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  • Unreported Judgment

Fowler v Workers' Compensation Regulator (No 2)

 

[2020] QIRC 64

QUEENSLAND INDUSTRIAL RELATIONS COMMISSION

CITATION:

Fowler v Workers' Compensation Regulator (No 2) [2020] QIRC 064

PARTIES:

Fowler, Lewis Richard

(Appellant)

v

Workers' Compensation Regulator

(Respondent)

CASE NO:

WC/2018/13

PROCEEDING:

Appeal against decision of the Workers' Compensation Regulator

DELIVERED ON:

6 May 2020

HEARING DATES:

25 February 2019, 26 February 2019, 2 August 2019 and 3 October 2019

DATES OF WRITTEN SUBMISSIONS:

Appellant's written submissions filed on 22 November 2019 and Respondent's written submissions filed on 16 December 2019

MEMBER:

Merrell DP

HEARD AT:

Townsville

ORDERS:

  1. Pursuant to s 558(1)(c) of the Workers' Compensation and Rehabilitation Act 2003, the review decision of the Respondent is set aside and another decision is substituted, namely that the Appellant's application for workers' compensation dated 27 July 2017 is one for acceptance.
  1. The Respondent is to pay the Appellant's costs of the appeal.

CATCHWORDS:

WORKERS' COMPENSATION – APPEAL AGAINST DECISION OF WORKERS' COMPENSATION REGULATOR – PHYSICAL INJURY – worker employed as a Pathology Services Assistant – worker had diagnosed right shoulder subacromial bursitis – whether there was an aggravation of worker's right shoulder subacromial bursitis – whether aggravation arose out of or in the course of employment – whether employment was a significant contributing factor to the aggravation – review decision of the Workers' Compensation Regulator set aside and a new decision substituted, namely that the worker suffered an injury within the meaning of the Worker's Compensation and Rehabilitation Act 2003

LEGISLATION:

Workers' Compensation and Rehabilitation Act 2003, s 32, s 558 and sch 6

CASES:

Adelaide Stevedoring Co Ltd v Forst [1940] HCA 45; (1940) 64 CLR 538

Alsco Pty Ltd v VICA Mircevic [2013] VSCA 229

Church v Workers' Compensation Regulator [2015] ICQ 031

Commonwealth v Beattie [1981] FCA 88; (1981) 53 FLR 191

Davidson v Blackwood [2014] ICQ 008

Holtman v Sampson [1985] Qd R 472

JBS Australia Pty Ltd v Q-COMP [2013] ICQ 13

Monroe Australia Pty Ltd v Campbell [1995] 65 SASR 16

Nilsson v Q-Comp [2008] QIC 74; (2008) 189 QGIG 523

Omanski v Q-Comp [2013] ICQ 7

Ramsay v Watson [1961] HCA 65; (1961) 108 CLR 643

Rossmuller v Q-COMP [2010] ICQ 4

Wiechmann v Lovering and WorkCover Corporation [1992] 59 SASR 203

APPEARANCES:

Mr J. Greggery QC instructed by Ms T. Cox of Organic Legal for the Appellant.

Mr B. McMillan of counsel directly instructed by Ms A. Schultz and later Ms K. Bednarek of the Respondent.

Reasons for Decision

Introduction

  1. [1]
    The general background to this appeal is summarised in Fowler v Workers' Compensation Regulator[1] at paragraphs [1] to [11]. Both parties adopted that summary.[2] To that extent, these reasons for decision should be read with those paragraphs.
  1. [2]
    Mr Fowler contends that his right shoulder injury:
  • was an aggravation of a pre-existing right shoulder injury, namely, subacromial bursitis;
  • occurred over a period of time from 21 February 2017 to 20 June 2017; and
  • occurred while he was doing his usual work activities which involved:
  1. standing at varying heights of tables, benches and desks;
  2. undertaking repetitive reaching movements away from his body up to at least 2,850 times per day; and
  3. the repetitive use of the right arm abduction, lifting or retrieving samples at or above shoulder height and, in respect of some tasks, the requirement to overreach due to the ergonomic setup of the various benches.[3]
  1. [3]
    Mr Fowler then relevantly contends that he suffered an aggravation of a right shoulder injury in the course of his employment over a period of time from 21 February 2017 to 20 June 2017 and that his employment was the significant contributing factor to the aggravation.[4] In this appeal, Mr Fowler gave evidence and also called evidence from Dr John Maguire, Orthopaedic Surgeon.
  1. [4]
    The Workers' Compensation Regulator ('the Regulator') contends that Mr Fowler has a personal injury, namely, right shoulder pain[5] but that the injury is not an injury as defined in s 32 of the Workers' Compensation and Rehabilitation Act 2003 ('the Act') because that injury did not arise out of, or in the course of, his employment; and, or in the alternative, his employment was not a significant contributing factor to that injury.[6] The Regulator called evidence from Dr Chris Cunneen, Occupational and Environmental Physician, and Dr Sid O'Toole, Occupational and Environmental Physician.
  1. [5]
    There is no dispute that, at the relevant time, Mr Fowler was a worker within the meaning of s 11 of the Act.[7]
  1. [6]
    Mr Fowler submitted that by the conclusion of the evidence, the single issue in dispute was whether his repetitive arm movements in his employment duties were causative of the increased pain reported to his General Practitioner on 22 June 2017 and the bursitis with impingement identified on an ultrasound of his right shoulder conducted on 22 June 2017.[8]
  1. [7]
    Mr Fowler then submitted that the single issue was further refined to the point of whether force, in addition to repetitive arm movements, was required to cause an aggravation of the pre-existing subacromial bursitis and that the refined issue was the subject of differing opinions from Dr Maguire on the one hand, and Dr Cunneen and Dr O'Toole on the other.[9]
  1. [8]
    The Regulator did not accept that the issue for determination had been narrowed to the extent suggested by Mr Fowler. The Regulator submitted that it was necessary for the Commission to make a finding as to whether Mr Fowler suffered an aggravation or reoccurrence of his previously diagnosed right shoulder bursitis, and if so, whether his employment was a significant contributing factor to the occurrence of that injury.[10]
  1. [9]
    I agree with the Regulator's submissions. The hearing of Mr Fowler's appeal is a hearing de novo,[11] and the issue to be decided is that decided in the review decision,[12] namely, whether Mr Fowler suffered an injury within the meaning of the Act.
  1. [10]
    The issues for determination are:
  • did Mr Fowler suffer an aggravation of his right shoulder, subacromial bursitis which arose out of or in the course of his employment? and, if so
  • was Mr Fowler's employment a significant contributing factor to the aggravation?
  1. [11]
    In my view, Mr Fowler did suffer an aggravation of his right shoulder, subacromial bursitis which arose out of his employment and that his employment was a significant contributing factor to that aggravation.
  1. [12]
    My reasons follow.

The Act and relevant principles

  1. [13]
    An aggravation of a physical injury is an 'injury' within the meaning of the Act if the aggravation arises out of, or in the course of employment, and the employment is a significant contributing factor to the aggravation.[13]
  1. [14]
    The activation of pain is equated with the aggravation of an existing physical injury even though there is no change to the underlying pathology.[14] There is no distinction between an 'exacerbation' and 'aggravation' of an injury[15] and 'aggravation' includes 'acceleration'.[16]
  1. [15]
    For an aggravation to occur, the employment must significantly contribute to the occurrence of the injury. It is insufficient to establish that the employment was the setting in which the aggravation occurred or the background to its occurrence.[17] There is no requirement for a claimant to show that the aggravation is a significant aggravation.[18]
  1. [16]
    The onus is on Mr Fowler to prove, on the balance of probabilities, that he had an injury within the meaning of the Act.[19]
  1. [17]
    Where there are differing opinions of qualified medical practitioners about the question of whether a worker has suffered an injury within the meaning of the Act, there are a number of principles to observe in considering that expert evidence. Relevantly to this case they are:
  • the primary duty of a tribunal is to find ultimate facts, and so far as is reasonably possible to do so, to look not merely to the expertise of the expert witnesses, but to examine the substance of the opinion expressed; and in doing so, the tribunal may not accept the opinion of an expert witness, and in cases where the experts differ, the tribunal will apply logic and common sense to the best of its ability in deciding which view is to be preferred or which parts of the evidence are to be accepted;[20]
  • a qualified medical practitioner may, as an expert, express an opinion as to the nature and cause, or probable cause of an injury, but it is for the tribunal to weigh and determine the probabilities, and in doing so, the tribunal may be assisted by the medical evidence; however, that task is for the tribunal not the witnesses and the tribunal must ask itself whether, on the whole of the evidence, it is satisfied on the balance of probabilities, of the fact;[21]
  • whether a worker has suffered an injury within the meaning of the Act is a question of fact which is not necessarily resolved by acceptance or rejection of medical testimony;[22] and, thus, the tribunal may consider the medical evidence and by a course of reasoning which, combined with common sense and the application of logic to physiological facts infer, on the balance of probabilities, a causal connection with an injury;[23]
  • in resolving disputes between experts, it is simply not a matter of adding up the witnesses on each side[24] or by the mere perusal of a variety of documentary medical reports;[25]
  • when faced with competing opinions, which are both supported by sound reasoning, the tribunal's function is to decide the issue at hand and that may require the tribunal to accept one opinion over the other, and in doing so the tribunal would not normally substitute its opinion on the medical diagnosis for that of the experts and give scientific medical reasons for doing so; and the tribunal's persuasion to prefer one opinion over another may well be based on factors such as that the expert's opinion was tested under crossexamination, or that the opinion was given by a person eminent in his or her field, or that the opinion was supported by clinical observations;[26] and
  • other guiding considerations include the expert's qualifications, impressiveness and cogency of reasoning and exposition (not always a decisive ground), preparation for and application to the problem in hand, and the extent to which the witness had a correct grasp of the basic, objective facts relevant to the problem.[27]

