Supreme Court New South Wales Medium Neutral Citation: Casey v Pel-Air Aviation Pty Ltd; Helm v Pel-Air Aviation Pty Ltd [2015] NSWSC 566 Hearing dates: 2 February 2015, 3 February 2015, 4 February 2015, 5 February 2015 and 6 February 2015 Date of orders: 15 May 2015 Decision date: 15 May 2015 Jurisdiction: Common Law Before: Schmidt J Decision: Judgment for the plaintiffs Catchwords: TORTS – negligence – negligence of airline operator – whether injuries compensable under the Civil Aviation (Carriers' Liability) Act 1959 (Cth) - damages - non-economic loss – economic loss – superannuation – out-of-pocket expenses – past and future care - STATUTORY CONSTRUCTION – relevant rules of statutory construction - construing International Conventions - the purpose of the Montreal Convention – proper construction of s 9E of the Civil Aviation (Carriers' Liability) Act – post traumatic stress disorder ('PTSD') claim – PTSD and the proper construction of Article 17 of the Montreal Convention – evidence establishes that plaintiff's PTSD is a compensable "bodily injury" Legislation Cited: Acts Interpretation Act 1901 (Cth) Aviation Legislation Amendment (Liability and Insurance Act 2012 (Cth) Civil Aviation (Carriers' Liability) Act 1959 (Cth) Civil Liability Act 2002 (NSW) Carriage by Air Act 1935 (Cth) Interpretation Act 1987 (NSW) International Monetary Agreements Act 1947 (Cth) Motor Accidents Act 1988 (NSW) Cases Cited: Air France v Teichner and Ors (1984) 7 S&B Av R 141 American Airlines Inc v Georgeopoulos And Anor [1996] NSWCA 13 American Airlines Inc v Georgeopoulous [No 2] [1998] NSWCA 273 Bobian v Czech Airlines 93 Fed Appx 406 (3d Cir 2004), Dare v Pulham [1982] HCA 70; (1982) 148 CLR 658 Doe v United Airlines, Inc 160 Cal App 4th 1500 (2008) In re Air Crash at Little Rock Arkansas on June 1, 1999 291 F 3d 503 (8th Cir 2002) Eastern Airlines Inc v Floyd 499 US 530 (1991) Ehrlich v American Airlines Inc 360 F 3d 366 (2d Cir 2004) IW v The City of Perth [1997] HCA 30; (1997) 191 CLR 1 Khoury v Government Insurance Office (NSW) [1984] HCA 55; (1984) 165 CLR 622 King v Bristow Helicopters Ltd [2002] UKHL 7; [2002] 2 AC 628 Kotsambasis v Singapore Airlines Ltd (1997) 42 NSWLR 110 Linsell v Robson [1976] 1 NSWLR 249 Matchan v Lyons [2003] NSWCA 384; (2003) 40 MVR 466 Mead v Kerney [2012] NSWCA 215 Mills v Meeking [1990] HCA 6; (1990) 169 CLR 214 Nash v Sunshine Porcelain Potteries Ltd [1959] HCA 7; (1959) 101 CLR 353 Nestle Australia Ltd V McDougall [1998] NSWCA 158 Povey v Qantas Airways Limited [2005] HCA 33; (2005) 223 CLR 189 Public Transport Commission (NSW) v J Murray-More (NSW) Pty Ltd [1975] HCA 28; (1975) 132 CLR 336 Rocklea Spinning Mills Pty Ltd v Anti Dumping Authority [1995] FCA 210; (1995) 56 FCR 406 Rosman v Trans World Airlines Inc 34 NY 2d 385 (1974) South Pacific Air Motive Pty Ltd v Magnus [1998] FCA 1107; (1998) 87 FCR 301 SAS Trustee Corporation v Woollard [2014] NSWCA 75; (2014) 86 NSWLR 367 State of Queensland v Commonwealth of Australia [1989] HCA 36; (1989) 167 CLR 232 Terrafranca v Virgin Atlantic Airways Ltd 151 F 3d 108 (3d Cir 1998) Weaver v Delta Airlines Inc 56 F Supp 2d 1190 (D Mont 1999) Texts Cited: DC Pearce and RS Geddes, Statutory Interpretation in Australia (8th ed, 2014, LexisNexis Butterworths) at [4.6], [1.9] and [3.43] - [3.50] House of Representatives, Commonwealth, Civil Aviation (Carriers' Liability) Bill 1959, Parliamentary Debates (Hansard), 7 April 1959 at 927 House of Representatives, Commonwealth, Aviation Legislation Amendment (Liability and Insurance) Bill 2012, Parliamentary Debates (Hansard), 22 August 2012 at 9510 Category: Principal judgment Parties: Karen Casey David Helm Pel-Air Aviation Pty Ltd Representation: Counsel: Mr RS McIlwaine SC with Mr G Graham (Plaintiffs) Mr D Fagan SC with Mr D Lloyd Solicitors: Everett Evans Solicitors (Penrith) (Plaintiffs) GSG Legal (Defendant) File Number(s): 2010/385262 2011/46508 Publication restriction: None Judgment 1. In November 2009 CareFlight (NSW) Limited sent a nurse and a doctor in its employ, Ms Karen Casey and Dr David Helm, from Sydney to help transport a seriously ill patient and her husband from Samoa to Melbourne. They were then to return to Sydney. The plane was operated by Pel-Air Aviation Pty Ltd. On the flight to Melbourne the plane was scheduled to land at Norfolk Island to refuel. It crashed during that leg of the flight and Ms Casey and Dr Helm were both seriously injured. 2. They now seek to recover damages from Pel-Air. 3. It was not in issue that the weather at Norfolk Island that night was so stormy, that over some 45 minutes four attempts to land were aborted. Eventually the pilot decided to ditch the plane into the ocean, advising the passengers that it had almost run out of fuel. Remarkably, all six people aboard the plane survived the resulting crash, but the plane soon sank. A life raft had not been deployed and so the survivors all had to remain afloat in heavy seas, in the darkness, with no lights, no beacons or any form of communication. They were all rescued after some 90 minutes, by a fishing boat, which had set out from Norfolk Island. 4. Before it hit the water, the plane was travelling at such speed that the violence of the impact caused it to break up behind the wings. Both Ms Casey and Dr Helm had prepared themselves for the impact by putting on life jackets, using their lap seat belts and adopting the brace position. Still, they were flung violently around in their seats during the crash, each suffering injuries as a result, Ms Casey's more serious than those which Dr Helm suffered. 5. After the crash, they were together in the back section of the sinking plane with the patient. Ms Casey was trapped in her seat by her seatbelt. Water was rising quickly and both she and Dr Helm were in pain from their injuries. Luckily, both Dr Helm and Ms Casey were very fit. They were able to attend to the patient, who was strapped into a stretcher. No life jacket could be found for her and she needed their help to get out of the plane. 6. Together Ms Casey and Dr Helm managed to free the patient, while Ms Casey remained trapped in her seat. After Dr Helm and the patient escaped, Ms Casey also managed to free herself. She swam to the emergency exit, inflated her life vest and jumped into the ocean, where she was struck in the head by the wing of the plane. Only half of her life jacket inflated. She tried unsuccessfully to further inflate the jacket manually and then swam to join the others. 7. Ms Casey and Dr Helm assisted the others who were then all in the water, but who had no life jackets, to remain afloat. Ms Casey supported the patient by herself, with considerable difficulty because of the state of her vest and her injuries, for some 70 minutes. Ms Casey described the state that she was in during that time to have been cold, wet, in considerable pain, fatigued, terrified, swallowing water and vomiting, and beginning to drift into unconsciousness, when they were finally rescued. 8. Dr Helm supported the co-pilot during the time they were in the water, as well as trying to help keep the patient calm, in what he described as having been quite extraordinary circumstances. 9. Ms Casey was initially treated at Norfolk Island Hospital for hypothermia, shock and pain and then evacuated, while sedated, by CareFlight to Sydney, where she was admitted and treated at Nepean Hospital, for a range of physical injuries, over some days. She has since received ongoing treatment for those injuries, as well as for the psychiatric injuries which she has suffered. 10. Dr Helm was also shaken, distressed and severely bruised, when rescued. He was also suffering a nagging pain in his side and discomfort in his back. He did not initially seek further treatment on his return to Sydney. Unlike Ms Casey, while Dr Helm suffered psychological consequences of his experience, he does not consider that he has suffered any permanent psychological injury. The pain in his back, however, has gradually worsened over time. The issues 1. Ms Casey, Dr Helm and CareFlight claimed damages from Pel-Air, who accepted that the crash had been caused by the negligence of the pilot and co-pilot, for which it had vicarious liability. 2. The traumatic nature of what Ms Casey and Dr Helm had experienced was not in issue, nor that they had both suffered physical injuries in the crash. That Ms Casey had also suffered serious psychiatric injuries was not in issue, nor was that they had both received workers compensation payments from CareFlight. 3. The claims pressed by CareFlight were settled during the hearing on terms requiring Pel-Air to pay CareFlight an agreed sum in respect of workers compensation payments it had made to Ms Casey and Dr Helm. 4. There was also finally no issue between the remaining parties that: 1. Pel-Air held a licence in force under the relevant legislation and provided the plane which crashed to CareFlight pursuant to an agreement under which there was international carriage to which the 1999 Convention for the Unification of Certain Rules for International Carriage by Air (Montreal, 28 May 1999) [2009] ATS 3 (Montreal Convention) applied . 2. Ms Casey and Dr Helm were passengers on that plane. The Civil Aviation (Carriers' Liability) Act 1959 (Cth) applied as a result to their claims. 3. Their physical injuries were compensable under that Act. 4. The damages to which they were entitled had to be assessed in accordance with the provisions of the Civil Liability Act 2002 (NSW). Ms Casey 1. In Ms Casey's case the cause of some of her psychiatric injuries and whether they were compensable, given the proper construction of the Civil Aviation (Carriers' Liability) Act, were in issue, as were certain of the damages which she claimed. 