Osman v Accident Compensation Corporation

IN THE DISTRICT COURT HELD AT CHRISTCHURCH Decision No. 186 /2008 IN THE MATTER of the Injury Prevention, Rehabilitation and Compensation Act 2001 AND IN THE MATTER of an appeal pursuant to Section 149 of the Act BETWEEN SUZAN OSMAN (Al 457/05) Appellant AND ACCIDENT COMPENSATION CORPORATION Respondent HEARD at CHRISTCHURCH on 21 July 2008 APPEARANCES Mr M Elliot, Counsel for Appellant Mr I Hunt, Counsel for Respondent. RESERVED JUDGMENT OF JUDGE M J BEATTIE [1] The issue in this appeal arises from the respondent's decision of 14 January 2005, whereby it suspended entitlements to the appellant on the grounds that her ongoing medical condition was not attributable to the personal injury for which she had been granted cover in May 1997. [2] At the time the respondent made its decision, the appellant was aged 45 years, and it would be fair to say that from her teenage years onwards she has suffered from a number of bowel and gynaecological problems, and it is the respondent's assertion that there has simply been a continuation of those medical conditions and that the pelvic bleed for which she obtained cover in 1997 cannot be shown to be a cause of her ongoing chronic and recurring abdominal pain and bowel dysfunction. 457.05 (pg) 2 [3] Although it does not appear to have been specifically documented, the Court can infer from the date of what would seem to be the last medical report on the appellant from the United Kingdom, and the appellant's first presentation for medical treatment in Christchurch, that the appellant came to New Zealand from the United Kingdom some time after March 1993 and before August 1994, when there is the first record of her receiving medical attention in New Zealand. [4] In May 1997, the appellant was granted cover for personal injury by medical misadventure, being medical mishap. The personal injury was for a haemorrhagic following laparoscopic surgery on 14 March 1997. Cover was said to be for "haemorrhage from puncture site, requiring laparotomy x 2 and subsequent infection." [5] A description of the circumstances giving rise to the medical mishap is that given by Mr Richard Perry, Colorectal Surgeon, who provided a medical report to the respondent which led to its decision to suspend entitlements. Mr Perry described the injury event as follows: 'Ms Osman underwent laparoscopy at Southern Cross Hospital on the 14" of March 1997. Some minor adhesions between small bowel and vaginal vault were divided and rocedure was e was very straightforward. However at the end of the procedure it was noted that she was bleeding from the umbilical port site. This bleeding was managed by catheter tamponade. Six hours later, while still in Recovery, she developed ncreasing pain and was taken back to theatre where 300 to 400 cos of blood was removed from the peritoneal cavity. The wound was resutured. No other abnormality was found. Subsequent to this, Susan made a very slow recovery with a protracted ileus and advice was sought from a general surgeon, Mr Rob Robertson. He performed a laparotomy because of a presumptive diagnosis of small bowel obstruction. He found a healthy looking bowel with minor adhesions to the anterior abdominal wall but no other abnormality. (6] As further noted by Mr Perry, the appellant has subsequently had further operations and stomal constructions to manage abdominal pain and bowel dysfunction. A number of these operations have been complicated with sepsis and protracted recovery. [7] As earlier noted, the respondent relies upon the advice and opinion given to it by Mr Perry, supported by the opinions of Or Kevin Luey, Gastroenterologist, and Dr Al Donaghue, Gynaecological Surgeon. The appellant, for her part, relies upon the opinion of Mr R Robertson and Mr R J Kyngdon, General and Vascular Surgeon, who has provided two reports in response to those of Mr Perry. [8] From the respondent's perspective, the appellant's long history of abdominal, gynaecological and bowel problems, are relevant to the consideration of the medico- legal issue which this appeal poses, and central to the respondent's reasoning for its decision is that the appellant's current abdominal and bowel problems are a continuation of medical problems which have plagued the appellant from her teenage years onwards, and that the injury from the haemorrhage following the laparoscopy, is not causative of her current problems. [9] When Mr Perry gave his first report to the respondent in December 2004, he only had medical documents dating back to April 1995 relating to the appellant's treatment in New Zealand, and the information relating to her medical history in the United Kingdom was only from the appellant herself, although subsequently a significant amount of medical information in the form of medical reports, dating from February 1975 onwards, have been brought into the picture and all such information was