as a result of the claimant’s head injury.
Head injury – final comments
210.	Professor Batchelor was of the view that any cognitive impairment may have been caused by the claimant’s psychiatric or psychological conditions. The Panel notes that Medical Assessors Fukui and Mason (as well as Dr Newlyn) have assessed the claimant as having a major depressive disorder and post-traumatic stress disorder which had improved with treatment, but which had left some residual symptoms. Whole person impairment as a result of the psychiatric or psychological conditions has been assessed by Medical Assessor Fukui including impairments to social and recreational activities and social functioning.
211.	The Panel also notes the file of Dr Bokey and her views that the claims and dispute processes associated with the claim for compensation is likely affecting the claimant.
212.	While the Panel is of the view there is no emotional or behavioural impairment as a result of the claimant’s head injury. The Panel accepts that the claimant may have impairments as a result of her psychiatric or psychological conditions or the process involved with her compensation claim but these cannot be assessed as the consequences of her head injury.
213.	In summary while the Panel is satisfied the claimant did sustain a head injury in this accident, she has no assessable impairment as a result of any cognitive impairment arising from that injury.
Does the claimant have lower limb impairments?
Lower limb assessment generally
214.	The Panel notes the recent records produced by Dr Di Nallo and the insurer’s final submissions which suggest these documents do not demonstrate a material change in the claimant’s condition since the claimant was examined by Medical Assessor Cameron.
215.	Clause 1.21 of the Guidelines says that “the evaluation should only consider the impairment as it is at the time of the assessment”. While this clause appears to relate to the next clause and the prohibition of allowing for future deterioration it is an important clause requiring the Panel to evaluate the claimant’s injuries as they currently present and the impairment resulting from them at the time of the Review.
216.	The assessment of lower extremity impairment is governed by Chapter 3, section 3.2 of the AMA4 Guides. There are 13 methods of assessment provided for as follows:
(a)	limb length discrepancy (section 3.2a);
(b)	gait derangement (section 3.2b);
(c)	muscle atrophy (section 3.2c);
(d)	manual muscle-testing (section 3.2d);
(e)	range of motion (section 3.3e);
(f)	joint ankylosis (section 3.2f);
(g)	arthritis (section 3.2g);
(h)	amputations (section 3.2h);
(i)	diagnosis-based estimates (section 3.2i);
(j)	skin loss (section 3.2j);
(k)	peripheral nerve injuries (section 3.2.k);
(l)	causalgia and reflex sympathetic dystrophy (section 3.2l), and
(m)	vascular disorder (section 3.2m).
217.	Clause 1.70 and Table 5 state which of the above methods can and cannot be combined and Table 6 provides guidance is selecting the most appropriate method. The Guidelines at cls 1.76 to 1.110 provides specific interpretation and guidance on the various methods of assessment.
218.	Clause 1.68 of the Guidelines provides that each method used (of the 13 methods) should be calculated separately in lower extremity impairment (LEI) percentages and then, using Table 4, converted to a WPI. 
219.	Clause 1.70 says that “the most specific method, or combination of methods, of impairment assessment should be used” and if there are two specific methods, “the method providing the highest rating should be chosen”. 
220.	Clause 1.71 then says that if there is more than one injury in a limb, each injury is assessed separately and then the WPIs from each of those injuries combined.
Right femur fracture and muscle atrophy
221.	Movements of both hips were normal therefore there is no impairment in accordance with section 3.2e of the AMA4 using the range of motion method. 
222.	The fracture has healed with 1-6 degrees of varus. A femoral fracture attracts a WPI in accordance with section 3.2i and Table 64 of the AMA4 Guides if it has healed with a greater degree of angulation or malrotation (more than 10 degrees). 
223.	It is the clinical judgment of the medical members of the Panel that the right femur fracture is the cause of the one centimetre of muscle atrophy of the right thigh found by the Medical Assessors on re-examination when compared to the left. This is assessable in accordance with section 3.2c of the AMA4 Guides and cls 1.81 and 1.82 and Table 1a of the Guidelines.