2. As well as the consequences of the physical injuries which she suffered, Ms Casey suffers from a complex pain syndrome, a major depressive disorder, an anxiety disorder and post-traumatic stress disorder (PTSD). Her case was that all these injuries were compensable under the Civil Aviation (Carriers' Liability) Act. 3. Pel-Air conceded in final written submissions at [50] of mfi 8, that Ms Casey's major depressive disorder had been caused by her physical injuries and so it was compensable under the Civil Aviation (Carriers' Liability) Act. 4. The pain disorder was not dealt with in the written submissions, but in oral submissions it was explained that Pel-Air accepted that this disorder was also a bodily injury which was compensable under the Civil Aviation (Carriers' Liability) Act. Its final position in relation to Ms Casey's anxiety disorder was that it accepted that the evidence established that it was caused both by her physical injuries and by the PTSD which she suffers. Accordingly, Pel-Air also finally accepted that the anxiety disorder was compensable under the Civil Aviation (Carriers' Liability) Act. 5. Pel-Air did not, however, concede that Ms Casey's PTSD was compensable under the Civil Aviation (Carriers' Liability) Act. Its case was that the PTSD was a psychiatric disorder which had been caused by the trauma which Ms Casey had experienced during the crash; that it was not a "bodily injury" falling within Art 17 of the Montreal Convention; and that it was accordingly not compensable under Pt IA of the Civil Aviation (Carriers' Liability) Act. 6. On Pel-Air's case, even though the evidence established that Ms Casey had suffered serious physical injuries during the crash, that being the traumatic event which had caused her PTSD, the evidence did not establish either that this disorder had been caused by those physical injuries, or that the crash had caused any physical injury to Ms Casey's brain itself, of which her PTSD was a manifestation. In the result, it contended that she was not entitled to damages for the treatment she had received for PTSD and that her damages otherwise had to be assessed without regard to the consequences of that PTSD. 7. These issues raised questions of both fact and law. Dr Helm 1. In Dr Helm's case, it was only the assessment of certain of the damages which he claimed which was finally in issue. The evidence 1. There was relatively little disagreement between the parties about the evidence. 2. Evidence given by statements sworn by the lay witnesses was largely unchallenged. Ms Casey was cross-examined briefly as to various activities which she undertook in December 2013, which had been captured by surveillance videos taken over some 20 hours, some 20 minutes of which were tendered. What was there depicted was consistent with the evidence as to her physical capacities. 3. Ms Casey's daughter, Ms Jemma Patten and her mother, Ms Margaret de Brouwer, were also briefly cross-examined as to the nature of the assistance they had given Ms Casey, following the accident. 4. Numerous medical reports from treating and other doctors who had examined Ms Casey were tendered, as well as reports from occupational experts. Ms Casey's treating psychiatrist, Dr Richa Rastogi and the psychiatrist Dr Jonathan Phillips, who had prepared a joint report, gave concurrent evidence. The defendant had also obtained reports from another psychiatrist, Dr Peter Klug. His reports were tendered but he did not participate in the joint report and was not called to give evidence. Nor were Dr Charles New and Dr James Vote, the orthopaedic specialists whose joint report was also tendered, finally called. 5. Dr Helm was cross-examined as to evidence he had given in response to a report given by Dr Greg Lindsay, an Australian anaesthetist, as to the work involved in anaesthetics, as practised in Australia and how such work might be modified, in order to accommodate the ongoing effects of Dr Helm's physical injuries. Dr Lindsay was finally not called. 6. In Dr Helm's case a joint report prepared by Dr New and Dr Vote was also tendered, but none of the doctors who had examined him were called. The proper construction of s 9E of the Civil Aviation (Carriers' Liability) Act 1. It is convenient to begin with the issue lying between Ms Casey and Pel-Air, as to the proper construction of the Civil Aviation (Carriers' Liability) Act. That was put in issue on the pleadings, as was the question of whether the proceedings had been brought within time. What finally remained in issue was whether, on the proper construction of Pt IA of the Civil Aviation (Carriers' Liability) Act, the PTSD Ms Casey suffered as the result of the crash, was compensable under that Act. That raised an issue as to the proper construction of s 9E. 2. Ms Casey contended that properly construed, s 9E provided for a departure from the compensation scheme established by the Montreal Convention, by granting passengers such as her wider rights to compensation in respect of "personal injury" than available under the Convention, which restricted their rights to compensation to "bodily injury" of the kind with which Art 17 of the Montreal Convention is concerned. 3. The Civil Aviation (Carriers' Liability) Act is Commonwealth legislation which enacts into Australian law certain international conventions to which Australia is a signatory. They include the Convention for the Unification of Certain Rules Relating to International Carriage by Air (Warsaw, 12 October 1929) 137 LNTS 13 (Warsaw Convention) to which Australia became a signatory in 1929 and that which modernised it, the 1999 Montreal Convention, which is dealt with in Pt IA of the Civil Aviation (Carriers' Liability) Act. 4. There was also an issue lying between the parties as to the proper construction of Art 17 of the Warsaw Convention and Art 17 of the Montreal Convention. 5. For the reasons which follow, I have concluded that s 9E cannot be construed in the way for which Ms Casey contends. Relevant rules of statutory construction 1. The parties did not address the principles of construction which apply to the construction of the Civil Aviation (Carriers' Liability) Act or the two Conventions. They must, however, be applied when resolving the issues lying between the parties and so need to be identified. 2. The basic principles of statutory construction are those discussed by Bathurst CJ in SAS Trustee Corporation v Woollard [2014] NSWCA 75; (2014) 86 NSWLR 367 at [58]: "[58] ...As was said by the plurality in Alcan (NT) Alumina Pty Ltd v Commissioner of Territory Revenue (Northern Territory) [2009] HCA 41; (2009) 239 CLR 27 at [47], the task of statutory construction must begin with the words of the statute itself considered in context, which includes the general purposes and policy of the provisions. Ascertainment of the statutory purpose may be based on an express statement of purpose in the statute, inference from the text and, where appropriate, reference to extrinsic material: Certain Lloyd's Underwriters v Cross [2012] HCA 56; (2012) 248 CLR 378 at [23]-[25], [68] and [88]. As was pointed out by Kiefel J in that case, the starting point is the words in question, read in the context of the statute." 1. This accords with the provisions of the Acts Interpretation Act 1901 (Cth), where s 15AA requires that the interpretation that would best achieve the purpose or object of an Act, whether or not it is expressly stated, is to be preferred to each other interpretation. Section 15AB deals with the use of extrinsic material when legislation is interpreted, providing amongst other things: "15AB Use of extrinsic material in the interpretation of an Act (1) Subject to subsection (3), in the interpretation of a provision of an Act, if any material not forming part of the Act is capable of assisting in the ascertainment of the meaning of the provision, consideration may be given to that material: (a) to confirm that the meaning of the provision is the ordinary meaning conveyed by the text of the provision taking into account its context in the Act and the purpose or object underlying the Act; or (b) to determine the meaning of the provision when: (i) the provision is ambiguous or obscure; or (ii) the ordinary meaning conveyed by the text of the provision taking into account its context in the Act and the purpose or object underlying the Act leads to a result that is manifestly absurd or is unreasonable. … (3) In determining whether consideration should be given to any material in accordance with subsection (1), or in considering the weight to be given to any such material, regard shall be had, in addition to any other relevant matters, to: (a) the desirability of persons being able to rely on the ordinary meaning conveyed by the text of the provision taking into account its context in the Act and the purpose or object underlying the Act; and (b) the need to avoid prolonging legal or other proceedings without compensating advantage." 1. The practical consequences of giving a particular meaning to an Act must also be considered (see Public Transport Commission of New South Wales v J Murray-More (NSW) Pty Ltd [1975] HCA 28; (1975) 132 CLR 336). As must the fact that the Civil Aviation (Carriers' Liability) Act is a legislative scheme which provides for compensation, which must thus be interpreted so as to give full relief to the fair meaning that its language will allow, but restrained by what is fairly open on the words actually used (see Nash v Sunshine Porcelain Potteries Ltd [1959] HCA 7; (1959) 101 CLR 353 at 361; Khoury v Government Insurance Office of New South Wales [1984] HCA 55; (1984) 165 CLR 622 at 638 and IW v The City of Perth [1997] HCA 30; (1997) 191 CLR 1 at 11). 2. Also necessary to be borne in mind are the rebuttable rules of construction that the same words appearing in different parts of a statute are intended to have the same meaning and that different words are intended to have different meanings (see the discussion in DC Pearce and RS Geddes, Statutory Interpretation in Australia (8th ed, 2014, LexisNexis Butterworths) at [4.6]). 3. Because the Civil Aviation (Carriers' Liability) Act is Commonwealth legislation which enacts an international convention into Australian law, the meaning of the Montreal Convention, which appears in a schedule to the Act, is another important consideration in the interpretation of the Act. 4. Consideration must also be given to the Act's relevant legislative history and decisions which have considered its meaning. Previous decisions concerning the same or similar legislative provisions, even if not binding, may have strong persuasive authority. Also necessary to be borne in mind is the principle that when the Legislature does not change an Act following upon its interpretation, that may provide a basis for considering that it was satisfied with the ruling (see the discussion in DC Pearce and R Geddes, Statutory Interpretation in Australia (8th ed 2014, LexisNexis) at [1.9] and [3.43] - [3.50]). Construing International Conventions 1. In construing the Conventions, weight must be given to the interpretation which the international community attributes to the particular convention (see State of Queensland v Commonwealth of Australia [1989] HCA 36; (1989) 167 CLR 232 at 240 discussed in Rocklea Spinning Mills Pty Ltd v Anti Dumping Authority [1995] FCA 210; (1995) 56 FCR 406 at 421). 