available when Mr Perry made a second report in February 2007. That information was available to Mr Kyngdon when he made his principal report in September 2006 [10] All told, some forty medical reports on the appellant's medical history in the United Kingdom, between February 1975 and March 1993, are now part of the record and which have been considered and consulted by the specialists who have given opinions in relation to the issue in this appeal. [11] Medical reports relating to the appellant's treatment in New Zealand commence with a report from the Endocrinology Department of Christchurch Health in April 1995. although Mr Perry notes the earliest clinical records available to him were hand-written entries from Christchurch Hospital's Endocrinology Department from 9 August 1994. [12] In April 1995 the appellant was seen by Dr L Cook at the Gastroenterology Department at Christchurch Hospital, and his report noted that the appellant had been experiencing abdominal pain and intermittent bowel obstruction. [13] Both Mr Perry and Mr Kyngdon have documented the appellant's medical history since coming to New Zealand, and leading up to the surgery of March 1997 when the medical mishap occurred. [14] After noting the appellant's history from the United Kingdom, Mr Kyngdon stated as follows: 'Ms Osman was suffering similar symptoms in 1995 with pelvic pain and some bloating. Given the previous history of melanoma and an abnormality of the liver, it was appropriate that she underwent a laparotomy by Mr Grant Coulter. She was operated on in May 1995 and it was noted that "there were minimal intra-abdominal adhesions". On 10 December 1996 she was complaining of further severe left ilicac fossa pain and further dyspareunia. Mr Bashford arranged for a laparoscopy In summary, therefore, leading up to the date of the procedure from which medical misadventure was accepted, she had a long history of numerous operations both laparoscopic and open for pelvic and gynaecological problems. Bowel and bladder investigations were undertaken on a couple of occasions but predominantly all the procedures were gynaecological. It had been noted and documented that there were adhesions to the bowel. All of these could account therefore for her pre- existing bowel symptoms. In regard to childhood constipation this is not uncommon and Ms Osman has no clear recollection of this as a major problem." [15] In his summation of the medical picture which the appellant presented to him in December 2004, Mr Perry stated as follows: 'There is no doubt that Ms Osman is having a miserable life with chronic abdominal pain and bowel function which is extremely difficult to manage. This is further compounded by the presence of a stoma. It would, however, seem that this stoma is not alleviating her problems either. 1. Ms Osman's symptoms date back to her early adult life. It is impossible, in retrospect, to quantify the magnitude and impact of her symptoms over the years. Osman asserts that they have consistently become worse, particularly after the 1997 laparoscopy. There is no reason to disbelieve this. However, in perspective, she also stated that pain was a lot worse after her 1995 laparotomy. 2 Post operative intra-abdominal bleeding is not a rare occurrence. The thickening (scarring) noted in the abdominal wall at preoperative consultation would probably have increased the risk of wound related problems such as bleeding. The bleeding was managed appropriately by Mr Bashford. An episode of intra-abdominal bleeding appropriately treated is not a credible explanation for chronic abdominal pain or chronic bowel dysfunction. That this is the case is further supported by the absence of any significant adhesions or other pathology at the laparotomy conducted by Mr Robertson five days later. 3. Prolonged post-operative ileus, which is a delay in recovery of bowel function following an abdominal operation, is not uncommon. Patients with a prior history of abdominal pain and bowel dysfunction are much more vulnerable to this condition. Intraperitoneal bleeding may have increased the chance of this occurring, as could the second operation on the same day. 4. There is good evidence of bowel dysfunction existing prior to 1997." 