Matters not challenged by the Regulator

  1. [18]
    The parties provided concise and precise written submissions in support of their contentions.
  1. [19]
    Paragraphs [20]-[31] of these reasons for decision set out Mr Fowler's submissions as to the system of work, the original injury and further medical attendances and investigations.  The submissions, contained in these paragraphs, were not challenged by the Regulator.
  1. [20]
    Mr Fowler commenced working as a Pathology Services Assistant at Sullivan Nicolaides Pathology in Townsville ('SNP') in 2012 when he was 19 years old.  Mr Fowler worked eight hour shifts which included a 30 minute meal break and a 20 minute paid break resulting in work duties of seven hours and 10 minutes per shift.  Mr Fowler's duties increased over time and in 2016 he developed pain in his right shoulder which he attributed to repetition through the regular day-to-day job he was required to do.[28] 
  1. [21]
    Mr Fowler attended the Riverway Medical Centre on 22 August 2016 and the entry of his attendance records:

History:

right shoulder pain - since saturday

lab assistant in SNP - involves overhead movements

Examination:

asymmetric shoulder

positive tests:

internal rotation

adduction against resistance

emt the can

impingement?

Management:

explanation of the nature of condition

rest and avoid excessive range of motion

follow up in 1 week if not improving.[29]

  1. [22]
    Mr Fowler was provided with a Workers' Compensation Medical Certificate and an ultrasound was performed on 12 September 2016 which reported a normal shoulder save for:

Moderate thickening of subacromial subdeltoid bursa is seen with bursal distortion on abduction to 90 degrees with positive symptoms.[30]

  1. [23]
    Mr Fowler was treated by way of time off work, physiotherapy and cortisone injections and he returned to work by February 2017; and upon his return to work he gradually increased his duties and hours.[31]
  1. [24]
    On 7 February 2017, Dr O'Toole assessed Mr Fowler at the request of WorkCover Queensland ('WorkCover').  Mr Fowler gave Dr O'Toole a history of intermittent pain in the posterior shoulder and said that the discomfort was aggravated by lifting at reach and reaching overhead.  Dr O'Toole reported that: 'Hawkin's test, Jobe's test and O'Brien's test were negative' and relevantly diagnosed:

… resolved shoulder bursitis.  His ongoing symptoms are, on the balance of probabilities due to the deconditioning that has ensued from his cessation of normal activities.[32]

  1. [25]
    Dr O'Toole recommended that Mr Fowler build up to normal duties over the next two weeks.  On 14 February 2017, Mr Fowler reported to his General Practitioner that he was '… sent home today because [the] shoulder pain got worse at work and [nonsteroidal anti-inflammatory drug] is not enough.'[33]
  1. [26]
    In the course of his evidence, Mr Fowler gave a detailed account of his duties in the laboratory.  These were that various specimens were delivered during the work day, that coding, aliquoting and batching were performed on highly repetitive occasions according to the type of sample and the range of test to be performed and that he generally stood at the various workstations.[34]
  1. [27]
    In the course of coding, Mr Fowler repeatedly demonstrated a reaching movement with his right arm outstretched to obtain bags of samples from a basket which contained specimens.[35]
  1. [28]
    In the course of aliquoting, Mr Fowler described that he would reach with an outstretched arm to pick up a jar, reach for the label from the printer, reach for the straw and after aliquoting a specimen, would dispose of the straw in a sharps container that would be a little over shoulder height; and that he estimated he performed that reaching movement between 100 and 200 times per day in respect of urine samples and that the reaching requirements for blood samples were less than that for urine.[36]
  1. [29]
    In the course of batching specimens, Mr Fowler described reaching for plastic bags or labels at or above shoulder height to fill with various quantities of specimens according to the type of container; and in cross-examination he gave evidence that he would change arms to perform the reaching task according to his pain levels.[37]
  1. [30]
    Mr Fowler described that his pain increased in his right shoulder from his return to full duties when he performed the tasks of batching, coding and aliquoting which he said were repetitive.[38]
  1. [31]
    Between February and May 2017, Mr Fowler experienced some mental health issues for which he attended his General Practitioner.  On 26 May 2017, in his attendance, it was noted that his mental health plan was 'doing very well' but that he had right shoulder trapezius pain which was not affecting function or range of movement.  Mr Fowler reported increasing right shoulder pain on 15 June 2017 and on 21 June 2017, his shoulder pain was noted as 'ongoing' and an ultrasound of his shoulder was requested.[39]
  1. [32]
    The Regulator submitted that it was uncontroversial that Mr Fowler's work was highly repetitive involving the use of his hand and arms.[40]
  1. [33]
    Further, the Regulator submitted there was no dispute that Mr Fowler's previous claim for workers' compensation was accepted in August 2016 for right shoulder bursitis and that the claim ended in February 2017 following Dr O'Toole's assessment (in his report dated 10 February 2017) that his injury had resolved.[41]
  1. [34]
    The general issue for determination is whether Mr Fowler suffered an aggravation of his right shoulder, subacromial bursitis, and if so, whether that aggravation arose out of or in the course of his employment and whether Mr Fowler's employment was a significant contributing factor to the aggravation. 
  1. [35]
    Having regard to the matters not challenged by the Regulator, the relevant statutory provisions and legal principles, and the competing expert medical opinions, the specific issues for determination are:
  • did Mr Fowler experience the activation of pain in his right shoulder between 21 February 2017 and 20 June 2017? and, if so
  • was the activation of pain in Mr Fowler's right shoulder an aggravation of Mr Fowler's right shoulder subacromial bursitis? and, if so
  • did the aggravation of Mr Fowler's right shoulder subacromial bursitis arise out of or in the course of his employment? and, if so
  • was Mr Fowler's employment a significant contributing factor to the aggravation?

Did Mr Fowler experience the activation of pain in his right shoulder from 21 February 2017 to 20 June 2017?

  1. [36]
    Mr Fowler returned to work at SNP in February 2017.
  1. [37]
    The evidence referred to in Mr Fowler's unchallenged submissions, contained in paragraph [30] of these reasons for decision, is proof, on the balance of probabilities, that Mr Fowler experienced the activation of pain in his right shoulder from 21 February 2017 to 20 June 2017. 
  1. [38]
    That evidence included that:
  • when Mr Fowler resumed work in February 2017, the level of soreness, that he experienced in 2016, returned[42] and his level of soreness increased in that his shoulder was hurting when he was performing coding, batching and aliquoting;[43] and
  • his pain developed in the same way the first injury happened, namely, by just doing his job throughout the day of coding, batching or aliquoting and repetitive arm reaching.[44]

Was the activation of pain in Mr Fowler's right shoulder an aggravation of Mr Fowler's right shoulder subacromial bursitis?

  1. [39]
    This is the controversial issue amongst the expert witnesses.
  1. [40]
    This requires the determination of two questions.
  1. [41]
    First, as at February 2017 when he returned to work, did Mr Fowler have pre-existing subacromial bursitis?
  2. [42]
    Secondly, if he did, was the activation of pain in Mr Fowler's right shoulder an aggravation of that pre-existing subacromial bursitis?
  1. [43]
    These questions require a consideration of expert and other evidence, and the submissions of the parties.

Dr O'Toole's assessment as at 7 February 2017

  1. [44]
    At the request of WorkCover, Dr O'Toole examined Mr Fowler on 7 February 2017. 
  1. [45]
    Dr O'Toole conducted a clinical examination of Mr Fowler.[45] Dr O'Toole's assessment was that after assessing all information presented to him and taking a history from Mr Fowler and examining Mr Fowler, it was his opinion that Mr Fowler's diagnosis was '… resolved shoulder bursitis …' and his ongoing symptoms (of intermittent pain localised to the posterior shoulder[46]) were '… on the balance of probabilities due to the deconditioning that has ensued from his cessation of normal activities.'[47]

Mr Fowler's report to his General Practitioner on 14 February 2017

  1. [46]
    Mr Fowler consulted his General Practitioner on 14 February 2017 and reported that he was sent home that day because his shoulder pain got worse at work and the nonsteroidal anti-inflammatory drug was not enough.[48]

Mr Fowler's reports to his General Practitioner on 26 May 2017, 15 June 2017 and 21 June 2017

  1. [47]
    On 26 May 2017, Mr Fowler reported that he was suffering from right shoulder trapezius pain which was not affecting his function or range of movement.[49] Then, on 15 June 2017, Mr Fowler reported worsening right shoulder pain[50] and, on 21 June 2017, he described ongoing shoulder pain.[51]

The reports of the ultrasounds undertaken on 22 June 2017 and 20 July 2017

  1. [48]
    On 22 June 2017, Mr Fowler underwent an ultrasound of his right shoulder.  The report of that ultrasound is in evidence.  Dr C. Spies, the Radiologist who conducted the ultrasound, reported:

ULTRASOUND RIGHT SHOULDER

FINDINGS: The biceps tendon, subscapularis, supraspinatus infraspinatus, and teres minor tendons are intact.  The subdeltoid bursa is mildly thickened.  There is bursal impingement at 90degrees of abduction.