2. In Povey v Qantas Airways Limited [2005] HCA 33; (2005) 223 CLR 189, it was observed at [24] – [25]: "24 … The guiding principles of treaty interpretation are found in the Vienna Convention on the Law of Treaties. Article 31 provides that a treaty must be interpreted in good faith, in accordance with the ordinary meaning of the terms in their context and in the light of the object and purpose of the treaty. Interpretative assistance may be gained from extrinsic sources in order to confirm the meaning resulting from the application of Art 31, or to determine the meaning when interpretation according to Art 31 leaves the meaning "ambiguous or obscure" or "leads to a result which is manifestly absurd or unreasonable". 25. Importantly, international treaties should be interpreted uniformly by contracting states. But, of course, the ultimate questions are, and must remain: what does the relevant treaty provide, and how is that international obligation carried into effect in Australian municipal law? [Footnotes omitted]" The purpose of the Montreal Convention 1. In construing the Civil Aviation (Carriers' Liability) Act, its purpose must be borne in mind. Given that this legislation enacts the Montreal Convention into Australian law, in construing the Act it is also important to have regard to the purpose of the Montreal Convention. That was to modernise and consolidate the compensation scheme established by the Warsaw Convention and related instruments, which are still dealt with in other parts of the Act. 2. Both Conventions established a particular balance between the rights of passengers and the liabilities of carriers, in the event of an accident causing a passenger's death or injury. 3. The Warsaw Convention imposed absolute liability on carriers in respect of specified kinds of damage caused by the death, or certain injuries, suffered by passengers during international air carriage. 4. In the preamble to the Montreal Convention the contribution made by the Warsaw Convention is recognised; as well as the desirability of an orderly development of international air transport operations and the smooth flow of passengers, baggage and cargo, in accordance with the principles and objectives of the 1944 Convention on International Civil Aviation (Chicago, 7 December 1944) 15 UNTS 295. The need to ensure the protection of the interests of consumers in international carriage by air and to provide for equitable compensation, based on the principle of restitution, is also there referred to. The proper construction of s 9E of the Civil Aviation (Carriers' Liability) Act 1. In considering the proper construction of s 9E, it must be born in mind that Pt IA of the Civil Aviation (Carriers' Liability) Act alters the scheme established by the Montreal Convention, in a number of specified ways. 2. Whether s 9E involved such a departure was in issue in this case. 3. The starting point for determining the proper construction of s 9E of the Civil Aviation (Carriers' Liability) Act, appearing as it does in Pt IA, carriage to which the 1999 Montreal Convention applies, is its words, considered in their statutory context. 4. The purpose of s 9E, Pt IA and this Act as a whole, must be gleaned from their terms, there being in this statute no provision which deals expressly with the statutory purpose of any particular provision, or with the purpose of the Montreal Convention, to which s 9E refers (see the definition in s 9A). 5. The Civil Aviation (Carriers' Liability) Act enacts a number of international conventions to which Australia is a signatory into Australian law, in respect of carriage by air to which those conventions apply, in Pts I, IA, II, III and IIIA. Pt IV regulates carriers' liability for the death or injury of a passenger during interstate travel in Australia, to which these various Conventions do not apply. Pt IVA imposes obligations on carriers to have certain insurance, to ensure that compensation payable under the Act will be paid. 6. It follows that the purpose of the Civil Aviation (Carriers' Liability) Act is threefold. First, to enact into Australian law the provisions of the various Conventions with which it deals, which establish compensation schemes for international air passengers, subject to the departures from those Conventions which the Parliament determined were appropriate in the Australian context. Second, to also make provision for compensation for passengers' death or injury during the course of interstate air carriage. Third, to require carriers to maintain insurance, to ensure that passengers' entitlements under the Act will in fact be paid. 7. The purpose of Pt IA of the Civil Aviation (Carriers' Liability) Act is to give effect to the Montreal Convention, subject to the alterations there made. 8. The words of s 9E reveal that its purpose is not to confer any rights to compensation upon passengers. It is s 9B which grants such rights in circumstances to which the Montreal Convention applies, giving, as it does the Montreal Convention force of law, subject to the alterations made elsewhere in Pt IA. Section 9B provides: "9B The 1999 Montreal Convention to have force of law Subject to this Part, the 1999 Montreal Convention has the force of law in Australia in relation to any carriage by air to which the 1999 Montreal Convention applies, irrespective of the nationality of the aircraft performing that carriage." 1. The purpose of s 9E is to specify the liability of carriers in the event of a passenger suffering an injury to which the Convention applies. It provides: "9E Liability in respect of injury Subject to section 9F, the liability of a carrier under the Convention, in respect of personal injury suffered by a passenger that has not resulted in the death of the passenger, is in substitution for any civil liability of the carrier under any other law in respect of the injury." 1. The absolute liability imposed on the carrier by Art 17 of the Convention, for bodily injury, is thereby provided to be in substitution for the civil liability which the carrier has to the passenger under any other law, which would otherwise apply to the carrier. 2. In construing s 9E, s 9F must also be considered. Its purpose is to specify the carrier's liability to third parties. It provides: "9F Certain liabilities not excluded Nothing in the Convention or in this Part is to be taken to exclude any liability of a carrier: (a) to indemnify an employer of a passenger or any other person in respect of any liability of, or payments made by, that employer or other person under a law of the Commonwealth or of a State or Territory relating to workers' compensation; or (b) to pay contribution to a tort‑feasor who is liable in respect of the death of, or injury to, the passenger; but this section does not increase the limit of liability of a carrier in respect of a passenger beyond the amount fixed by, or in accordance with, the Convention." 1. Thus it can be seen that both s 9E and s 9F are concerned with the liabilities of carriers. Section 9E is concerned with their liability to passengers who have suffered injuries to which the Montreal Convention applies and s 9F with their liabilities to identified third parties. Section 9E does not confer any rights to compensation upon passengers. Ms Casey's construction of s 9E of the Civil Aviation (Carriers' Liability) Act must be rejected 1. The construction of s 9E for which Ms Casey contended, namely, that it was intended to effect a departure from the scheme established by the Montreal Convention, depends on the introductory words of s 9B, "Subject to this Part". Those words were argued by Ms Casey to reveal the Parliament's intention to depart from the scheme established by the Montreal Convention, in ways provided elsewhere in Pt IA, including in s 9E. 2. Undoubtedly, s 9B contemplates that there are departures from the Montreal Convention provided for elsewhere in Pt IA of the Act. That s 9E is one such departure was in issue. I am satisfied that properly construed, s 9E does not have the effect for which Ms Casey contended. 3. A departure from the balance of rights and liabilities established by the Montreal Convention, is clearly provided for in s 9C, for example. That section provides for the making of Regulations which depart from the Montreal Convention scheme, in relation to the liability of an Australian international carrier in respect of the death or injury of a passenger for "SDRs", which are dealt with in Art 21 of the Montreal Convention. "SDR" is defined in s 5 of the Act to mean "Special Drawing Rights within the meaning of the International Monetary Agreements Act 1947 (Cth)". 4. Ms Casey contended that s 9E provided for another departure from the Convention scheme, by granting passengers wider rights to compensation in respect of "personal injury", than the rights to compensation for "bodily injury" with which Art 17 of the Montreal Convention is concerned. 5. That s 9E may not be so construed, is supported by a number of considerations. First, from the purpose of the section itself, which I have already discussed, being concerned with a carrier's liability for personal injury, in circumstances to which the Montreal Convention applies. Section 15AA of the Acts Interpretation Act requires that a construction which promotes the purpose of an Act, must be preferred over one which does not (see Mills v Meeking [1990] HCA 6; (1990) 169 CLR 214 at 235). 6. In this case, that obligation supports the conclusion that by enacting s 9E, the Parliament intended to confine carriers' liability for personal injury to the compensation provided by the scheme created by the Montreal Convention, for compensation for damage sustained in case of "bodily injury of a passenger", provided in Art 17. That liability is "in substitution for any civil liability of the carrier under any other law in respect of the injury". 7. Under Australian law, injured passengers have rights under various laws in relation to personal injuries which they suffer. It is the limitation of those rights with which s 9E is concerned. By its enactment, s 9E limits carriers' liability for personal injuries to those provided for by Art 17 of the Montreal Convention. The result is that apart from cases where death results, under s 9E carriers are liable for damages only for "bodily injury", a narrower class of injury than "personal injury", as I will explain. 