16] Mr Perry then went on to consider the medico-legal issue which arises and his advice was as follows ". . . a single event of post operative bleeding involving 300 to 400 cos of blood would not be expected to have a long term impact on the patient's well-being, but it might cause a delay in a patient's recovery by no more than a few weeks at most. There are two elements to this delay in recovery. The first is the increased likelihood of delayed recovery of small bowel function (i.e., post operative ileus) secondary to blood in the peritoneal cavity. The 5 second is related to the need for a laparotomy with a larger abdominal wound to remove the blood and stop bleeding." Mr Perry qualified his advice noting as follows: The qualification relates simply to the fact that every abdominal operation - and in Ms Osman's case the need for a laparotomy to control the bleeding - 's associated with a risk of new adhesion formation and its sequelae of small bowel obstruction or abdominal pain. It is relevant and significant in this case, that Mr Robertson's subsequent laparotomy on day 5 demonstrated only ileus with no bowel obstruction and no significant adhesions." He concluded his advice as follows: "It is not credible to attribute Ms Osman's bowel dysfunction to the episode of post operative bleeding or its sequelae As of the time of Mr Robertson's laparotomy on day 5, bowel dysfunction was largely if not entirely attributable to an idiopathic bowel problem, not to adhesions. Currently, subsequent to further surgery, adhesions could be contributing as well. Furthermore, the high daily doses of narcotic analgesics upon which she is now dependent will be having a profound adverse effect on bowel function." [17] The respondent next sought the opinion of Or Kevin Luey, Gastroenterologist, and he reported to the respondent on 28 January 2005. In that report he noted the history both in New Zealand and the United Kingdom and his opinion on the contribution of the post-laparotomy haemorrhage to the appellant's ongoing symptoms was as follows: "Any contribution of the post-laparotomy haemorrhage to Mrs Osman's abdominal symptoms must be extremely small. It is hard to see how the moderate post- operative haemorrhage could directly cause her continuing abdominal pains and variable bowel habit in the absence of a bowel obstruction though her irritable bowel syndrome could hav uld have been aggravated gravated by the stress of the illness. I would not expect any possible component of her symptoms that could be due to the haemorrhage to persist for very long after she had recovered from the haemorrhage following the laparoscopy. I would therefore expect anything (sic) contribution from the haemorrhage to her ongoing abdominal symptoms to be extremely small." Further on in his report, Dr Luey summarised his position as follows: "In summary it is extremely unlikely that Mrs Osman's continuing abdominal pains symptoms are the result of her haemorrhage following the laparoscopy of March 1997. She did have a pre-existing chronic functional bowel disorder and her continuing symptoms are almost certainly due to a continuation of this disorder." [18] The respondent then sought the opinion of Dr Al Donaghue, Gynaecological Surgeon. He gave his opinion as follows: "This history is highly indicative of the probability that Ms Osman's suffering before and after the time of the laparoscopic operation on 14 March 1997 was due to intrinsic bowel dysfunction, and further that it is likely that her continued suffering is 6 because of this disease. In other words, I think that it is certain that the pre- operative dysfunction was not caused by the operation of 14 March 1997, and that (sic) is highly improbable that the continued dysfunction is caused by or results rom any outcome of the operation by Dr Bashford on 14 March 1997. " [19] The foregoing was the information which the respondent had in its possession at the time it issued its decision on 14 January 2005 to suspend entitlements. [20] A Review Hearing took place on 5 August 2005 at which the appellant was represented by Counsel, but for which no competing medical evidence was introduced. In her decision dated 12 August 2005, the Reviewer found on the evidence that there was no causal nexus between the appellant's current problems and the medical misadventure injury she suffered in 1997. The respondent's decision to suspend entitlements was therefore confirmed. [21] For the purposes of the appeal to this Court the appellant has now introduced medical opinion in the form of a report and then a subsequent letter from Mr R J Kyngdon, General and Vascular Surgeon. Mr Kyngdon first reported to the solicitors representing the appellant on 16 September 2006, and I have earlier set out part of that report as it related to the medical history in New Zealand prior to the medical mishap event. [22] Mr Kyngdon had details of the appellant's United Kingdom medical matters and he also set out what he assessed her present symptoms and medical condition was. He then summarised his opinion as follows: "Ms Osman has so far had a long and difficult life; early childhood trauma, later psychosexual trauma, a forced marriage, an unhappy marriage, multiple surgeries (12 or more for gynaecological problems), investigation of pelvic pain during the course of which investigations were undertaken to exclude bowel causes and urological causes, further interventions in New Zealan w Zealand resulting in complex surgery and management options resulting in a permanent colostomy with residual adhesions. The bleeding in 1997 following a