IMPRESSION: The subdeltoid bursa is mildly thickened with bursal impingement of abduction consistent with subdeltoid bursitis/peritendinosis. No rotator cuff tear.[52] 

  1. [49]
    Dr Spies conducted a further ultrasound on 20 July 2017 and relevantly reported:

ULTRASOUND RIGHT SHOULDER

FINDINGS: The biceps tendon, subscapularis, supraspinatus, infraspinatus, and teres minor tendons are intact.  The subdeltoid bursa is slightly thickened.  No impingement with abduction.  In the right lateral neck and upper back, no masses or collections.

IMPRESSION: Mild subacromial bursitis.  Intact rotator cuff.[53] 

Dr Cunneen's assessment as at 4 August 2017

  1. [50]
    By letter dated 1 August 2017, WorkCover asked Dr Cunneen to conduct an independent medical examination of Mr Fowler.
  1. [51]
    Dr Cunneen conducted a clinical examination of Mr Fowler, and had available to him an ultrasound scan of Mr Fowler's right shoulder conducted on 20 September 2016.[54]
  1. [52]
    In his report, under the heading of 'Discussion', Dr Cunneen stated:

Over past 12 months, this claimant has had recurrent episodes of right shoulder pain which upon further questioning/clinical examination, are actually right cervical pain associated with referred pain to right mantle region and right shoulder region.  Both my clinical examination and this claimant's past investigations would confirm the presence of no significant right shoulder pathology or right cervical pathology, apart from poor muscle tone and imbalance due to chronic postural kyphosis (poor posture).

I would opine this claimant has not sustained any work-related injury as there is no work event, rather his poor cervical and thoracic posture has given rise to referred pain.[55]

Dr Maguire's assessment as at 27 April 2018

  1. [53]
    By letter dated 26 April 2018, Mr Fowler's solicitors requested a medicolegal report from Dr Maguire.
  1. [54]
    Dr Maguire conducted his own clinical examination of Mr Fowler, and had access to ultrasounds of Mr Fowler's right shoulder including an ultrasound dated 12 September 2016, which showed '… significant subacromial bursitis of the right shoulder.'[56]
  1. [55]
    Under the sub-heading of 'Diagnosis:', Dr Maguire opined:
  1. Right shoulder bursitis of the subacromial region as a result of his work related activities and due to the repetitive and awkward nature of the activities.  This occurred throughout late 2016 and 2017 and subsequently lead to Mr Fowler ceasing employment.[57]
  1. [56]
    Under the heading 'Medicolegal Opinion:' and under the sub-heading 'Symptoms Consistent with Complaint:', Dr Maguire opined:

It is my opinion your client's symptoms are consistent with the complaints he describes and the mechanism of injury described.  I believe that Mr Fowler's explanation of the mechanism of injury is reasonable.[58]

  1. [57]
    Under the sub-heading of 'Attributability:', Dr Maguire opined:

I therefore believe that Mr Fowler's injury is 100% attributable to the workplace incident.  He is a young man and has no other cause for his injury that I am aware of.  There has been no other significant injury.[59]

  1. [58]
    In response to a specific question asked of Dr Maguire by Mr Fowler's solicitors, namely, whether Dr Maguire considered the original right shoulder injury was as a result of the repetitive movements required to code, batch and aliquot samples at three desks of varying height over an eight hour work day, Dr Maguire opined:

I believe his original injury is reasonably explained by the repetitive nature of the work duties and that subsequent to this, in 2017 he suffered a further aggravation of the same injury during this period.[60]

Dr Cunneen's supplementary report dated 27 September 2018

  1. [59]
    Following the provision of a further medical brief supplied on 11 September 2018, Dr Cunneen provided a supplementary medical report to the Regulator on Mr Fowler dated 27 September 2018.
  1. [60]
    In answer to the question of whether Mr Fowler sustained a further injury to his right shoulder, Dr Cunneen opined:

No.  Having perused all the additional reference material involving several hundred pages of medical notes as well as recent radiological investigations on Mr Fowler's cervical region and thoracolumbar spine performed 9 February 2018, my prior opinion as stated in my prior report dated 4 August 2017 remains unchanged.  There is no additional medical evidence within this file to alter my clinical assessment from 4 August 2017 that this claimant has not sustained further injury right shoulder region.

Indeed, as stated in my prior IME report that this claimant has the following:

  • Poor posture associated with right cervical, right mantle and right shoulder pain being due to poor posture

is also supported by the contemporaneous medical notes particularly from Riverway Medical Centre where Mr Fowler has undergone further X-rays of his cervical, thoracic and lumbar spine during February 2018 as well as a repeat ultrasound scan right shoulder during July 2017.  This ultrasound scan right shoulder demonstrated an intact right shoulder with no effusion, intact rotator cuff and very minor subacromial bursitis whilst X-rays at the time demonstrated loss of cervical lordosis which is consistent with his chronic muscle imbalance and strain of his neck region.[61]

  1. [61]
    In answer to the question of whether Mr Fowler's current condition was an aggravation of a pre-existing condition, and if so, the nature of the pre-existing condition, Dr Cunneen opined:

No.  I would state that Mr Fowler is not suffering from a pre-existing medical condition, rather he is suffering from a chronic muscle imbalance pertaining to his poor posture with rounded shoulders and increasing thoracic kyphosis, as seen on his thoracic X-rays from July 2017 and February 2018 which demonstrate the following:

  • Loss of normal cervical lordosis.
  • Mild thoracolumbar scoliosis and lordosis.

These spinal conditions in an otherwise healthy young male are due to chronic musculoligamentous imbalance of the spine alone are not due to any underlying spinal pathology or other significant medical conditions.[62]

  1. [62]
    Dr Cunneen was also provided with Dr Maguire's report dated 21 May 2017. Dr Cunneen stated that he disagreed with Dr Maguire's assessment because, having observed the videos demonstrating the type of work performed by a Laboratory Assistant at Northern Pathology, including the tasks of centrifuging and aliquoting, batching and coding, those tasks would not place any significant strain and force upon either Mr Fowler's right shoulder or neck. Dr Cunneen opined that Mr Fowler's prior employment, during 2017, was irrelevant to his chronic right shoulder and his (now) right cervical and right lumbar conditions.[63]

Dr O'Toole's further supplementary report dated 9 November 2018

  1. [63]
    Following a further medical brief supplied to him, Dr O'Toole provided a further supplementary medical report on Mr Fowler to the Regulator dated 9 November 2018.
  1. [64]
    In that report, Dr O'Toole relevantly stated:

Mr Fowler had, prior to my assessment, developed right shoulder bursitis which by the time of my assessment had resolved, leaving him with ongoing discomfort secondary to the amount of deconditioning that he had.

Rotator cuff pathology may be associated with subacromial bursitis, and the presence of bursitis has been associated with the development of, or worsening of rotator cuff tendinopathy.

The symptoms may include pain, decreased range of movement or trouble sleeping.

Bursitis can be idiopathic, related to overhead movement or, in some cases, related to recent trauma such as a fall.  My review of the work performed by Mr Fowler, both during my assessment and after when viewing the provided video, did not identify any activities that could reasonably be expected to cause bursitis in his shoulder.[64] 

Dr Maguire's supplementary report dated 7 February 2019

  1. [65]
    Dr Maguire further reviewed Mr Fowler on 18 January 2019 in relation to his right shoulder.  As part of that review, Dr Maguire viewed three videos forwarded to him by Mr Fowler's solicitors in relation to the tasks required of Mr Fowler namely coding, aliquoting and batching.[65]
  1. [66]
    Dr Maguire, in that report, relevantly opined:

Shoulder impingement leads to subacromial bursitis and this can occur as the result of the repetitive injury, particularly when performing tasks of repeated nature, even though they may be light tasks at or above shoulder level.  This is the classic mechanism for this.  Mr Fowler has an obvious mechanism for this impingement and bursitis to occur and he has imaging which confirms subacromial bursitis.  As such, I believe that my original opinion that Mr Fowler sustained a work related injury as a result of the repetitive nature of the tasks required of him is reasonable and therefore, I retain this opinion.

Dr Maguire's further supplementary report dated 27 May 2019

  1. [67]
    Following the first two days of the hearing of this appeal on 25 and 26 February 2019, Mr Fowler was given leave to rely upon a further supplementary report of Dr Maguire, in response to the oral evidence given by Dr O'Toole.  Dr Maguire's further supplementary report is dated 27 May 2019 and in that report he opined:
  • 'shoulder impingement syndrome ' and 'subacromial bursitis' are not necessarily the same terms in that shoulder impingement leads to subacromial bursitis and that impingement is the causation and bursitis is the result of the ongoing problem;[66]
  • impingement can occur for a number of reasons and the subacromial bursitis is the resultant pathological condition which occurs in response to shoulder impingement;[67]
  • the second edition of the American Medical Association Guides to the Evaluation of Disease and Injury Causation ('the AMA guides') clearly states that repetition alone can lead to subacromial bursitis and is one of the causative factors;[68]
  • force is not necessarily required, however repetition is certainly one of the major causative factors, as is repetitive activity occurring in an awkward position being defined as being associated with significant forward elevation as has occurred in the evidence provided in relation to Mr Fowler's case;[69]
  • in the reference to the AMA Guides, namely, the causative factors described in association with shoulder impingement and tendinopathy and subsequent bursitis, that Mr Fowler's work duties, as presented to him and as he witnessed on the video, and as discussed with Mr Fowler, were more than capable of having caused the pathology which has occurred;[70] and
  • as defined in the AMA Guides, the role of repetitive motion in impingement is important, force alone is not necessary and there is only some evidence associated with force being required.[71]
  1. [68]
    Dr Maguire concluded by stating:

In relation to highly repetitive work, there is some evidence associated with this.  In relation to force of work alone, there is insufficient evidence to say that this is necessary for the causation of this problem.  In relation to awkward postures however with more than 60° of forward elevation and abduction which is the same shoulder posturing undertaken by Mr Fowler, there is strong evidence for the causation of impingement and subsequent bursitis.