8. Secondly, the structure of s 9E itself does not support the construction for which Ms Casey contended. Unlike s 9C, s 9E does not expressly identify that a departure from the scheme of the Montreal Convention is thereby provided. In the absence of such express provision, such a departure, not revealed by the words used in the section itself, ought not lightly to be inferred. 9. Thirdly, that no such departure was intended by s 9E, is also supported by the relevant history of the Civil Aviation (Carriers' Liability) Act. Fourthly, it is also supported by relevant case law. Legislative history 1. That history includes that the Warsaw Convention was first enacted into Australian law by the Carriage by Air Act 1935 (Cth). The terms of that Convention were written in English, French and Spanish, but it provides that in the event of inconsistency, the French text will prevail. That has given rise to certain difficulties of interpretation over the years, discussed in various of the authorities to which I will refer, which do not now arise in relation to the Montreal Convention. That is because that Convention was written in five languages, including English. 2. The English text of the Warsaw Convention appears in Sch 2 to the Civil Aviation (Carriers' Liability) Act. Article 17 of that Convention there provides: "The carrier is liable for damage sustained in the event of the death or wounding of a passenger or any other bodily injury suffered by a passenger, if the accident which caused the damage so sustained took place on board the aircraft or in the course of any of the operations of embarking or disembarking." 1. Significantly, for the question which has here arisen for consideration, s 3 of the 1935 Carriage by Air Act did not deal with either personal or bodily injury, but rather provided: "3. - (1.) The Governor-General may, by notice published in the Gazette, declare the date upon which the Convention shall come into force in respect of the Commonwealth or of any Territory of the Commonwealth. (2.) Upon a date being declared in pursuance of the last preceding sub-section, the provisions of the Convention shall, so far as they relate to the rights and liabilities of carriers, passengers, consignors, consignees and other persons, and subject to this section, have the force of law in the Commonwealth and in any Territory in respect of which a notice has been published in the Gazette in pursuance of the last preceding sub-section in relation to any carriage by air to which the Convention applies, irrespective of the nationality of the aircraft performing that carriage. (3.) The Governor-General may, by notice published in the Gazette, from time to time, declare-(a) who are the High Contracting Parties to the Convention; (b) the territory in respect of which any such Party is bound by the Convention; and (c) the extent (if any) to which any such Party has availed himself of the provisions of the Additional Protocol to the Convention, and any such notice shall, except to the extent (if any) to which it has been superseded by a subsequent notice under this section, be conclusive evidence of the matters so declared. (4.) Any liability imposed by Article seventeen of the Convention on a carrier in respect of the death of a passenger shall be in substitution for any liability of the carrier under any other law in respect of the death of that passenger, and the provisions set out in the Second Schedule to this Act shall have effect with respect to the persons by and for whose benefit the liability so imposed is enforceable and with respect to the manner in which it may be enforced." 1. The Carriage by Air Act was repealed in 1959 by the Civil Aviation (Carriers' Liability) Act, but its provisions and the Warsaw Convention were taken up in Part III of the new Act. That Act also gave effect to the 1955 Hague Protocol (Protocol to Amend the Convention for the Unification of Certain Rules Relating to International Carriage by Air, Signed at Warsaw on 12 October 1929 (The Hague, 28 September 1955) ICAO Doc 7632) amending the Warsaw Convention in Pt II and introduced liability in respect of interstate air travel, in Pt IV. When introduced into Parliament, its purposes were explained to include giving effect to the Hague Protocol which amended the Warsaw Convention. 2. Pertinently, the Hague Protocol did not amend Art 17 of the Warsaw Convention. Section 13 of the Civil Aviation (Carriers' Liability) Act, however, dealt separately with a carriers' liability for "personal injury". It did not use the Convention term "bodily injury". Sections 13 and 14 then provided: "13. Subject to the next succeeding section, the liability of a carrier under the Convention in respect of personal injury suffered, by a passenger, not being injury that has resulted in the death of the passenger, is in substitution for any civil liability of the carrier under any other law in respect of the injury. 14. Nothing in the Convention or in this Part shall be deemed to exclude any liability of a carrier - (a) to indemnify an employer of a passenger in respect of liability of that employer under a law of the Commonwealth or of a State or Territory of the Commonwealth providing for compensation to workmen or employees in respect of accidents arising out of or in the course of their employment; or (b) to pay contribution to a tort-feasor who is liable in respect of the death of, or injury to, the passenger, but this section does not operate so as to increase the limit of liability of a carrier in respect of a passenger beyond the amount fixed by or in accordance with the Convention." 1. Importantly for the resolution of the construction of s 9E which has arisen in this case, it is relevant that s 13 of the Civil Aviation (Carriers' Liability) Act has not been amended since 1959. Furthermore, s 9E, the equivalent section later enacted in Pt IA in relation to the Montreal Convention, was enacted in similar terms to s 13. 2. The English version of the Montreal Convention appears at Sch 1A to the Civil Aviation (Carriers' Liability) Act. Also relevant to the construction of s 9E is that Art 17(1) of the Montreal Convention is in relevantly similar terms to the English translation of Art 17 of the Warsaw Convention. Article 17(1) of the Montreal Convention provides: "The carrier is liable for damage sustained in case of death or bodily injury of a passenger upon condition only that the accident which caused the death or injury took place on board the aircraft or in the course of any of the operations of embarking or disembarking." 1. It is the meaning of the term "personal injury", which is used both in s 9E and in s 13, which has arisen for consideration in this case. That question does not appear to have previously arisen for consideration, although the meaning of the term "bodily injury", used in Art 17 of the Warsaw Convention has earlier been considered by Australian courts, as well as by courts of other signatory countries, including the United States, Israel and the United Kingdom. 2. In construing s 9E it is also relevant to consider that the term "personal injury" was also used in s 28 of Pt IV - Other carriage to which this Act applies, when the Civil Aviation (Carriers' Liability) Act was first enacted in 1959. It then provided: "Liability of the carrier for death or injury Subject to this Part, where this Part applies to the carriage of a passenger, the carrier is liable for damage sustained by reason of the death of the passenger or any personal injury suffered by the passenger resulting from an accident which took place on board the aircraft or in the course of any of the operations of embarking or disembarking." 1. Pertinently, in the Second Reading Speech, reference was made to Australia's acceptance of the limitations of the Convention and the Protocol in relation to international travel, but not in interstate transport (see House of Representatives, Commonwealth, Civil Aviation (Carriers' Liability) Bill 1959, Parliamentary Debates (Hansard), 7 April 1959 at 927). That explains why the term "personal injury" was used as it was in s 28. 2. Section 28 was amended in 2012 by the Aviation Legislation Amendment (Liability and Insurance Act) 2012 (Cth), when, amongst other things, the term "personal injury" was replaced with the term "bodily injury". The level of compulsory insurance required under the Act was also then increased, as was the cap on liability for domestic travel, to $725,000. In the Second Reading Speech (see House of Representatives, Commonwealth, Aviation Legislation Amendment (Liability and Insurance) Bill 2012, Parliamentary Debates (Hansard), 22 August 2012 at 9510) it was then explained as to the amendment to s 28 that: "The bill also harmonises Australia's commitments under the Convention for the Unification of Certain Rules for International Carriage by Air, signed 28 May 1999 (the Montreal convention) by amending references in the [Civil Aviation (Carriers' Liability) Act 1959] Act concerning 'personal injury' and substituting it with 'bodily injury'. This brings our domestic liability arrangements in line with the international framework established under the Montreal convention and implemented by more than 100 states around the world. This will mean that domestic carriers will no longer be liable for mental injuries irrespective of whether other 'physical injuries' have also been incurred." 1. This explanation reflected that the meaning of s 28 had earlier been considered by the Full Federal Court in South Pacific Air Motive Pty Ltd v Magnus [1998] FCA 1107; (1998) 87 FCR 301. There it was held that the term "personal injury" used in s 28 had a different meaning to the Warsaw Convention term "bodily injury". It was concluded that "personal injury" was a broader term than "bodily injury", encompassing both physical and mental injury (see at 317 (Beaumont J)) and psychological injury (see at 342 (Sackville J)). 