laparoscopy was accepted as medical misadventure. The complications resulting from this included a second look procedure and then further surgery. It is well recognised that bleeding is a cause of ileus and promotes adhesions during the organisation of residual blood in the peritoneal cavity. Although it was evacuated it is likely that the bleeding precipitated further adhesion formation. It is likely that the cumulative abdominal surgery promoted further adhesions. Each time adhesions are surgically divided more adhesions form again. The fact that no abnormality was found a week later when Mr Robertson performed a laparotomy tells us nothing beyond the fact that there was no mechanical 7 obstruction. Adhesions can be early fibrinous or later dense fibrous adhesions. It takes a longer time for dense fibrous adhesions to develop. I am not clear on the rationale behind the subsequent decision to form the ileostomy but I do not dispute the decision given the available evidence Mr Robertson had at the time.' Mr Kyngdon then gave as his overall conclusion as follows: "In the absence of the intervention and subsequent complications relating to the bleeding, I think it is likely that she would have continued to suffer from intermittent pelvic pain and probably intermittent abdominal distension. She managed reasonably well after the laparotomy performed by Grant Coulter for a number of years. The problems following the port site bleed, the ileus and the second look procedure appeared to precipitate her current problems There were minimal adhesions prior to the 1997 operation which resulted in medical misadventure. Now, she has clear abdominal symptoms which are a lot more defined than they were beforehand. Therefore, in my opinion the cause of the current problems are twofold: (1) Continuing pelvic pain which is a continuation of what she had before. (2) Intermittent abdominal symptoms which are significantly worse than she had before and probably directly related to the extra interventions she had following the bleed. The question "is there any cause or nexus between current problems and the medical misadventure injury or any treatment required for that injury?" I think the answer is fairly clear that there appears to be a clear link with the bleeding, evacuation, a second look and then subsequent surgery. If it had not been for the bleed and the necessity to call n Mr Robertson it is probable that she would have gone back to her normal pattern. It is recognised that bleeding may promote adhesion formation and ileus and the fact that this resulted in at least two extra early interventions before the fashioning of the ileostomy and its subsequent complications, that I would have to say that there is indeed a causal link in this particular case between the haemorrhage and the current bowel dysfunction." [23] As earlier noted, Mr Perry did not have the benefit of the United Kingdom medical reports when he gave his first report, and his opinion was further sought in February 2007, with him being provided with all those United Kingdom reports and also the report from Mr Kyngdon. Amongst other matters, Mr Perry was asked to advise whether he agreed or disagreed with Mr Kyngdon's report and his conclusions. As a comment on the United Kingdom reports, Mr Perry stated: "The UK records paint an undeniable picture of chronic abdominal pain, from which no ong term relief comes from surgical intervention. It is clear that Ms Osman had a long established history of abdominal, bowel and gynaecological problems before she came to New Zealand. A typical feature of chronic abdominal pain, particularly when associated with bowel dysfunction such as bloating and constipation, is that surgical freeing of adhesions rarely brings about long term relief of symptoms." 8 Mr Perry then summarised the history as follows: "In summary there is nothing in the new records that changes my opinion that Ms Osman suffered a pre-existing bowel dysmotility that contributed to her abdominal pain and also to symptoms of constipation and bloating." His final word was as follows: "In my opinion the weight of evidence is strongly against ascribing Ms Osman's current situation exclusively or primarily to the post-operative bleed in March 1997 or to the other laparotomy five days later. It is more likely than not that her long term clinical course would have been little different if the episode of post-operative bleeding had not occurred. It is possible that the day 5 laparotomy may not have been necessary if bleeding had not occurred. It is improbable that this laparotomy, performed on the background of many previous laparotomies, would have contributed more than a minor effect on the long term clinical course." [24] As has been noted, the surgeon who carried out the laparotomy some six days after the laproscopy procedure on 14 March 1997, was Mr Robert Robertson, General Endoscopic Surgeon. From that