224.	The claimant’s impairment is assessed as a mild impairment which attracts a finding of 6% LEI or 2% WPI.
Right tibia/fibula fracture
225.	The fractures have healed satisfactorily with minimal malignment. The Panel notes that Table 64 of AMA4 Guides provides an impairment percentage for malalignment of a tibial shaft fracture. If there is a 10-14 degree malalignment this attracts a WPI of 8% and 
15-19 degrees a 12% WPI. It is the clinical judgment of the medical members of the Panel that the claimant’s right tibia and fibula fractures have healed in good alignment with no evidence of a greater than 10 degree malalignment.
226.	The Panel also notes that hip-plateau-angle (HPA) and shaft-plateau-angle (SPA) measurements documented in the 6 June 2022 X-ray are not used for permanent impairment assessment. Neither Dr Balalla nor Dr Di Nallo mention these measurements in their reports or attribute any significance to them. WPI due to malignment of tibial shaft fractures and femoral shaft fractures are assessed with Table 64 of the AMA4 Guides, and the angulation is measured clinically. The Medical Assessors found no evidence of malignment at the re-examination. The reports of both Dr Balla and Dr Di Nallo state that the alignments were good or satisfactory. The report of Dr Harris, another orthopod, also said the right tibia shaft and right femur shaft had healed and were in good position.
227.	Pelvic tilt was also recorded in the recent radiology however there is no impairment associated with that condition provided for in Table 64 of the AMA4 Guides or elsewhere.
228.	The claimant walks normally and therefore the gait derangement method of assessment is not applicable. 
229.	It is the clinical judgment of the medical members of the Panel that the most appropriate method of assessment for the right tibia and fibula fracture is the range of motion method (section 3.2e) and Table 41 (page 78) in the AMA4 Guides. As the right knee range of motion is nearly normal (140 degrees compared to 150) and an impairment can only be assessed if flexion is less than 110 degrees, the impairment resulting from the right tibia/fibula fracture is assessed as 0% WPI.
Right knee injury
230.	While the footnote to Table 62 (page 53 of the AMA4 Guides) in section 3.2g “Arthritis” is often used in motor accident claims and attracts a 2% WPI, this can only be given if there is a history of direct trauma to the knee, complaints of pain in the knee and audible crepitation on examination of the knee. While the claimant satisfied the first two criteria, there was no crepitation found by the Medical Assessors at the examination in October 2023.
231.	The medical members of the Panel consider that the range of motion method (section 3.2e) and Table 41 (page 78) in the AMA4 Guides could be used. As the right knee range of motion is normal, it would be assessed as 0% WPI using this method.
232.	Diagnosis related estimated in section 3.2i and table 64 are often used in lower limb assessments. The Panel has considered many of the knee-related conditions contained in table 64.
233.	Clinically there is no evidence of ligament rupture in the right knee. 
234.	The Panel notes the MRI report of 13 March 2023 which assesses the TT-TG distance in the right leg. A normal measurement is less than 15 mm and an abnormal measurement is considered one with greater than 20mm in patients who have a higher risk of recurrent patellar dislocations. The TT-TG distance is useful to plan for knee surgery but is not a measure of impairment. The report however did raise with the Panel a question about whether the claimant should be assessed as having “patellar subluxation or dislocation with residual instability” which attracts a 3% WPI according to Table 64 (page 85) of the AMA4 Guides.
235.	The claimant reported to Dr Di Nallo in March 2021 that her right patella was dislocating. Following imaging and the operation in June of that year Dr Di Nallo found no true dislocation but a catching of the soft tissues behind the knee. Dr Di Nallo did not mention recurrent patella dislocation in his report of 14 March 2023 or in the records that followed. The Medical Assessors found no evidence of patella dislocation when the claimant was examined in October 2023. There is therefore no assessable impairment in relation to the findings of the MRI report and the symptoms of catching reported by the claimant.
236.	However, Dr Di Nallo clearly documented an accidental fracture of the right medial femoral condyle during what appears to be a difficult removal of the femoral nail in surgery on 23 November 2022 and that this fracture required fixation with two 50mm screws. This was a significant complication as the medial femoral condyle is one half of the weight bearing articular surface of the distal femur.