Therefore, there is more than enough evidence available in the literature to state that there is a combination of factors required, though highly repetitive work and awkward postures are either shown with some evidence or strong evidence for the causation of this particular condition.  This is clearly defined in the reference material to which Dr O'Toole refers in providing his opinion.[72]

  1. [69]
    Exhibit 15 was an extract from the AMA Guides.  Page 319 of Exhibit 15 relevantly provided:

Impingement syndrome of the shoulder occurs when soft tissues, the subacromial bursa tendon(s), primarily the supraspinatus and perhaps the long head of the biceps and/or other portions of the rotator cuff, are pinched between structures above - the acromion, coracoacromial ligament and/or distal clavicle - in the greater tuberosity below.  This occurs during shoulder elevation (abduction and/or flexion) between 70° and 120°.  This compression can cause subacromial bursitis plus abrasion, inflammation, and/or attenuation of the tendon(s), and in turn predisposition to tearing. Tendonitis may, in fact, be both an effect and cause of impingement, because an inflamed, swollen, and hence enlarged tendon occupies more subacromial space and is more likely to be impinged upon during shoulder elevation.  SIS[73] occurs somewhat frequently in persons whose work or avocational pursuits involve repetitive abduction and/or flexion, and is usually manifested by pain upon and limitation of shoulder elevation. 

  1. [70]
    Page 322 of Exhibit 15 contained Table 9-31, which relevantly provided:

Risk Factor

Reference and Comments

Highly repetitive work alone or in combination with other factors

Some evidence.  A cross-sectional study of a historical cohort of 1591 workers found a shoulder impingement syndrome ratio of 5.27 among current and 7.90 among former slaughterhouse workers. The authors concluded that "shoulder intensive work" is a risk factor for SIS. A cross-sectional study to evaluate the effect of individual characteristics and workplace factors (physical and psychosocial) or neck and/or shoulder pain and muscular tenderness found that the prevalence thereof was 7.0% among participants performing repetitive work and 3.8% among referents.  A 4-year prospective cohort study found that high shoulder repetition was right related to onset of neck and/or shoulder pain and tenderness.

A study found that repetitive movements in awkward positions and/or prolonged elevation of upper limb(s) was associated with development of shoulder pain.[74]

Dr O'Toole's further supplementary report dated 9 July 2019

  1. [71]
    By his further supplementary report dated 9 July 2019, Dr O'Toole stated that:
  • Dr Maguire's further supplementary report dated 27 May 2019 did not change his opinion as expressed earlier in his reports and in the evidence he gave before the Commission on 26 February 2019;[75]
  • he disagreed with Dr Maguire's opinion that 'bursitis' and 'shoulder impingement syndrome' were not interchangeable because when impingement becomes symptomatic, in the form of bursitis, it is the syndrome associated with impingement;[76]
  • there is a difference between an action that is repetitive and an action that is merely repeated and that repetitive actions are considered potentially hazardous when they are performed more than twice per minute and are performed continuously for 30 minutes at a time or for a total of two hours per shift;[77] and
  • Mr Fowler's actions were repeated but not repetitive and that the loads when he was performing were also not requisite to making the total combined forces sufficient enough to result in his work activities being a significant contributing factor in the development of his shoulder condition.[78]
  1. [72]
    The parties marshalled their submissions around the evidence of Dr O'Toole and Dr Cunneen and whether or not their opinions should be preferred to those of Dr Maguire.

The parties' submissions about the evidence of Dr O'Toole

Mr Fowler's submissions

  1. [73]
    Mr Fowler submitted that the 'single issue' was quickly identified in the crossexamination of Dr O'Toole, when Dr O'Toole opined that the activities performed by Mr Fowler in the workplace were not severe enough to cause subacromial bursitis in the first place and by his adamant expression of the view that '… repetitive movement, on its own, is insufficient and, thus, it is beyond the capacity-or a significant force involved as well.  And usually we see that above 90 degrees of affliction, or abduction in the shoulder, and generally requires significant force as well as the repetition.'[79]
  1. [74]
    Mr Fowler submitted that:
  • in reaching the conclusion expressed in the paragraph immediately referred to above, Dr O'Toole also relied upon the AMA Guides which he said identified that repetition alone was insufficient to cause subacromial bursitis; and
  • Dr O'Toole disagreed with the proposition, accepted by Dr Cunneen, irrespective of the force involved, that the repetitive movements of Mr Fowler's duties were sufficient to cause an aggravation of the pre-existing condition.[80]
  1. [75]
    It was then submitted that when the adjourned hearing resumed on 3 October 2019, after the provision of the AMA Guides to which Dr O'Toole referred, Dr O'Toole conceded some matters which contradicted his earlier position in that, he was taken to page 322 of the AMA Guides and conceded that:
  • his evidence, in reliance on the AMA Guides, which he said identified that repetition alone was insufficient to cause subacromial bursitis, was not supported by the AMA Guides;
  • his evidence, in that regard, was obviously an error on his part;
  • he had the opportunity to correct his error before providing the further report for the resumed hearing;
  • he did not correct his error; and
  • he could find no reason why he did not correct that error.[81]
  1. [76]
    Mr Fowler submitted that the concessions made by Dr O'Toole confirmed that he was an advocate for his own opinion and that he was not giving evidence in accordance with his duty to the court and, further, despite the basis of his opinion being entirely eroded by those concessions, Dr O'Toole steadfastly refused to accept any contrary possibility other than that the cause of the bursitis was unable to be explained.[82] In this regard, Mr Fowler referred to Dr O'Toole's evidence in cross-examination, on 3 October 2019, at T 420, lines 11 to 45.
  1. [77]
    Mr Fowler submitted that the opinion of Dr Maguire should be preferred to that of Dr O'Toole because:
  • Dr Maguire's qualifications and experience put him in a better position to diagnose, to make treatment and to make surgical decisions in respect of subacromial bursitis considering that Dr Cunneen accepted as much while Dr O'Toole, who had equal or lesser qualifications to Dr Cunneen, did not;[83]
  • Dr Maguire's opinion, based upon his higher qualifications and expertise, accorded with the authoritative literature referred to by Dr Cunneen and Dr Maguire and Dr Maguire was not challenged on his opinion to the effect contained in his further supplementary report (Exhibit 14) after being provided with the AMA Guides;[84] and
  • Dr O'Toole:
  1. did not examine him (Mr Fowler) after he went off work in June 2017;
  2. did not order an ultrasound for the purpose of his (Dr O'Toole's) assessment of Mr Fowler's right shoulder bursitis in February 2017, despite accepting that it would have assisted in determining the extent of the bursal swelling at the time; and
  3. overall, presented as a partisan and non-responsive witness who gave evidence to justify his original report to WorkCover, misled the Commission as to the content of the AMA Guides and did not correct his error when given the opportunity, and that such conduct, particularly the failure to correct his evidence, ought to cause grave reservations about his evidence generally.[85]

The Regulator's submissions

  1. [78]
    The Regulator made specific submissions about how the competing medical evidence should be weighed. 
  1. [79]
    The Regulator submitted that:
  • Dr Maguire examined Mr Fowler on 27 April 2018, some 10 months after Mr Fowler had ceased work in July 2017;
  • Dr O'Toole assessed Mr Fowler on 7 February 2017, after Mr Fowler had been away from work for several months and before the alleged aggravation, the subject of the present appeal; and
  • Dr Cunneen's examination of Mr Fowler on 4 August 2017, shortly after Mr Fowler ceased work in July 2017, was the most proximate to Mr Fowler actually undertaking the work duties said to have caused the injury and, in that context, the results of Dr Cunneen's examination were particularly important and Dr Cunneen found no evidence of right shoulder bursitis.[86]
  1. [80]
    The Regulator submitted that Dr Maguire's evidence, as to his clinical examination of Mr Fowler in April 2018 and as Mr Fowler's Orthopaedic Surgeon and treating physician, was not challenged and that neither Dr Cunneen nor Dr O'Toole disagreed with Dr Maguire's diagnosis as at April 2018.[87]
  1. [81]
    The Regulator also submitted that the issue for determination was not whether Mr Fowler had right shoulder bursitis in April 2018, but whether that condition arose or was aggravated during the period of his employment from February to July 2017 and whether his work was a significant contributing factor to the injury.[88]
  1. [82]
    In this regard, the Regulator submitted that it was properly conceded by Dr Cunneen that Dr Maguire's qualifications and experience put him in a better position to treat and manage Mr Fowler's injury (as diagnosed by Dr Maguire in April 2018); however, when regard was had to the specialist training and experience of Dr O'Toole and Dr Cunneen, as Occupational and Environmental Physicians in identifying the mechanism of workplace injuries, and the concurrence of their opinions as to the role of Mr Fowler's work in his injury, the evidence of Dr O'Toole and Dr Cunneen should be preferred to the evidence of Dr Maguire.[89]
  1. [83]
    The Regulator also claimed that the assessments by Dr O'Toole and Dr Cunneen of Mr Fowler bookended the period of Mr Fowler's return to work which Mr Fowler contended aggravated his right shoulder bursitis; yet, Dr O'Toole could find no clinical evidence of bursitis before Mr Fowler returned to work in February 2017 and Dr Cunneen found no clinical evidence of bursitis after Mr Fowler ceased work in July 2017.[90]
  1. [84]
    The Regulator referred to Dr O'Toole's assessment of Mr Fowler on 7 February 2017 at the request of WorkCover.  In this regard, the Regulator pointed to Dr O'Toole's written report of that assessment in which Dr O'Toole:
  • noted Mr Fowler's report of continuing intermittent pain in his right shoulder; and
  • described his findings on clinical examination of Mr Fowler, namely:

… Inspection of the right shoulder failed to elicit any swelling, erythema, scarring or other obvious deformity.  Palpation of the shoulder soft tissue and bony structures was normal. Testing of range of motion elicited 180 degrees of flexion and 50 degrees of extension.  He achieved 50 degrees of adduction and 180 degrees of abduction.  He achieved 90 degrees of internal rotation and 90 degrees of external rotation.  Hawkin's test, Jobe's test and O'Brien's test were negative.  Neurovascular examination of the right arm was unremarkable.[91]

  1. [85]
    The Regulator then referred to:
  • Dr O'Toole's opinion, as at 7 February 2017, that Mr Fowler's right shoulder bursitis had resolved and his ongoing symptoms were, on the balance of probabilities, due to the deconditioning that had ensued from his cessation of normal activities;[92]
  • Dr O'Toole's evidence before the Commission where he explained that he had formed that opinion on the basis of his examination of Mr Fowler, his observation that there was no objective measure to the examination that indicated ongoing subacromial bursitis and that Mr Fowler did not complain of any pain during the examination;[93]
  • Dr O'Toole's acceptance, in cross-examination, that he could have, but did not request any imaging of Mr Fowler's right shoulder, explaining that there was no clinical requirement or reasoning to do so as imaging was used to support a clinical diagnosis and because, following his history and clinical examination, there were no signs of ongoing impingement which, according to Dr O'Toole, indicated that Mr Fowler's condition had resolved;[94]
  • Dr O'Toole's evidence, in cross-examination, about the role of imaging in diagnosis of bursitis, namely, that clinically, Mr Fowler did not demonstrate signs of impingement and therefore, even if the imaging displayed part of the bursa sticking or being slightly larger, because Mr Fowler was clinically asymptomatic, such imaging would not have changed his opinion;[95] and
  • Dr O'Toole's evidence in re-examination that:
  1. it was not possible to diagnose bursitis on ultrasound imaging alone and that the use of imaging was to support or refute a clinical diagnosis; and
  2. he had considered the ultrasound reports of 22 June 2017 and 20 July 2018, and the impressions noted in them, in coming to his opinions.[96]
  1. [86]
    The Regulator also referred to Dr O'Toole's concession that he had been mistaken in his previous evidence that the AMA Guides did not provide support for repetition alone being causative of shoulder tendinopathy and further referred to Dr O'Toole's evidence that the AMA Guides suggests that there was some evidence, but that the evidence was not statistically significant which was the reason why repetition alone was not enough to be a causative factor.[97]
  1. [87]
    The Regulator submitted that the AMA Guides speak for themselves and that, contrary to Mr Fowler's submissions, Dr O'Toole did not mislead the Commission but misstated the effect of the content of the AMA Guides in his earlier evidence and properly conceded that error when invited to do so.[98]
  1. [88]
    Finally, the Regulator submitted that:
  • contrary to Mr Fowler's submissions, Dr O'Toole's evidence did demonstrate an ability to make reasonable concessions;
  • Dr O'Toole's evidence, as set out in paragraph 37 of Mr Fowler's submissions, was consistent with Dr O'Toole's opinion that Mr Fowler's right shoulder bursitis had resolved at the time of his assessment of Mr Fowler on 7 February 2017;
  • given the concurrent opinion of Dr Cunneen that there was no clinical evidence of bursitis when Dr Cunneen examined Mr Fowler on 4 August 2017, Dr O'Toole's opinion that Mr Fowler's shoulder pain was not caused by his repetitive work, and Dr O'Toole's disinclination to alter that opinion by reference to the ultrasound reports, were entirely reasonable;[99] and
  • as Dr O'Toole noted in his evidence in cross-examination, the majority of cases of subacromial bursitis are idiopathic and, as such, there needs to be evidence of causation before some particular activity is identified as causative.[100]

The parties' submissions about the evidence of Dr Cunneen

Mr Fowler's submissions

  1. [89]
    Mr Fowler submitted that, contrary to the opinion expressed in his report, Dr Cunneen accepted, in cross-examination, that there was pathology of the right shoulder in the nature of subacromial bursitis demonstrated in the ultrasound of 22 June 2017 and that the bursal impingement associated with complaints of pain leads to a high correlation between the impingement and bursitis.[101]
  1. [90]
    Mr Fowler further submitted that the 'single issue' of causation, identified earlier in his submissions, was quickly confirmed by Dr Cunneen when in crossexamination, in response to the proposition that the classic mechanism for the injury is repetitive movement of the shoulder between 67 degrees and above, Dr Cunneen stated '… under a significant load'. Mr Fowler submitted that Dr Cunneen did not otherwise qualify the proposition.[102]
  1. [91]
    Mr Fowler concluded his submissions regarding Dr Cunneen's evidence by submitting:
  • in support of his opinion in respect of the necessity for force or load in addition to repetition, Dr Cunneen cited his own experience as an Occupational Physician and the AMA Guides;
  • on the critical question of whether his (Mr Fowler's) work duties of aliquoting and batching, involving movements of his arm between 60 and 90 degrees, would be likely to lead to a recurrence of pre-existing subacromial bursitis, Dr Cunneen conceded it would; and
  • Dr Cunneen's concession above, in the context of the medical history and imaging, supports his case.[103]

The Regulator's submissions

  1. [92]
    The Regulator referred to Dr Cunneen's first report, dated 4 August 2017, in which Dr Cunneen opined that his clinical examination and Mr Fowler's past investigations confirmed the presence of no significant right shoulder pathology or right cervical pathology apart from poor muscle tone and imbalance due to chronic poor posture.[104]
  1. [93]
    The Regulator submitted that, in respect of Dr Cunneen's extensive cross-examination about the ultrasound investigations in June and July 2017, his explanation was that while the ultrasound investigations revealed a thickened bursitis with some impingement, that finding needed to be assessed with his clinical assessment which he could not equate with a further aggravation of right shoulder pathology.[105]
  1. [94]
    The Regulator further submitted that notwithstanding Mr Fowler's submission that Dr Cunneen accepted that there was pathology of the right shoulder in the nature of subacromial bursitis demonstrated in the ultrasound of 22 June 2017, that needed to be understood in the context of the clarification Dr Cunneen sought to make in his evidence at the time, namely, that notwithstanding the impressions taken from the ultrasound reports, his diagnosis was based on his clinical assessment of Mr Fowler on 4 August 2017 which detected no evidence of right shoulder bursitis.[106]
  1. [95]
    The Regulator also submitted that Mr Fowler's submission - that Dr Cunneen conceded that Mr Fowler's work duties of aliquoting and batching, involving movements of his arm between 60 and 90 degrees, would be likely to lead to a recurrence of pre-existing subacromial bursitis - was based on the assumption that Mr Fowler had pre-existing subacromial bursitis which was work-related; however it was apparent from Dr Cunneen's evidence that he did not accept Mr Fowler had pre-existing subacromial bursitis, being an opinion consistent with Dr O'Toole's opinion based upon Dr O'Toole's assessment and clinical examination of Mr Fowler in February 2017.[107]
  1. [96]
    The Regulator concluded by submitting that Dr Cunneen's purported concession to the expertise of Dr Maguire needed to be understood and considered in the entirety of Dr Cunneen's evidence, namely:
  • Dr Cunneen's evidence in cross-examination was that he only made the concession in respect of Dr Maguire's expertise in respect of treatment issues and diagnosis management, but not in relation to the mechanism of injury;[108] and
  • Dr Cunneen's evidence in re-examination was that as an Occupational and Environmental Physician, he had training or experience in understanding the mechanism of injury for the purposes of diagnosis and that, when he examined Mr Fowler, the mechanism of injury and his clinical assessment were not consistent with a diagnosis of subacromial bursitis.[109]
  1. [97]
    I prefer the evidence of Dr Maguire to that of Dr O'Toole and Dr Cunneen.  There are a number of reasons for this.

Dr O'Toole

  1. [98]
    Dr O'Toole's evidence was that:
  • repetitive shoulder height or above movement, in Mr Fowler's work, which did not involve significant force, could not lead to subacromial bursitis;[110]
  • subacromial bursitis could not be caused by the repeated lifting or moving of Mr Fowler's right arm in the course of aliquoting, batching and coding;[111]
  • repetition regardless, Mr Fowler's work activities could not, on a physical or organic level, cause subacromial bursitis;[112]
  • he based his opinions on the combination of his own experience and also the AMA Guides, including that the AMA Guides identify that repetition alone was insufficient and that significant force also had to be involved;[113] and
  • critical to his opinion about the question of the cause of Mr Fowler's subacromial bursitis and critical to his opinion about whether Mr Fowler was able to return to work or not was that irrespective of the repetition involved in Mr Fowler's work, the forces could not have led to any recurrence of the swelling of the bursa.[114]
  1. [99]
    At the resumed hearing on 3 October 2019, the AMA Guides were put into evidence. Dr O'Toole was cross-examined about the AMA Guides and about his evidence at the earlier hearing.  It was put to Dr O'Toole that the AMA Guides permitted the diagnosis of shoulder tendinopathy based on repetition alone, in response to which Dr O'Toole answered: 'On highly repetitive work alone, yes.'[115] Dr O'Toole further stated that his earlier evidence, which was to the contrary, was an error on his part.[116]
  1. [100]
    Dr O'Toole was further cross-examined during which he stated:

Well, you’re prepared to assume that it’s a different definition. I’m asking you to assume the converse. Assume that there was clinical impingement in the course of the ultrasound on 22 June. Does that change your opinion?---It changes my opinion that there was impingement at that time, yes.