2. In the result, on this legislative history, prior to the 2012 amendment to s 28, in the case of domestic interstate air travel, carriers had liability for purely psychological injury, that being an injury encompassed by the term "personal injury", which they did not have in the case of international travel. That was settled in Kotsambasis v Singapore Airlines Ltd (1997) 42 NSWLR 110, to which I will return. There it had been concluded that carriers did not have liability for psychological injury, in the case of international travel to which the Warsaw Convention applied. That explains why the 2012 amendment to s 28 was explained to have been intended to harmonise domestic liability arrangements, in line with the international framework established under the Montreal Convention, which replicated the relevant Warsaw Convention provisions. 3. It follows that, in 2012, by amending s 28 of the Civil Aviation (Carriers' Liability) Act to replace the broader term "personal injury" with the Convention term "bodily injury", the legislature reduced the range of injuries compensable under Part IV of the Act in the case of interstate air travel, to those compensable under both the Warsaw and Montreal Conventions. No amendments were then, however, made to either s 9E or s 13, where the broader term "personal injury" remained, consistently with their purpose, namely to enact the Montreal and Warsaw Conventions into Australian law. 4. It was argued for Ms Casey that in amending s 28 as the legislature did after the Full Federal Court had considered the proper meaning of the term "personal injury" there used in South Pacific Air Motive Pty Ltd v Magnus, but not amending s 13 or s 9E, the parliamentary intention of those sections, namely, to impose wider liability for compensation for psychological injuries suffered by passengers than flowed from the term "bodily injury" which the Montreal Convention provided for, was confirmed. This reflected that s 9E was another of the departures contemplated by s 9B of the Act. 5. On Pel-Air's case, s 9E was not amended in 2012 when s 28 was, because, properly construed, the effect of s 9E was to limit carrier's liability for damages for personal injury suffered by passengers, to those available under the provisions of the Montreal Convention, that is damages for "bodily injury" and no more. 6. On the case advanced for Ms Casey, such a construction would make s 9E otiose, given the provision made in s 9B, which enacted the Montreal Convention into law, subject to the statutory alterations provided in Part IA, one of which was that provided in s 9E. 7. That may not be accepted. It is s 9B which enacts the Montreal Convention into Australian law, as I have explained, subject to the departures elsewhere provided in Pt IA. Without the limitation introduced by s 9E upon carriers' liability for damages under any other law in respect of the "injury", flowing from any "personal injury" which passengers suffer, carriers would have liability under the Montreal Convention for "bodily injury", given force by s 9B. They would also have liabilities for such injuries under other Australian laws. Because that was not intended, s 9E limited carriers' liability for personal injury under other laws, leaving them only with the absolute liability imposed by the Montreal Convention for "bodily injury". 8. The practical result of s 9E for passengers is that when injured in circumstances to which the Montreal Convention applies, they can only successfully pursue carriers for any "bodily injury" which they have suffered, to which the Montreal Convention applies. 9. That explains why, when enacting the amendments to the Civil Aviation (Carrier's Liability) Act which gave effect to the Montreal Convention, the legislature did not use the Convention term "bodily injury" in s 9E, but instead used the term "personal injury", also long used in s 13 in respect of the Warsaw Convention. 10. That conclusion is also supported by s 9H, which deals with contributory negligence. It relevantly provides that: "9H Contributory negligence (1) For the purposes of Article 20 of the Convention, if, in an action against a carrier under the Convention relating to damage: (a) sustained in the case of death or bodily injury of a passenger; or (b) sustained in the case of destruction or loss of, or of damage to, baggage of a passenger; or (c) sustained in the event of the destruction or loss of, or damage to, cargo; or (d) occasioned by delay in the carriage by air of a passenger, a passenger's baggage, or cargo; the carrier proves that the damage was caused by, or contributed to by, the negligence of the passenger or the consignor of the cargo, the damages recoverable in respect of the damage must be assessed in accordance with this section." 1. The use of the term "bodily injury" in s 9H in relation to contributory negligence, is also consistent with a construction of s 9E, that limits damages recoverable under Pt IA from an international carrier to those arising from "bodily injury". 2. As I have explained, the term "personal injury" was also originally used in s 28 of the Act, which appears in Pt IV, which applies to domestic carriage of passengers in an aircraft by the holder of an airline licence or a charter licence in the course of commercial transport operation, or where the 1999 Montreal Convention, the Warsaw Convention, the Hague Protocol, the Montreal Protocol No. 4 (Protocol No 4 to Amend the Convention for the Unification of Certain Rules Relating to International Carriage by Air, Signed at Warsaw on 12 October 1929, as amended by the Protocol Done at the Hague on 28 September 1955 (Montreal, 25 September 1975) ICAO Doc 9148) and the Guadalajara Convention (Convention, Supplementary to the Warsaw Convention, for the Unification of Certain Rules relating to International Carriage by Air Performed by a Person other than the Contracting Carrier (Guadalajara, 18 September 1961) 500 UNTS 32) do not apply (see s 27). 3. The term "personal injury", it is apparent from a proper reading of s 9E, s 13 and s 28, was used consistently, when the Civil Aviation (Carriers' Liability) Act was enacted. The result was that the liability of carriers for personal injury suffered during interstate carriage under s 28, was initially not limited to damages flowing for "bodily injury", as was the case in respect of international carriage to which s 13 and later when Pt IA was enacted to give effect to the Montreal Convention, to which s 9E applied. 4. That position changed in 2012, when s 28 was amended by adoption of the Convention term, with the result that thereafter, carriers' liability in the case of injury not causing a passenger's death was, during both interstate and international travel, limited to "bodily injury". 5. It follows that, properly construed, s 9E does not, as was contended for Ms Casey, grant her the right to compensation for personal injuries which she suffered in the crash. Her rights to compensation under the Civil Aviation (Carriers' Liability) Act flow from s 9B and Pel-Air's liability for those injuries are by s 9E confined to any bodily injury which she has suffered. The case law 1. That conclusion is also supported by relevant case law. 2. The meaning of "bodily injury" in Art 17 of the Warsaw Convention arose for consideration in American Airlines Inc v Georgeopoulos [1996] NSWCA 13. There a passenger had claimed damages for personal injuries, including nervous shock and mental suffering. A case was stated on the question of whether nervous shock and mental suffering fell within Art 17. The contest turned in part on whether the approach of the Israel Supreme Court in Air France v Teichner (1984) 7 S&B Av R 141 as to the meaning of Art 17 should be preferred over that of the Supreme Court of the United States in Eastern Airlines Inc v Floyd 499 US 530 (1991). 3. The Court of Appeal considered that the stated case was inappropriate and misconceived, having been based on agreed facts which included that the passenger had claimed damages for nervous shock or mental suffering "and (on) no other basis". Sheller JA (with whom Clarke JA and Simos AJA agreed) took the view that absent a finding as to the nature of the injury suffered, it was not possible to decide whether the passenger had suffered "bodily injury", within the meaning of Art 17. His Honour observed that nervous shock "might or might not have caused an injury to the passenger's body tissues". 4. Before the case returned to the Court of Appeal, Kotsambasis was decided. There Meagher JA considered that the term "bodily injury", (not defined in the Warsaw Convention, or in the Civil Aviation (Carriers' Liability) Act)), was ambiguous and that its meaning had to be resolved by looking at the intention of the Warsaw Convention's contracting parties and adopting a purposive approach to its interpretation (see at 114). 5. His Honour also considered the adjective "bodily" to be a word of limitation, which had to be given effect. Following Eastern Airlines Inc v Floyd, where Marshall J had considered the history of the negotiation of the Convention and the state of the law in many of the other contracting states at the time, his Honour concluded that the term was "not intended to, and on the proper interpretation of the Convention does not, include purely psychological injury" (at 115). It was not there considered necessary to resolve the question left open in Eastern Airlines Inc v Floyd, as to whether the term also encompassed psychological injuries accompanied by physical injuries. 6. That question arose for consideration in American Airlines Inc v Georgeopoulos [No 2] [1998] NSWCA 273, where the passengers' claims failed. Sheller JA noted that the only direct physical injuries suffered by one of the passengers in that case had been bruising and back pain experienced the next day and a mild post-traumatic stress disorder. The second passenger had not suffered any physical injury, but had also suffered a mild post-traumatic stress disorder. There was no evidence of any structural alteration to either passengers' bodily tissues, or of any alteration in the function of an organ, or neurochemical change, or any other form of damage to tissues or organs. 