time on the appellant came under his care and he carried out several surgical procedures in the following years and reports of these have been provided in the bundle of documents produced for this appeal. [25] In November 2003, Mr Robertson provided a report to the respondent of the details of his attendances on the appellant from March 1997 onwards. His report sets out the ongoing problems which the appellant has had and he was aware that the respondent was, as he put it, ". . . seeking to disentangle the bleed (which has cover) over the myriad of other problems which antedate this and do not have cover." Mr Robertson stated as follows: "I first became involved in the care of Susan Colenso following her surgery in March 1997. She had undergone a laparoscopy on the 14 March 1997 and there was bleeding from the abdominal wound. Attempts had been made to control this but about six hours following the operation she developed a lot of pain and the surgeon caring for her, Mr D H Bashford, performed a laparotomy and evacuated the blood. About six days after this she had failed to improve and I was consulted and saw Susan Colenso and in conjunction with Mr Bashford performed a second laparotomy. I subsequently saw her on 26 May 1997 because she had continued to have abdominal pain and she had been re-admitted to hospital and was found to have had a collection in her wound which had discharged. She was seen by me again in June 1997 and again in July 19097. At that time I thought she was developing a sub acute small bowel obstruction and investigated this with a Gastrograffin xray of the small bowel. This did not show evidence of obstruction at the time. She was seen by me in August 1997 on two occasions and as the pain and discomfort in her abdomen had failed to settle I arranged or her to have an operation at Christchurch Hospital through the waiting list. This was undertaken on the 17 October 1997 when she had a laparotomy with freeing of adhesions because of the chronic obstruction from her adhesions and an ileostomy constructed. Subsequent to this she has had further surgery and many hospital admissions because of the ongoing problems with her abdomen. Her most recent operation was undertaken on 6 August 2003 when she had a further laparotomy, closure of her ileostomy and resection of part of the right side of her bowel and formation of colostomy. 9 Since this operation she has had considerable improvement but is still not completely recovered from her problem I was not involved in Mrs Colenso's care prior to March 1997 but note that she had had number of operations mainly relating to gynaecological surgery which had been undertaken in the United Kingdom prior to that time. I am unable to confirm whether the problems that have persisted since 1997 are secondary to that surgery or are a recurrence of pre-existing problems. I can say that while surgery is sometimes necessary to deal with particular problems within the abdomen the issue of adhesion formation and the effects from this are extremely hard to point to one particular event or episode. However, when surgery is complicated by bleeding as hers was in March 1997, then the risk of adhesions does become more of a problem. This then has a ow on effect to the ove the GI tract and in effect this may cause what had previously been a relative minor or unknown problem to become a problem. I consider that the broad range of symptoms that have eventuated for her are contributed to by a number of factors and the abdominal bleed in March 1997 must have been a significant event in contributing to this." [26] The Court received extensive written and oral submissions from counsel for both parties, and not unnaturally Mr Elliot submitted that the opinion of Mr Kyngdon, supported as it was by that of Mr Robertson, should be preferred to that of Mr Perry, supported as it was by Or Luey and Dr Donaghue [27] Central to Mr Elliot's submissions in support of a continuing causal nexus, was the contention that at least one of the appellant's ongoing problems was the adhesions which had been present to a greater or lesser degree ever since the misadventure surgery, and which he contended Mr Kyngdon and Mr Robertson had attributed as sequelae of the bleed. (28] Mr Hunt, on the other hand, submitted that the principal ongoing problems of the appellant were associated with bowel dysfunction and abdominal pain, and that these were matters that were not attributable to any misadventure factor and were indeed a continuation of the appellant's pre-existing problems. Counsel submitted that there was no basis in fact for cover for entitlements to be extended for those medical conditions. DECISION [29] This is an appeal from a decision of the respondent made pursuant to Section 117(1) of the Act, whereby it suspended entitlements to the appellant, which suspension in effect related only to weekly compensation, on the basis that the appellant's ongoing incapacity was no longer attributable to her covered injury. 