237.	A fracture to the medial femoral condyle is covered in Table 64, page 85 of the AMA4 Guides under “supracondylar or intercondylar fracture”. Such a fracture, if undisplaced gives a 5% LEI or 2% WPI. Any residual displacement or angulation gives a much higher rating of 5 to 10% WPI or more.
238.	The AMA4 Guides do not give a detailed rationale for the development of all the tables and figures. However, it is the clinical judgment of the medical members of the Panel that any fracture involving a joint articular surface (even if perfectly reduced) leads to the risk of post-traumatic osteoarthritis in particular to a major weight-bearing joint such as the knee.
239.	Due to the claimant’s undisplaced tibial plateau fracture sustained in surgery related to the injuries sustained in the accident, the Panel assesses 5% LEI (2% WPI) for the right knee injury.
Right ankle and foot – soft tissue injury
240.	A report of a CT scan of the right foot on the day of the accident showed “small fractures”. The discharge summary refers to a right ankle “dislocation”. The claimant’s right ankle has been the source of complaints and was examined carefully by Medical Assessors Wan and Couch at the re-examination.
241.	Using the range of motion method of assessment, for ankle impairments an assessment is undertaken of both the ankle joint using Table 42 (page 78) in the AMA4 Guides and the hindfoot joint using Table 43 (also at page 78).
242.	In Ms Kallus-Lawson’s case, the Medical Assessors found a normal and symmetrical range of motion in the right ankle joint leading to no assessable impairment.
243.	However, the Medical Assessors note that Table 43 provides for the following for a hindfoot impairment:
(a)	if inversion is 10-20 degrees (a mild impairment attracting a 1% WPI), and
(b)	if eversion is 0-10 degrees (also a mild impairment attracting a 1% WPI).
244.	The measurements recorded at the re-examination show Ms Kallus-Lawson has a 30 degree inversion which is not an assessable impairment and 10 degrees of eversion which gives a 2% LEI (1% WPI).
245.	While the range of motion method is the usual method of assessment, the Panel notes that other methods of assessment for the ankle and foot are available.
246.	The Panel noted with interest the MRI report of the right ankle dated 19 September 2022 and this finding:
“Small focus full thickness cartilage loss at the calcaneal side of the inferior calcaneocuboid joint approximately 12 x 10mm with focal moderate sub-articular oedema. Associated cortical irregularity. No demonstrable cartiage loss from the opposing cuboid. Remainder of the calcaneocuboid joint normal.”
247.	The Panel considers this to be a significant finding. Due to the claimant’s young age this finding cannot be explained as age-related. Neither is it a developmental anomaly. 
248.	The Panel has set out in paragraph 179(b) above, a summary of the CT scan results of the claimant’s right foot from on the day of the accident. This showed “several small fractures of the right foot” the most severe of which was said to involve the calcaneus and cuboid, with “calcaneoocuboidal joint space widening and subluxation”. The medical members of the Panel consider that the loss of articular cartilage and underlying cortical (bone surface) irregularity found reported in September 2022 is the result of the trauma that occurred in the subject accident and has caused an impairment.
249.	In the diagnosis based estimated section of AMA4 Guides, table 64 at page 86 provides or a “hindfoot-Intra-articular fracture with displacement - calcaneocuboid bone”. The unusual term “calcaneocuboid bone” means, in the Medical Assessors’ view either the calcaneus or cuboid bone, involving the articular surface of the calcaneocuboid joint. 
250.	In the light of the CT scan on the date of the accident and the more recent MRI scan, the Panel considers it appropriate to assess the significant damage to the right calcaneocuboid joint seen on MRI using the “hindfoot-intra-articular fracture with displacement-calcaneocuboid bone” of Table 64 which gives a LEI of 7% which converts to a WPI of 3%.
251.	As diagnosis-based estimates from Table 64 and range of motion impairments may not be combined, therefore the higher of the two impairments (7% LEI or 3% WPI) is used. 
Total right limb impairment
252.	Using the combined values chart at page 322 of the AMA4 Guides:
(a)	the 7% LEI for the right hindfoot calcaneal cuboid fracture is combined with the 6% LEI for the right femur fracture to give 13%;
(b)	this 13% LEI is combined with the 5% LEI for the right knee to give 18%, and
(c)	the total right lower limb impairment is 18 % LEI which, using table 4 converts to 7% WPI.