7. Sheller JA, with whom Meagher and Beazley JJA agreed, held that: "… I do not think Article 17 means that if the passenger died or suffered bodily injury, the carrier is liable for any damage caused by the accident if the damage was not the result of the death or bodily injury. Nor do I think the US Supreme Court suggested otherwise. The question which the US Supreme Court did not decide was whether if the passenger suffered bodily injury, the passenger could recover damages for psychic injuries which flowed from the bodily injury, even though not entitled to damages for psychic injuries if there was no bodily injury. At 544 the US Supreme Court said: Two explanations commonly are offered for why the subject of mental injuries never arose during the Convention proceedings: (1) many jurisdictions did not recognise recovery for mental injury at that time, or (2) the drafters simply could not contemplate a psychic injury unaccompanied by a physical injury. In my respectful opinion, consistent with this it could not be suggested that if a passenger was shocked by the fear of imminent death in a plane crash and thereafter injured her hip in obeying a direction to move to the front of the aircraft, she would be able to recover for her mental injuries, but if she had not injured her hip, such recovery would have been denied. I think the US Supreme Court, when it used the word 'accompanied', had in mind to leave open the question whether the carrier was liable for mental injuries, consequent upon physical injuries, or emotional shock which had resulted in organic damage such as a coronary thrombosis or stroke. I think Stein JA in Kotsambasis at 121 correctly delimited the ambit of recovery for psychic injury when he said where mental anguish follows and is caused by physical injury, recovery for both injuries is covered …. Moreover, if the psychological injury is proven to be a species of bodily injury, then it would constitute "bodily injury" within the article. Mr Evatt accepted that the stress disorder was not the consequence of any physical injury. The appellant is not therefore liable under Article 17 … " 1. These Australian decisions were later considered by the House of Lords in King v Bristow Helicopters Ltd [2002] UKHL 7; [2002] 2 AC 628. Lord Hope of Craighead there agreed with the NSW approach to Eastern Airlines Inc v Floyd (see at [122]). Lord Hobhouse of Woodborough dealt with these decisions at [169] - [172], also agreeing with the approach there adopted to the meaning of "bodily injury". 2. In none of these Australian cases was any consideration given to the meaning of the term "personal injury" used in s 13 and whether the use of that wider term there and in s 9E, gave passengers the right to recover damages for any psychological injuries they suffered, which were not compensable under either the Warsaw or Montreal Convention, as Ms Casey claims in these proceedings. Section 9E was not directly relevant in those cases, but s 13 was and yet the construction point here raised by Ms Casey, was not pursued. 3. The explanation for that appears to be that s 13, like s 9E, concerned as they both are with the liability of carriers, not the rights of passengers, do not grant passengers the right Ms Casey claims she has in this case under s 9E, to compensation for personal injury. 4. Also in issue in this case, however, is whether the PTSD which Ms Casey suffers as the result of the crash is a "bodily injury" caused by the crash. That raises mixed questions of fact and law, which makes it necessary to further consider the case law, to which I will return. Ms Casey's PTSD claim 1. As I have explained, in New South Wales it was settled by Georgeopoulos [No 2] that Art 17 of the Warsaw Convention draws a distinction between the mind and the body. Article 17 of the Montreal Convention also draws that distinction. Whether a passenger has suffered a compensable bodily injury is a matter of fact, to be determined on the evidence led in a particular case. 2. In the result, consistently with Pel-Air's concessions in this case, which accord with the case law to which I have referred, Ms Casey's complex pain syndrome, depression and anxiety disorders, were finally accepted as being compensable bodily injuries, under the Montreal Convention. That reflects they are each either mental injuries consequent upon physical injuries; emotional shock which results in organic damage; mental anguish which follows and is caused by physical injury; or psychological injury proven to be a species of bodily injury and thus each compensable. 3. Ms Casey's case was that the evidence also established that, like all the other injuries which she had suffered, her PTSD was also such a compensable "bodily injury" under Art 17 of the Montreal Convention. Further, given the nature and complexity of her other injuries, their treatment and consequences, even if Pel-Air was correct, that would have no practical effect on the orders made in her favour in this case. 4. Pel-Air disputed this. On its approach, which relied on various international authorities, properly construed the term "bodily injury" in Art 17 of the Montreal Convention did not encompass PTSD. Further, the evidence did not establish that the PTSD which Ms Casey suffers was the result of the physical injuries which she had suffered, nor had it involved or caused any injury to her body. That, too, was in issue. 5. For reasons which follow, I have firstly concluded that a diagnosis of PTSD does not exclude the possibility that evidence in a particular case may establish that a person has suffered a bodily injury compensable under the Montreal Convention. Secondly, that the evidence establishes that the PTSD which Ms Casey suffers and for which she also has been unsuccessfully treated, is consequent on damage to her brain and to other of her bodily processes, which have had the result that her brain is no longer capable of functioning normally. Either the PTSD is at least in part a manifestation of that damage, or that damage has caused or contributed to the PTSD, or there is a combination of such cause and effect, which has put Ms Casey into the position she is now in. Whichever it is, the result is that the PTSD which Ms Casey suffers, is a compensable bodily injury. 6. Accordingly, I have also concluded that this bodily injury must also be reflected in the damages which Ms Casey is awarded. PTSD and the proper construction of Article 17 of the Montreal Convention 1. The proper construction of Art 17 was in issue. 2. It seems to me that despite the conclusions reached in the authorities relied on for Pel-Air, the conclusion it urged, that PTSD is a psychiatric injury for which compensation cannot be recovered under Art 17 of the Convention, given its proper construction, must be rejected. 3. The fact that other cases decided in other signatory countries have resulted in claims relating to PTSD failing, is not a basis upon which it may be concluded, without an analysis of the evidence led in a case where a claim is advanced in relation to PTSD, that such an injury is not compensable under Pt IA of the Act. 4. Pel-Air's case was that on the proper construction of Art 17 of the Montreal Convention, emotional distress unaccompanied by bodily injury was not compensable, nor were alterations to a person's body associated with mental distress, or physical manifestations of emotional injuries. In order for PTSD to be compensable, it was thus argued, what was required was evidence that it had been caused by the physical injuries Ms Casey had sustained. There was no such evidence and so this aspect of her claim could not succeed. 5. Ms Casey's case was that the evidence established that the crash had caused her body to cease functioning normally, in various ways, causing the PTSD from which she continued to suffer. That evidence established that the PTSD had involved bodily injury, compensable under Art 17. 6. The meaning of Art 17 of the Warsaw Convention has received considerable judicial attention in Australia and other signatory countries. Article 17 of the Montreal Convention does not appear to have arisen for such wide consideration, but the authorities on the construction of Art 17 of the Warsaw Convention, must unquestionably be given considerable weight when Art 17 of the Montreal Convention is construed. 7. Pel-Air summarised the propositions which it argued could be drawn from the relevant Australian and American decisions to be: (a) The jurisprudence on Article 17 of the Warsaw Convention is relevant to the construction of Article 17 of the Montreal Convention; (b) emotional distress unaccompanied by bodily injury is not recoverable under Article 17; (c) alterations to a person's body associated with mental distress do not constitute bodily injury under Article 17 of the Montreal Convention. What is required is an objective identifiable palpable observable injury to the body; (d) in order for damages for mental distress to be recovered they must be caused by physical injuries sustained; (e) physical manifestations of emotional injuries are not recoverable. 1. Of considerable persuasive authority is the House of Lord's judgment in King on the proper construction of Art 17 of the Warsaw Convention, which adopts a similar approach to its construction as was adopted in the Australian authorities to the construction of the Warsaw Convention, which I have dealt with earlier. Those authorities were there referred to with approval. 2. I am satisfied that propositions (c) – (e) advanced for Pel-Air do not follow from these authorities. They are not supported by the conclusions reached either in the Australian authorities or by King, to which insufficient attention was paid in the submissions advanced for Pel-Air. 3. To press the construction for which it contended, Pel-Air also relied on Doe v United Airlines, Inc 160 Cal App 4th 1500 (2008), where the Court of Appeal in California concluded (at 1512 - 1513) that: "The majority rule, as disclosed by our survey of case authority, is that alterations in an individual's body and behavior intrinsically or characteristically associated with mental distress do not constitute bodily injury under the Warsaw Convention. This rule encompasses alterations or changes in an individual's brain and nervous system characteristically tied to PTSD. At bottom, the rule rests on the recognition that mental distress typically and regularly manifests itself in an individual's brain, nervous system, body, and behavior." 1. This view does not accord with that reached in Georgeopoulos [No 2], Kotsambasis or King, to which I will return. 2. Pel-Air also relied on Ehrlich v American Airlines Inc 360 F 3d 366 (2d Cir 2004), where the United States Court of Appeals Second Circuit was considering a claim for mental injuries in a case where the passengers had suffered various physical injuries. It accepted that Art 17 of the Warsaw Convention permitted recovery for mental injuries, to the extent that emotional distress was caused by physical injuries suffered (see at 376). It was, however, concluded that carriers were not liable for mental injuries which accompany, but are not caused by bodily injuries (at 385). 