10 [30] The terms of cover granted to the appellant on 5 May 1997 were for personal injury caused by events following laparoscopy surgery carried out on 14 March 1997 by Mr D H Bashford, Obstetrician and Gynaecologist. The injury identified was that of haemorrhagic from the puncture site and which condition required two subsequent laparotomies, the first performed by Mr Bashford some six hours after the initial surgery, and the second performed by Mr Robertson, General Surgeon, some six days later. [31] The medical misadventure identified was that of medical mishap, and where it was considered rare that there was a haemorrhage from the midline after the puncture had effectively been considered sealed. [32] The reason for the original laproscopy carried out by Mr Bashford was the severe abdominal pain that the appellant had been experiencing in her lower right abdomen, described by the specialists as 'right iliac fossa' [33] The source of that pain was considered to be pelvic adhesions which had formed and which from the appellant's history had been an ongoing problem. The surgery of Mr Bashford involved a division of those adhesions from the bowel to the vault of the vagina. [34] As a matter of law, it is the case that any ongoing problems associated with that haemorrhagic would be covered under the terms of the appellant's cover granted to her in May 1997. The subsequent problems which the appellant suffered from were in large measure accepted as being identified with the March 1997 mishap, and Mr Robertson, Surgeon, is on record as attending to the appellant on a number of occasions and carrying out several laparotomies because of ongoing abdominal pain caused by abdominal adhesions [35] It is equally the case that the appellant had a history pre-dating March 1997 of adhesions, bowel obstructions and pelvic pain. This is documented in the substantial body of medical reports from the United Kingdom and these have been referred to by Mr Perry, Mr Kyngdon and others in their reports in relation to issues pertaining to this appeal 11 [36] The reports make it clear that the appellant had had a long history of bowel dysfunction and that this was an ongoing problem for her. [37] With that as the background, the issue in this appeal requires a consideration of the appellant's medical condition at or about the time that the respondent issued its decision in January 2005. It is at that point that the appellant was seen and examined by Mr Perry and where he said that the appellant was experiencing chronic and recurring abdominal pain and bowel dysfunction. He noted that the abdomen was generally tender, especially around the stoma. [38] The formation of the colostomy and stoma had been carried out by Mr Robertson in August 2003 at the time he performed a further laparotomy. It is also the case that that operation was required to divide adhesions which had appeared and it was his advice that the surgery of March 1997 increased the risk of adhesions arising subsequently, and this is certainly what has occurred. [39] Having considered all the specialist evidence, particularly from 1996 onwards, I find that as of January 2005, the appellant's situation was that she was still suffering from bowel dysfunction problems, and that these were a continuation of problems which had plagued her for a large part of her adult life. In addition to those problems, I find that between March 1997 and August 2003 the appellant also began to suffer more acutely from peritoneal adhesions, consequent upon the bleed of March 1997. As was stated by Mr Kyngdon, "It is well recognised that bleeding is a cause of ileus and promotes adhesions during the organisation of residual blood in the peritoneal cavity. Although it was evacuated it is likely that the bleeding precipitated further adhesion formation. It is likely that the cumulative abdominal surgery promoted further adhesions. Each time adhesions are surgically divided, more adhesions form again." [40] When that quotation is put alongside that of Mr Perry when he was giving his opinion on whether the single event of post-operative bleeding was the cause of all the appellant's ongoing problems, and he indicated that it was not, he did qualify that advice when he stated: "The qualification relates simply to the fact that every abdominal operation - and in Ms Osman's case the need for a laparotomy to control the bleeding - is associated with a risk of new adhesion formation and its sequelae of small bowel obstruction or abdominal pain." 12 [41] Alongside those two quotations, there is the advice from Mr Kyngdon that in his opinion the appellant's current problems were two-fold. Firstly, continuing pelvic pain which was a continuation of what she had before. By that, I take him to mean the long history of bowel dysfunction and other associated medical problems