Left lower limb assessment
Left tibia fracture
253.	The fracture has healed satisfactorily with minimal malignment. The claimant walks normally. 
254.	It is the clinical judgment of the medical members of the Panel that the only possible applicable method is the range of motion method (section 3.2e) and Table 41 in the AMA4 Guides. As the left knee range of motion is normal, it is assessed above as 0% WPI (0% LEI).
255.	While the footnote to Table 62 in section 3.2g “Arthritis” is often used in motor accident claims and attracts a 2% WPI, this can only be given if there is a history of direct trauma, complaints of pain and audible crepitation on examination. While the claimant satisfied the first two, there was no crepitation found by the Medical Assessors at the examination.
256.	The most recent records of Dr Di Nallo diagnose a medial tibial stress syndrome. This does not attract an impairment percentage in the AMA4 Guides or the Guidelines. The most recent MRI of 17 October 2023 did not show any new or stress fracture in the left tibia or fibula.
Left knee injury – including peroneal nerve injury
257.	The movements of the left knee are normal. There is no crepitus and no evidence of ligament or meniscus injury. 
258.	There is no motor deficit in the left knee joint and no dysesthesia. However, there is a sensory impairment related to the superficial peroneal nerve injury which can attract a 2% impairment as explained below. However, the impairment must be adjusted due to the severity or grade of the impairment to the peroneal nerve. The severity is assessed by the Medical Assessors in accordance with Table 11a of the AMA4 Guides as grade 2 due to “decreased sensibility with or without abnormal sensation or pain, which is forgotten during activity”. A grade 2 sensory deficit of between 1 – 25% is provided for in the Guides, however cl 1.59 of the Guidelines requires the maximum amount (25%) must be used.
259.	In accordance with section 3.2k and Table 68 (page 89) of the AMA4 Guides the impairment is arrived by taking 25% (the maximum sensory deficit) of 2% (sensory impairment of the superficial peroneal nerve) = 0.5% WPI, which is rounded up to 1% WPI (2% LEI).
Left ankle 
260.	Movements of left ankle joint were normal however there was a diminution in both inversion and eversion movements of the hindfoot resulting from the peroneal nerve injury.
261.	Each of the impairments to the hindfoot attract a 1% WPI however, cl 1.85 of the Guidelines permits only the most severe deficit (and not both) can be used. As they are both the same, then a 2% LEI (1% WPI) is assessed for the hindfoot impairment.
Total left limb impairment
262.	Using the combined values chart at page 322 of the AMA4 Guides the 2% LEI for the left tibia/fibula fracture (with nerve damage) and the 2%LEI for the left hindfoot are combined and give a left lower limb impairment of 4% LEI. This converts to 2% WPI.
CONCLUSION
263.	The claimant’s right lower limb impairment (7% WPI) is combined using the chart at page 322 of the AMA4 Guides with the left lower limb impairment (2%) to give 9% WPI.
264.	Combining this 9% with the 4% WPI from Medical Assessor Curtin’s assessment of the nose and scarring gives a total WPI of 13% for the claimant’s physical injuries.
265.	The Panel notes the recently produced records from Dr Di Nallo. It is clear that the claimant is still having treatment to her lower limbs and there is the possibility of further surgery. This raised the prospect with the Panel that the claimant’s lower limb impairment may not be permanent. It is however the clinical judgment of the medical members of the Panel that while long term deterioration of the claimant’s injuries may occur, it is unlikely there will be substantial change in the impairment in the short term with or without treatment and that therefore it is appropriate to assess all injuries as stabilised and impairments permanent. 
266.	The Panel has assessed a greater level of impairment (9%) than Medical Assessor Cameron (3%). It therefore follows that his certificate should be revoked.
267.	Similarly, because the Panel’s assessment of those injuries Medical Assessor Cameron assessed when combined with Medical Assessor Curtin’s assessment produced a WPI of greater than 10% it follows that Medical Assessor Cameron’s combined certificate issued on 4 June 2022, should also be revoked.