3. Pel-Air also relied on Bobian v Czech Airlines 93 Fed Appx 406 (3rd Cir 2004), where the United States Court of Appeals Third Circuit considered a claim that PTSD caused by a plane flown into a hurricane had caused physical changes to the brain, which constituted a bodily injury under Art 17 of the Warsaw Convention. It was concluded that (at 408): "We agree with Judge Debevoise that the relationship between the physical and emotional dimensions of human existence was well known to the drafters of the Warsaw Convention who nonetheless required "lesion corporelle". In our view, plaintiffs' position on post-traumatic stress disorder would abolish the requirement of palpable and conspicuous physical injury, but this can only be done by a change to the language of the Convention. We also note that none of the plaintiffs has brought forward cognizable evidence that his or her brain has changed physically from an earlier state. Our view is supported by a very recent exhaustive and scholarly decision, Ehrlich v American Airlines Inc …" 1. The French term "lesion corporelle" is a reference to the English term "bodily injury". Pel-Air also relied on similar conclusions reached in: In re Air Crash at Little Rock Arkansas 291 F 3d 503 (8th Cir 2002) by the United States Court of Appeals Eighth Circuit, where there was found to be no proof that the PTSD suffered by the passenger involved physical changes to the brain; Terrafranca v Virgin Atlantic Airways Ltd 151 F 3d 108 (3d Cir 1998), where the United States Court of Appeals Third Circuit concluded that mere physical manifestations of emotional injures are not sufficient and that direct, concrete bodily injury, as opposed to mere manifestation of fear or anxiety must be proven. Rosman v Trans World Airlines Inc 34 NY 2d 385 (1974) where the Court of Appeals of New York took the view that Article 17 requires palpable conspicuous physical injury and that mental injury with observable "bodily", as distinguished from "behavioral manifestations", had to be established: at 400. 1. Pel-Air distinguished Weaver v Delta Airlines Inc 56 F Supp 2d 1190 (D Mont 1999), where summary judgment was given in favour of a passenger who claimed damages for actual brain damage caused by extreme stress during her flight experiences, which had resulted in PTSD, where the carrier had failed to raise a factual issue about the claim. That judgment was considered in Doe v United Airlines to be of limited precedential value and on Pel-Air's case, would not be followed. 2. In King, the authorities relied on by Pel-Air were also considered. There, reference was made to the negotiation of the Montreal Convention, where efforts to include in Art 17 a reference to mental injury had not been agreed and instead, the term bodily injury used in the Warsaw Convention was adopted (see at [105]). The claims there made in respect of PTSD also failed on the evidence, but the possibility that the evidence in a particular case might establish that PTSD was a compensable bodily injury, was accepted. 3. As I have explained, while in Eastern Airlines Inc v Floyd, the Supreme Court of the United States had left open the question of whether a passenger could recover mental injuries accompanied by physical injuries under the Warsaw Convention, that was considered and resolved in this State at least, in Georgeopoulos [No 2] on the basis of Stein JA's conclusions in Kotsambasis. That approach is consistent with that discussed in King. 4. The principles which flow from those decisions, while not strictly binding on the construction of Art 17 of the Montreal Convention, should be followed and applied to the evidence led in a particular case brought in respect of a claim to which that Convention applies, irrespective of whether the claim advanced in a particular case relates to a diagnosis of PTSD, or some other injury or disorder. 5. In the result, contrary to what was submitted for Pel-Air, it seems to me that if it is proven on the evidence that a particular psychiatric injury, including PTSD, is caused by a physical injury, that is to the brain or other parts of the body, damages for both injuries may be recovered. Further, a psychiatric injury may in a particular case itself be proven on the evidence to be "a species of bodily injury", compensable under Art 17. 6. In King, no evidence had been led to show that the mental injury or illness which the two plaintiffs, Mr King and Ms Morris, had each suffered, was caused to any extent by any physical injury. 7. It was thus concluded that Ms Morris, a minor who had suffered no physical injuries when touched on the thigh by another passenger during a flight, but who had developed a single episode of major depressive illness later, could not recover under Art 17. Ms Casey's circumstances are quite different. 8. Mr King had also suffered no physical injury during the helicopter accident in which he had been involved, but he had developed several psychiatric disorders, including PTSD, as well as peptic ulcer disease caused by stress, which had caused severe pain and an exacerbation of pre-existing symptoms. It was concluded that Mr King was entitled to recover damages for the peptic ulcer and the pain associated with it under Art 17 of the Warsaw Convention, but not the PTSD. That conclusion accords with the concessions made by Pel-Air in relation to Ms Casey's physical injuries, the pain syndrome she suffers and her major depression and anxiety disorders. 9. In relation to Ms Casey's claim for the PTSD it is pertinent to refer to a number of observations in King, relevant to the arguments which the parties here advanced, with which I agree and respectfully adopt. 10. First, Lord Nicholls of Birkenhead, who agreed with Lord Steyn, Lord Hope of Craighead and Lord Hobhouse of Woodborough, considered at [3] that while shock, anxiety, distress, grief and other emotional disturbances alone do not fall within Art 17: "[3] … The brain is part of the body. Injury to a passenger's brain is an injury to a passenger's body just as much as an injury to any other part of his body. Whether injury to a part of a person's body has occurred is, today as much as in 1929, essentially a question of medical evidence. It may be that, in the less advanced state of medical and scientific knowledge seventy years ago, psychiatric disorders would not have been related to physical impairment of the brain or nervous system. But even if that is so, this cannot be a good reason for now excluding this type of bodily injury, if proved by satisfactory evidence, from the scope of article 17." 1. Lord Mackay of Clashfern agreed with Lord Hope of Craighead, adding at [8] "[8] … if an injury to the brain of a passenger is found to have occurred, and the other conditions requisite to qualify for compensation under article 17 are present, compensation under the article cannot be refused on the ground that in 1929, this fact would not have been known, with the result that at that time, medical opinion would have been that the passenger had suffered only mental injury. Like my noble and learned friend Lord Nicholls of Birkenhead I do not see merit in adding words to the description of injury which are not present in the Convention text and I would apply the simple test, does the evidence demonstrate injury to the body, including in that expression the brain, the central nervous system and all the other components of the body?" 1. Lord Hope of Craighead observed at [49]: "[49] … The branch of medical science which is concerned with psychiatric disorders and disturbances is still in the process of development. It is not yet fully understood. We are able to identify physical conditions which have been brought about by a psychiatric route. Mr King's peptic ulcer disorder is a physical condition of this type. We can also identify various psychiatric illnesses which, according to our present state of knowledge, appear not to have been the product of any kind of physical injury. But the distinction between what I have described as a mental injury and a physical injury is unclear, and the extent to which it can be maintained is debatable. It may now be possible to show objectively, by means of expert medical evidence, that a psychiatric illness is due to a disturbance within the patient's own central nervous system which drugs can control or alleviate." 1. At [125], his Lordship said: "[125] It would be wrong to regard article 17 as limited by the state of medical and scientific knowledge that was current in the 1920s. There is no reason to think that the contracting parties intended that no account should be taken of developments in medical science in determining the question whether a passenger has sustained a bodily injury. I agree with my noble and learned friend Lord Mackay of Clashfern that, if the brain could be shown to have been injured and the other conditions for compensation under article 17 are satisfied, it would not be right to refuse compensation under the article on the ground only that in 1929 an injury of that kind would not have been capable of being demonstrated. Whether or not there is such an injury will always depend on the evidence. But the fact remains that a bodily injury is conceptually distinct from any injury which affects the mind: Mullany & Handford, Tort Liability for Psychiatric Damage (1993), p18." 