which have been reported on, many of which are of a gynaecological nature. Secondly, the intermittent abdominal symptoms which are significantly worse than she had before and which he considered were related to the extra interventions she had following the bleed, and by that I understand him to mean the re-formation of new adhesions from time to time which may require surgery to remove. [42] In his later advice of 15 August 2007, Mr Kyngdon stated: "Mr Perry has described the background and presented his conclusions that there is a longstanding functional bowel disorder. My report included possibilities of coexisting organic problems." [43] This position is that which was stated by Mr Robertson in November 2003, where again he referred to the particular problems pertaining to the appellant's abdomen and the issue of adhesion formation, and where he stated that the bleeding increased the risk of adhesions [44] Whilst it is the case that the appellant had a pre-existing history of adhesions, bowel obstruction and long-term pelvic pain, I find that on the balance of probabilities the issue of post March 1997adhesions is one that can be sheeted home to the misadventure injury, and that the appellant must continue to have cover for any medical attention required which is associated with any re-emergence of adhesions in the locations affected by the bleed and which may require further laparotomies. [45] I find that any issues relating to incapacity which can be identified as being caused by the re-emergence of adhesions, would come within the bounds of the appellant's cover, but that if the incapacitating features of the appellant's condition are associated with abdominal pain and bowel dysfunction from other causes, then those medical conditions are not covered, and if they are the cause of incapacity then entitlements consequent upon that incapacity cannot be had. [46] The respondent made its decision under Section 117 of the Act on the basis that the appellant's medical condition, as it presented in December 2004 and January 2005, as evidenced in the medical reports of Mr Perry, Dr Luey and Dr Donaghue, are to the 13 effect that the appellant's symptoms were due to a continuation of her pre-existing chronic bowel dysfunction. [47] I note that Mr Kyngdon supports a causal link between the haemorrhage and the appellant's current bowel dysfunction, but I find that this opinion is outweighed by the opinions of Mr Perry, Dr Luey, Dr Donaghue and Mr Robertson. The plain fact of the matter is that the appellant had significant bowel dysfunction before the misadventure surgery, and that simply cannot be put to one side [48] It may be that Mr Kyngdon is simply stating that since the offending surgery, there has been an aggravation of her pre-existing condition, that is certainly what is accepted as being the position by Mr Perry, and I find that the appellant's history makes it more probable than not that complications associated with her bowel is a continuation of her pre-existing condition. As Mr Perry stated, a functional bowel disorder, pelvic inflammation and adhesions can co-exist. He stated that in his experience minor adhesions rarely, if ever, cause significant bowel dysfunction. [49] Accordingly then, the position as I find it, is that the evidence establishes that at the time the respondent made its decision to suspend entitlements, the problems which were then disabling to the appellant, were abdominal pain and bowel dysfunction, and as noted by Mr Kyngdon, the appellant has problems with the colostomy, which is somewhat painful and requires daily irrigation, and occasionally the bag comes off. [50] I find that those symptoms are wholly associated with her pre-existing bowel dysfunction, and therefore the respondent was correct to identify that the appellant was not covered for that condition and that it was not a condition associated with the personal injury for which she had cover. [51] Having said that, I find that in the event of the appellant being identified as having incapacitating features arising from the re-emergence of peritoneal adhesions which would require further surgical treatment, and if the presence of those adhesions were of themselves disabling, then the appellant would be entitled to weekly compensation during the period of any such disablement [52] On the facts as i have found them, that situation did not pertain at the time the respondent made its decision to suspend entitlements. 14 [53] Accordingly, I find that the respondent was correct to suspend entitlements as it did and at the same time that decision may need to be the subject of medical review in the event of the disabling symptoms of the appellant changing to those which are correctly identifiable with the terms of her cover for personal injury. (54] For the foregoing reasons, this appeal is dismissed. DATED this 19" day of August 2008 -: M J Beattie District Court Judge