All right?---At the time of the ultrasound.

All right. Assuming that there was impingement at the time of the ultrasound - - -?---Yes.

- - - do you accept that the pain – increase in symptoms of pain associated with that during the period of February to June 2017 leading up to that impingement were related in a causal way to those shoulder movements?---No, I do not believe that they were related to the shoulder movements that were performed in his work.

And why can you say that if the result after four months of increasing pain and shoulder movements is clinical impingement when it didn’t exist prior to the return to work?---That is indicative of the bursitis progressing. The condition itself is worsening. There could be a number of other activities that he’s performing outside of work that were – were also contributing to this. It’s the – the cumulative force and repeated nature in respect to his [indistinct] that’s sufficient to cause a worsening.

And so do you return to your original position that his return to work between February and June 2017 leading to the impingement in June is coincidental with the shoulder movements and not causally related?---I agree it is not causally related by activities performed in his work.

That is, it is coincidental. He merely had an underlying condition which is activity - - -?---Or caused by other factors.

Please let me finish. That he had an underlying condition which caused him to experience pain when performing work with his right shoulder, but not in any causal way. Is that what you’re saying?---Yes.

All right. Even if there is clinical impingement at the end of that four months associated with an increase in pain?---Yes.

All right. And even though you cannot identify any other cause?---That is correct.

All right. Do you agree that the shoulder movements caused an aggravation of the pre-existing bursitis?---No, I do not because aggravation would result in a permanent worsening.

All right. Do you agree that the shoulder movements made the pre-existing bursitis worse between February and June 2017 to the point where there was thickening of the bursa and impingement?---No, I do not.

And why do you say that?---Because, again, the activities that have been described and seen in the videos that have been shown and taken from the history that was taken from Mr Fowler, they are of insufficient magnitude to result in that.

And you maintain that position despite your concession that the representation you made about the AMA guides with repetition being insufficient was an error?---I maintain that – that the reference to the guides that I made did not fully explain my position and that that was an error on my behalf.

Well, it was further than that. It actually misrepresented the effect of the AMA guides, not your position. You’ve agreed with me about this?---Yes.[117]

  1. [101]
    It seems to me that Dr O'Toole, when cross-examined at the resumed hearing on 3 October 2019, retreated from his earlier evidence in February 2019 in that when the AMA Guides were put to him, he conceded that highly repetitive work alone would permit a diagnosis of shoulder tendinopathy.  To that extent, his earlier evidence that repetition and force was required was, in my view, inconsistent with his later evidence on 3 October 2019.
  1. [102]
    It also seems to me that Dr O'Toole's evidence that when he examined Mr Fowler in February 2017, Mr Fowler's pain was due to deconditioning,[118] was inconsistent with the findings of the ultrasounds undertaken in June and July 2017, both of which found a thickening of the bursa. The June 2017 ultrasound found bursal impingement at 90 degrees of abduction.

Dr Cunneen

  1. [103]
    As Mr Fowler submitted, in cross-examination, Dr Cunneen accepted that the ultrasound undertaken of Mr Fowler's right shoulder, on 22 June 2017 'caught subacromial bursitis'[119] and further that Dr Cunneen accepted that, generally, bursal impingement associated with complaints of pain leads to a very high correlation between the impingement and the pain.[120]
  1. [104]
    Furthermore, as Mr Fowler submitted, it was put to Dr Cunneen that if he assumed Mr Fowler repeatedly raised his shoulder to, at or above shoulder height in the course of aliquoting and repeatedly raised his right shoulder to, at or above shoulder height in the process of batching, that would be consistent with the development of subacromial bursitis. Dr Cunneen's response was: 'Only if under a significant load.'[121]
  1. [105]
    Dr Cunneen's last answer, in paragraph [104] of these reasons for decision, was explored further in cross-examination:

All right. Now, when you say under significant load, are you referring there to your own experience or are you referring to some authoritative journal or text articles?---Well, I’m actually referring (1) to experience and (2) to the books we have from the AMA, American Medical Association, Guides to the Evaluation of Injury and Disease Causation, second edition 2012 that addresses that fact. And the hand movement that one moves above [indistinct] unless you’ve got a pre-existing problem and that’s not the issue here. It does not give rise to pathology, as opposed to if you’ve got significant strain or load and as I said on page 5 under the three dot points, would not place any significant strain or force. So, I think I qualified my assessment. I think the need to actually move it above or within 60 to 90 degrees or above [indistinct] on its own does not give rise to subacromial bursitis on a permanent basis. It’s actually the mechanism for what you’re doing in that that’s used to determine if that’s significant load.[122]

You just stated a further qualification in your answer about the absence of a pre-existing condition, which was not an issue here. Assume that Mr Fowler has a pre-existing subacromial bursitis which is work-related. Would the repetitive movements involved in lifting the arm between to 60 to 90 degrees and above in aliquoting and in batching be likely to lead to a recurrence of that injury?---Yes.[123]

  1. [106]
    The Regulator submitted that Dr Cunneen's last answer, in paragraph [105] of these reasons for decision, needed to be considered in the context that Dr Cunneen, like Dr O'Toole, did not accept Mr Fowler had a pre-existing subacromial bursitis.[124]
  1. [107]
    However, for the reasons I give below, I prefer Dr Maguire's evidence that once the condition of subacromial bursitis occurs, it does not necessarily go away and that on a consideration of Mr Fowler's evidence and Dr Maguire's evidence, Mr Fowler, as at February 2017, had pre-existing subacromial bursitis.
  1. [108]
    Dr Cunneen's evidence in re-examination was that as an Occupational and Environmental Physician, he had training or experience in understanding the mechanism of injury for the purposes of diagnosis, and that when he examined Mr Fowler, the mechanism of injury and his assessment of Mr Fowler was not consistent with a diagnosis of subacromial bursitis.[125]  However, Dr Cunneen's affirmative answer to the question that repetitive movements involved in lifting the arm between 60 to 90 degrees and above in aliquoting and in batching would be likely to lead to a recurrence of pre-existing subacromial bursitis, was inconsistent with his earlier evidence that the mechanism of injury, as described by Mr Fowler, would be consistent with a diagnosis of subacromial bursitis only if under a significant load. 

Dr Maguire

  1. [109]
    Contrary to what appeared to be suggested in the Regulator's submissions,[126] Dr Maguire's evidence was not only about Mr Fowler's diagnosis of right shoulder bursitis as at April 2018.  Dr Maguire's opinion, as set out in his report dated 21 May 2018 was that Mr Fowler's original injury was reasonably explained by the repetitive nature of the work duties and that subsequent to that, in 2017, Mr Fowler suffered a further aggravation of the same injury during that period.[127] 
  1. [110]
    Further, Dr Maguire's evidence in re-examination, was that on the assumption that Mr Fowler reported an increase in pain on returning to full-time duties from February 2017 through to June 2017, when his pain led to the June 2017 ultrasound, '… you can presume that it is one of the triggers for his pain getting worse, yes.'[128]
  1. [111]
    Dr Maguire was not cross-examined about his further supplementary report (Exhibit 14).  In that report, Dr Maguire gave evidence about the AMA Guides, namely that:
  • repetition alone can lead to subacromial bursitis and is one of the causative factors;
  • force is not necessarily required; and
  • repetition is certainly one of the major causative factors as is repetitive activity occurring in an awkward position, which was defined as being associated with significant forward elevation as has occurred in the evidence provided in relation to Mr Fowler.[129]
  1. [112]
    Dr Maguire's evidence that the repetitive nature of Mr Fowler's work, which not only reasonably explained Mr Fowler's original injury but also the aggravation of Mr Fowler's injury in 2017, was unchanged throughout his three reports dated 21 May 2018,[130] 7 February 2019[131] and 27 May 2019.[132]
  1. [113]
    In addition, Dr Maguire's evidence that Mr Fowler's work was strong evidence for the causation of impingement and subsequent bursitis, was supported by the AMA Guides as referred to in Exhibit 15.
  1. [114]
    The Regulator also submitted that the fact that Dr Maguire found evidence of right shoulder bursitis on examination in April 2018 does not suggest that injury was caused by Mr Fowler's work, since the majority of cases of bursitis are idiopathic.[133]  However, that submission disregards Dr Maguire's consistent evidence about the cause of the aggravation of Mr Fowler's subacromial bursitis, particularly when regard is had to the causes of impingement and shoulder tendinopathy as set out in the AMA Guides.[134]
  1. [115]
    Dr Cunneen's evidence that, on the assumption that Mr Fowler repeatedly raised his shoulder to, at or above shoulder height in the course of aliquoting and repeatedly raised his right shoulder above shoulder height in the process of batching would be consistent with the development of subacromial bursitis if under 'significant load',[135] was also inconsistent with the AMA Guides upon which he relied for his opinion.
  1. [116]
    While that evidence of Dr Cunneen was based on his view that Mr Fowler did not have pre-existing bursitis,[136] for the reasons given below, I find that Mr Fowler did have preexisting subacromial bursitis as at February 2017 when he recommenced work at SNP.

Did Mr Fowler have pre-existing subacromial bursitis when he returned to work at SNP in February 2017?

  1. [117]
    Mr Fowler was examined by Dr O'Toole on 7 February 2017. Mr Fowler complained of intermittent pain localised to the posterior shoulder which was aggravated by lifting at reach and reaching overhead and described a decreased range of motion in the shoulder affecting most directions.[137]
  1. [118]
    Mr Fowler was examined by Dr Cunneen on 4 August 2017.  Dr Cunneen opined that Mr Fowler had not sustained any work-related injury as there was '… no work event, rather his poor cervical and thoracic posture has given rise to referred pain'.[138] However,  Mr Fowler described to Dr Cunneen that since February 2017, he had noted intermittent pain over the right cervical region, right mantle region and right shoulder region and that he continued working but noted any activity above shoulder height, requiring lifting and prolonged sitting, worsened his pain.[139]
  1. [119]
    Mr Fowler was examined by Dr Maguire on 27 April 2018.  Mr Fowler described to Dr Maguire that when his WorkCover case closed in February 2017, he was still experiencing pain in the shoulder and that throughout the course of 2017, his pain continued to worsen.[140]
  1. [120]
    There can be no doubt that Mr Fowler had suffered subacromial bursitis in 2016.  An ultrasound undertaken of Mr Fowler's right shoulder on 12 September 2016 found a moderate thickening of the subacromial subdeltoid bursa with bursal distortion on abduction to 90 degrees with positive symptoms; and the impression recorded by the Radiologist was '… Mild subacromial subdeltoid bursitis due to impingement.'[141] There was no dispute that Mr Fowler's previous claim for workers' compensation was accepted in August 2016 for right shoulder bursitis and that the claim ended in February 2017 on the basis of Dr O'Toole's report dated 10 February 2017.
  1. [121]
    Mr Fowler was still suffering from right shoulder pain in February 2017 when he returned to work at SNP[142] and he continued to suffer from right shoulder pain until June 2017 when Mr Fowler reported to his General Practitioner that his shoulder pain was not getting any better and an ultrasound was requested.[143] The ultrasound undertaken in June 2017 found a mildly thickened subdeltoid bursa and a bursal impingement at 90 degrees of abduction. The second ultrasound undertaken in July 2017 found a slightly thickened subdeltoid bursa but with no impingement with abduction.  The impression recorded by the Radiologist in the June and July 2017 ultrasounds were, respectively 'subdeltoid bursitis/peritendinosis' and 'Mild subacromial bursitis'.
  1. [122]
    Mr Fowler's evidence that the work duties he was performing which caused the symptoms he described when he returned to work at SNP in February 2017, in my view, points to, on the balance of probabilities, that Mr Fowler's right shoulder subacromial bursitis had not 'resolved' by the time he returned to work in February 2019.  Dr Maguire's evidence supports this conclusion.
  1. [123]
    It was put to Dr Maguire, in cross-examination, that if Mr Fowler's work was the cause of his bursitis, it could be expected that the condition would resolve, at least to some extent, upon Mr Fowler ceasing that activity.[144] Dr Maguire's response was that once the condition occurs it does not necessarily go away which, Dr Maguire stated, was the reason why:

… we end up operating on so many people with this particular condition, because once it's triggered, it doesn’t always go away once you rest them.  So, we try and do things non-operatively, sometimes a condition does not relieve itself at all even with the injections.  The injection only works seven to eight of-70 to 80 per cent of the time, so that means 20 to 30 per cent of people, despite having the injection and rest, the pain doesn't go away at all, so they may go on to have surgery and that's despite removing them from the environment that is causing the problem.[145] 

  1. [124]
    The Regulator submitted that Dr Maguire, Dr Cunneen and Dr O'Toole all agreed that bursitis was properly diagnosed on clinical examination and perhaps then confirmed with imaging.[146] However, Dr Maguire's evidence went further.  Under cross-examination, it was suggested to Dr Maguire that it was possible that a person could have an ultrasound that reveals a bursal impingement but would not be otherwise demonstrating any clinical symptoms of bursitis.[147] Dr Maguire disagreed with that and said that most people, if they have bursitis, will have some degree of pain.[148]
  1. [125]
    As referred to above, I prefer the evidence of Dr Maguire to that of Dr O'Toole and Dr Cunneen.  Furthermore, Dr Maguire is an Orthopaedic Surgeon who gave evidence of his experience in the treatment of patients with subacromial bursitis.[149]  While Dr Cunneen[150] and Dr O'Toole[151] conceded that they would defer to Dr Maguire's opinions about the diagnosis management and the treatment of subacromial bursitis, it is Dr Maguire's qualifications and experience as an Orthopaedic Surgeon, that, in my view, gives persuasive force to his evidence that the condition of subacromial bursitis does not necessarily go away upon taking the patient out of the environment causing the problem. 
  1. [126]
    For these reasons, having regard to Mr Fowler's evidence about the pain he experienced when performing his work duties upon returning to work at SNP in February 2017, and Dr Maguire's evidence, I am of the view that Mr Fowler had pre-existing subacromial bursitis when he returned to work at SNP in February 2017.

Was the activation of pain in Mr Fowler's right shoulder an aggravation of Mr Fowler's right shoulder subacromial bursitis?

  1. [127]
    Dr Maguire's evidence was that the mechanism of work described by Mr Fowler, upon his return to work at SNP in February 2017, aggravated his pre-existing bursitis.[152]
  1. [128]
    The AMA Guides, referred to by Dr Maguire in his further supplementary report[153] provided that that there was insufficient evidence to show that forceful work was an occupational risk factor for shoulder tendinopathy impingement.[154] That evidence was inconsistent with Dr Cunneen's and Dr O'Toole's evidence in crossexamination when they cited the AMA Guides as authority for their evidence that the repeated reaching above shoulder height, under significant load, was consistent with the development of subacromial bursitis.
  1. [129]
    For these reasons, I find that the activation of pain in Mr Fowler's right shoulder was an aggravation of Mr Fowler's right shoulder subacromial bursitis.

Did the aggravation of Mr Fowler's right shoulder subacromial bursitis arise out of or in the course of his employment?

Was Mr Fowler' employment a significant contributing factor to the aggravation?

  1. [130]
    These two matters can be considered together.
  1. [131]
    The Regulator accepted, as uncontroversial, that Mr Fowler's work was highly repetitive involving the use of his hand and arms. The evidence referred to in Mr Fowler's unchallenged submissions, contained in paragraphs [26] to [29] of these reasons for decision, is proof, on the balance of probabilities, that Mr Fowler's job between February 2017 and June 2017 involved the repetitive reaching and outstretched movements of his right arm. 
  1. [132]
    Mr Fowler's evidence was that upon him returning to work in February 2017, his right shoulder hurt more when he was performing his batching, coding and aliquoting duties.[155]
  1. [133]
    For the reasons given earlier in these reasons for decision, I prefer Dr Maguire's evidence to that of Dr O'Toole and Dr Cunneen. This includes Dr Maguire's evidence about the mechanism of the aggravation of Mr Fowler's pre-existing right shoulder bursitis being the repetitive and awkward nature of the work Mr Fowler performed when he resumed work at SNP in February 2017.[156] 
  1. [134]
    On Mr Fowler's evidence and on Dr Maguire's evidence, I find that the aggravation of Mr Fowler's right shoulder subacromial bursitis, that occurred between 21 February 2017 and 20 June 2017, arose out of his employment at SNP between 21 February 2017 and 20 June 2017 and that his employment was a significant contributing factor to that aggravation. 

Conclusion

  1. [135]
    The issues for determination in this matter were:
  • did Mr Fowler suffer an aggravation of his right shoulder, subacromial bursitis when he returned to work as a Pathology Services Assistant at SNP between February 2017 in June 2017; and, if so
  • was Mr Fowler's employment a significant contributing factor to the aggravation.
  1. [136]
    On the evidence of Mr Fowler and my preference for the evidence of Dr Maguire over that of Dr O'Toole and Dr Cunneen, I find that Mr Fowler did suffer an aggravation of his pre-existing right shoulder subacromial bursitis when he returned to work as a Pathology Services Assistant at SNP between February 2017 and June 2017. I also find that aggravation arose out of his employment and that his employment was a significant contributing factor to the aggravation.
  1. [137]
    Pursuant to s 558(1)(c) of the Act, I set aside the review decision of the Regulator and I substitute another decision, namely, that Mr Fowler's application for workers' compensation dated 27 July 2017 is one for acceptance.
  1. [138]
    The Regulator must pay Mr Fowler's costs of the appeal.

Footnotes

[1] [2019] QIRC 149.

[2] Mr Fowler's submissions filed on 22 November 2019, para. 1 ('Mr Fowler's submissions') and the Worker's Compensation Regulator's submissions filed on 16 December 2019, para. 2 ('the Regulator's submissions').

[3] Mr Fowler's Statement of Facts and Contentions filed on 6 April 2018, paras. 23, 24, 25 and 26 ('Mr Fowler's contentions').

[4] Mr Fowler's contentions, para. 30.

[5] The Regulator's Statement of Facts and Contentions filed on 3 May 2018, para. 15 ('the Regulator's contentions').

[6] The Regulator's contentions, para. 16.

[7] The Regulator submissions, para. 3.

[8] Mr Fowler's submissions, para. 2.

[9] Mr Fowler's submissions, paras. 3-4.

[10] The Regulator's submissions, paras. 6-7.

[11] Church v Workers' Compensation Regulator [2015] ICQ 031, [27] (Martin J, President).

[12] Ibid [37]-[38].

[13] Workers' Compensation and Rehabilitation Act 2003, s 32(3)(b)(i).

[14] Commonwealth v Beattie [1981] FCA 88; (1981) 53 FLR 191, 201 (Evatt and Sheppard JJ).

[15] Omanski v Q-Comp [2013] ICQ 7, [11] (President Hall).

[16] Workers' Compensation and Rehabilitation Act 2003, sch 6 (definition of 'aggravation').

[17] JBS Australia Pty Ltd v Q-COMP [2013] ICQ 13, [3] (President Hall).

[18] Ibid [5].

[19] Rossmuller v Q-COMP [2010] ICQ 4, [2] (President Hall).

[20] Holtman v Sampson [1985] Qd R 472, 474 (D.M Campbell, Macrossan and Thomas JJ).

[21] Ramsay v Watson [1961] HCA 65; (1961) 108 CLR 643, 645 (Dixon CJ, McTiernan, Kitto, Taylor and Windeyer JJ).

[22] Nilsson v Q-Comp [2008] QIC 74; (2008) 189 QGIG 523, 526 (Hall P).

[23] Adelaide Stevedoring Co Ltd v Forst [1940] HCA 45; (1940) 64 CLR 538, 563, (Rich ACJ).

[24] Davidson v Blackwood [2014] ICQ 008, [19] (Martin J, President).

[25] Wiechmann v Lovering and WorkCover Corporation [1992] 59 SASR 203, 208 (Olsson J, Bray CJ, 204 and Mullighan J, 212 agreeing)

[26] Alsco Pty Ltd v VICA Mircevic [2013] VSCA 229, [95] (Robson AJA).

[27] Monroe Australia Pty Ltd v Campbell [1995] 65 SASR 16, 27 (Bollen J, Doyle CJ at 17 and Debelle J at 30 agreeing).

[28] Mr Fowler's submissions, paras. 6-7 and the Regulator's submissions, para. 9.

[29] Mr Fowler's submissions, para. 8 and the Regulator's submissions, para. 9. See also Exhibit 1, page 39.

[30] Mr Fowler's submissions, para. 9 and the Regulator's submissions, para. 9.

[31] Mr Fowler's submissions, para. 10 and the Regulator's submissions, para. 9.

[32] Mr Fowler's submissions, para. 11 and the Regulator's submissions, para. 9.

[33] Mr Fowler's submissions, paras. 12-13 and the Regulator's submissions, para. 9.

[34] Mr Fowler's submissions, para. 14 and the Regulator's submissions, para. 9.

[35] Mr Fowler's submissions, para. 15 and the Regulator's submissions, para. 9.

[36] Mr Fowler's submissions, para. 16 and the Regulator's submissions, para. 9.

[37] Mr Fowler's submissions, para. 17 and the Regulator's submissions, para. 9.

[38] Mr Fowler's submissions, para. 18 and the Regulator's submissions, para. 9.

[39] Mr Fowler's submissions, paras. 19-21 and the Regulator's submissions, para. 9.

[40] The Regulator's submissions, para. 10.

[41] The Regulator's submissions, para. 11.

[42] T 1-26, ll 17-21.

[43] T 1-26, ll 25-28.

[44] T 1-27, ll 9-12.

[45] Exhibit 12, third page, seventh and eighth paragraphs and fourth page, first paragraph.

[46] Exhibit 12, second page, last paragraph.

[47] Exhibit 12, fourth page, third paragraph.

[48] Exhibit 1, page 30.

[49] Exhibit 1, page 26.

[50] Exhibit 1, pages 24-25.

[51] Exhibit 1, page 24.

[52] Exhibit 1, page 85.

[53] Exhibit 1, page 86.

[54] Exhibit 10, page 5 of 7.

[55] Exhibit 10, page 5 of 7.

[56] Exhibit 8, page 5 of 9.

[57] Exhibit 8, page 6 of 9.

[58] Exhibit 8, page 7 of 9.

[59] Exhibit 8, page 7 of 9.

[60] Exhibit 8, page 8 of 9.

[61] Exhibit 11, page 3 of 8.

[62] Exhibit 11, page 3 of 8.

[63] Exhibit 11, page 5 of 8.

[64] Exhibit 13, pages 4 and 5 of 5.

[65] Exhibit 9, page 1 of 3.

[66] Exhibit 14, page 2 of 4.

[67] Exhibit 14, page 2 of 4.

[68] Exhibit 14, page 2 of 4.

[69] Exhibit 14, page 2 of 4.

[70] Exhibit 14, page 3 of 4.

[71] Exhibit 14, page 3 of 4.

[72] Exhibit 14, page 3 of 4.

[73] Subacromial Impingement Syndrome.

[74] Footnotes omitted.

[75] Exhibit 16, page 1 of 3.

[76] Exhibit 16, page 2 of 3.

[77] Exhibit 16, page 3 of 3.

[78] Exhibit 16, page 3 of 3.

[79] Mr Fowler's submissions, para. 32.

[80] Mr Fowler's submissions, paras. 33-34.

[81] Mr Fowler's submissions, para. 35

[82] Mr Fowler's submissions, para. 36.

[83] Mr Fowler's submissions, para. 38.

[84] Mr Fowler's submissions, para. 39.

[85] Mr Fowler's submissions, para. 40.

[86] The Regulator's submissions, para. 32.

[87] The Regulator's submissions, para. 33.

[88] The Regulator's submissions, para. 34.

[89] The Regulator's submissions, para. 35.

[90] The Regulator's submissions, para. 36.

[91] The Regulator's submissions, para. 14.

[92] The Regulator's submissions, para. 15.

[93] The Regulator's submissions, para. 15.

[94] The Regulator's submissions, para. 16.

[95] The Regulator's submissions, para. 17.

[96] The Regulator's submissions, paras. 18-19.

[97] The Regulator's submissions, para. 20.

[98] The Regulator's submissions, para. 21.

[99] The Regulator's submissions, para. 22.

[100] The Regulator's submissions, para. 23.

[101] Mr Fowler's submissions, para, 27.

[102] Mr Fowler's submissions, para. 28.

[103] Mr Fowler's submissions, paras. 29-31.

[104] The Regulator's submissions, para. 24.

[105] The Regulator's submissions, para. 25.

[106] The Regulator's submissions, paras. 26 and 27.

[107] The Regulator's submissions, paras. 28-29.

[108] The Regulator's submissions, para. 30.

[109] The Regulator's submissions, para. 31.

[110] T 2-26, ll 13-17.

[111] T 2-27, ll 23-25.

[112] T 2-30, ll 24-25.

[113] T 2-30, ll 27-36.

[114] T 2-36, ll 22-26.

[115] T 4-16, ll 29-33.

[116] T 4-17, ll 33-38.

[117] T 4-19, l 35 to T 4-20, l 46.

[118] Exhibit 12, page 4, third paragraph.

[119] T 2-5, ll 43-46.

[120] T 2-6, ll 15-17.

[121] T 2-16, ll 28-32.

[122] T 2-16, ll 34-46.

[123] T 2-17, ll 8-12.

[124] The Regulator's submissions, paras. 28-29.

[125] T 2-18, ll 21-31.

[126] The Regulator's submissions, paras. 33-34.

[127] Exhibit 8, page 8 of 9.

[128] T 1-67, ll 1-9.

[129] Exhibit 14, page 2 of 4, paragraph number 2.

[130] Exhibit 8, page 8 of 9, paragraph number 4.

[131] Exhibit 9, page 2 of 3, fourth paragraph.

[132] Exhibit 14, page 2 of 4, paragraph number 2.

[133] The Regulator's submissions, para. 38.

[134] Exhibit 15, page 320 and page 322.

[135] T 2-16, ll 15-22.

[136] T 2-16, ll 34-46.

[137] Exhibit 12, page 2, eighth paragraph and page 3, first paragraph.

[138] Exhibit 10, page 5 of 7.

[139] Exhibit 10, page 2 of 7.

[140] Exhibit 8, pages 2 and 3 of 9.

[141] Exhibit 1, page 83.

[142] Exhibit 1, page 30 - the entry for Tuesday, 14 February 2017.

[143] Exhibit 1, page 24 - the entry for Wednesday, 21 June 2017.

[144] T 1-66, ll 10-11.

[145] T 1-66, ll 11-19.

[146] The Regulator's submissions, para. 37.

[147] T 1-60, ll 31-33.

[148] T1-60, ll 33-34.

[149] T 1-66, ll 10-19

[150] T 2-11, ll 37-42 and T 2-15, l 34 to T 2-16, l 13.

[151] T 2-10, ll 11-14 and T 2-10, ll 29-30.

[152] Exhibit 8, page 8 of 9, paragraph number 4.

[153] Exhibit 14, page 2 of 4, paragraph number 2 and page 3 of 4, first paragraph.

[154] Exhibit 15, pages 320 and 322.

[155] T 1-26, l 21 to T 1-27, l 12.

[156] Exhibit 8, page 6 of 9, paragraph number 1 and page 8 of 9, paragraph number 4.

Close

Editorial Notes

  • Published Case Name:

    Lewis Richard Fowler v Workers' Compensation Regulator (No 2)

  • Shortened Case Name:

    Fowler v Workers' Compensation Regulator (No 2)

  • MNC:

    [2020] QIRC 64

  • Court:

    QIRC

  • Judge(s):

    Merrell DP

  • Date:

    06 May 2020

Appeal Status

Please note, appeal data is presently unavailable for this judgment. This judgment may have been the subject of an appeal.
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