1. Lord Hobhouse of Woodborough observed at [141] – [143]: "[141] The word bodily is simpler. It means pertaining to the body. There must be an injury to the body. It is, as it must be, accepted that the brain, the central nervous system and the glands which secrete the hormones which enable the brain and the rest of the central nervous system to operate are all integral parts of the body just as much as are the toes, heart, stomach and liver. They are all susceptible to injury. The mechanisms by which they can be injured vary. An ingested poison might injure the stomach or liver. A lack of oxygen will injure the brain by causing the death of brain cells. An injury to the heart may be caused by a blow or by a traumatic experience or by over-exertion. In every case there is a cause, external to the organ in question, which produces a change in the structure or ability to function of the organ. If the change, either alone or in conjunction with changes in other organs, is properly described as an injury, it is a bodily injury. Since the body is a complex organism depending for its functioning and survival upon the interaction of a large number of parts, the injury may be subtle and a matter of inference not direct observation. The medical science of diagnosis exists to enable the appropriate inferences to be drawn from the observed evidence. Medicinal treatments (as with drugs) are prescribed on the basis that there is a physical condition which can be reversed or alleviated by physical means. [142] Bodily injury does not import visibility nor palpability nor externality. Its use in Article 17 in addition to the use of the words "death" and "wounding" ("blessure") and the inclusion of the word "any" confirm this. Take an incident which ruptures a spleen or causes some other internal injury. The doctor infers that the injury has been caused from other signs and symptoms and ultimately confirms it by an invasive (surgery) or non-invasive (ultrascan or x-ray) procedure. An incident may damage someone's optic nerve in a location or manner which cannot be observed; the person may as a result have no sight in that eye; this will be a bodily injury even though there is no thing palpable, conspicuous or visible. The use of the word "palpable" in the discussion of the meaning of Article 17 typifies the dangers of the use of loose terminology which does not aid clarity but, rather, creates ambiguity. "Palpable" is a term which has a precise meaning - capable of being felt by touch - which is its medical meaning. But it also has a metaphorical usage - readily perceived by the senses or the mind. It will be readily understood that the precise meaning is too restrictive and cannot be justified as a gloss upon the simple phrase bodily injury. The metaphorical usage likewise cannot be justified and is impractical and unprincipled. Is the judge or arbitrator to say: "Having heard the evidence I am satisfied that the passenger suffered an injury but I cannot say that I readily perceived it"? The obvious attraction of using words such as "palpable" is that they give an illusion of clarity when in truth they enable the user to avoid clarity and simply serve to detract from the clarity of the primary terminology. [143] Thus, bodily injury simply and unambiguously means a change in some part or parts of the body of the passenger which is sufficiently serious to be described as an injury. It does not include mere emotional upset such as fear, distress, grief or mental anguish (cf argument (8)). A psychiatric illness may often be evidence of a bodily injury or the description of a condition which includes bodily injury. But the passenger must be prepared to prove this, not just prove a psychiatric illness without evidence of its significance for the existence of a bodily injury." 1. At [152], his Lordship observed: "[152] It is a feature of the brain and the central nervous system that the manner in which it works has inevitably limited the knowledge and understanding of how the organ functions and its pathology. It is an interrelated and interdependent system. Only limited knowledge could be gained from the examination of the anatomy of a corpse. In the living subject, the scope for intrusive investigation was very limited. In the popular perception, this has led to the perpetuation of theories of psychic disembodiment long after they have any scientific justification. There now exist techniques for investigating the functioning of the living brain and the central nervous system together with the roles played by neurotransmitters, hormones and electrical impulses. Physical changes can be scanned and observed using sophisticated instruments and the alterations in the normal chemistry of the brain can now be detected by sophisticated sampling techniques. What was previously invisible can now be made visible. These developments have two relevant results. It can now be shown by valid scientific techniques that certain psychiatric symptoms correspond to physical changes in the brain. Psychiatry (the science of mental illness) has been able to develop a more reliable classification and aetiology enabling better diagnoses to be made and more reliable opinions to be given as to the probable causation of observed disorders. What these developments have changed is not the phenomena nor the meaning of the language used in the article but the ability to adduce evidence relevant to the factual issues raised by the article." 1. It thus remains now to explain why I have come to conclude that the evidence established on the balance of probabilities, that the PTSD which Ms Casey suffers is a bodily injury compensable under the Montreal Convention. The evidence establishes that Ms Casey's PTSD is a "bodily injury" 1. The evidence established that the terrifying, painful experiences which Ms Casey underwent in the crash, affected her mind, with resulting emotional distress, which is not compensable under the Convention. The crash also, however, caused various injuries to her body, three psychiatric conditions and a pain syndrome, which are all compensable bodily injuries under the Montreal Convention. 2. The evidence established that not only the functioning of parts of Ms Casey's body, but the functioning of her brain and other bodily processes necessary for her brain's normal functioning, were damaged in ways which resulted in her developing a complex pain disorder and various psychiatric conditions. She has not been able to recover from the damage done to her body and brain and has lost their normal functioning, in a variety of ways. Because of the nature of those injuries and the pain and other problems which they continue to cause, she has never been able to recover her health. 3. The ongoing effects of the physical damage to her body also adversely impacted her recovery from the anxiety disorder, major depression and PTSD which she developed after the crash. Those four conditions also impacted upon each other. They have all been unsuccessfully treated with the pharmacological and other treatments which Ms Casey has pursued diligently, but unsuccessfully. The PTSD which Ms Casey suffers has been treated unsuccessfully, by the same kinds of treatment which have been directed at her other psychiatric conditions. 4. PTSD was the only injury which Pel-Air did not accept as having involved any bodily injury. Ms Casey has met the onus falling upon her to establish that the PTSD is also a bodily injury caused, at least in part, by the injuries to her body. It has been impacted both by the pain syndrome which those injuries have caused and by the other two psychiatric treatment resistant conditions which Ms Casey suffers. They have all exacerbated the nature and severity of her PTSD; they continue to affect its treatment; and they have inhibited her recovery from that disorder. 5. Ms Casey's failure to respond to the treatment she has received for both PTSD and her other psychiatric conditions, is consistent with Ms Casey having suffered organic damage to her brain and other parts of her body on which its normal functioning depends. That is also consistent with her recovery from her PTSD having been precluded by the damage which helped cause that disorder. 6. To understand why I have come to these conclusions, it is necessary to turn to the evidence. Ms Casey's injuries 1. An understanding of the nature and extent of Ms Casey's injuries and their impact, must begin with the evidence of how she functioned before and after the accident. The evidence was voluminous and needs to be referred to in some detail, in order to explain the conclusions which I have reached. 2. All of that evidence has to be considered in the context of the expert evidence which the parties led from Dr Rastogi and Dr Phillips. In their reports, joint report and oral evidence, they explained not only the nature and complexity of Ms Casey's injuries, their interaction and consequences, but how this made the task of attempting to separate her injuries and their results not only a difficult exercise, but also quite an artificial one. 3. The experts also explained their clinical application of developments in neuroscience, which have led to an increased understanding by practising clinicians such as they, of the role which neurotransmitter chemicals play in brain function and in the development and treatment of psychiatric disorders, including depression, anxiety and PTSD. Those advances have been accompanied by advances in neuropharmacology which they use to treat such disorders. Research and understanding of brain functioning continues to evolve, as does understanding of the mechanics of how such pharmacological treatments work, in clinical practice. 4. It is now known that certain psychiatric disorders are caused by alterations in neurotransmitter pathways in the brain and that the pharmacological treatments used to treat these disorders work by altering neurotransmitter pathways, which are malfunctioning. How particular patients respond to medication and treatments prescribed by clinicians differs. Effective treatment still has to be determined clinically, with each patient. 5. This evidence shed considerable light on significant objective evidence that revealed that not only had Ms Casey's mind initially been adversely affected by her understandable distress and the other emotional reactions she had, to what she had experienced during the crash and its aftermath, but that amongst the many bodily injuries which she suffered were injuries which damaged the ability of her brain to function normally. Despite ongoing intensive treatment, her body has never been able to recover its normal functioning. Ms Casey's former functioning 1. Ms Casey's written evidence was largely unchallenged. I accept it, supported, as it was, by the evidence of her mother, stepfather, children, friends and work colleagues, by her medical records and the expert evidence. It was also supported by what was depicted on the video in evidence and by her evidence in cross-examination. 2. Ms Casey is the single mother of three children for whom she cared and supported at the time of the crash. She was then aged 39 years, fit, active and high functioning in all aspects of her life. She is a highly trained and experienced nurse, then employed by CareFlight as a nurse educator/flight nurse. She was highly regarded by her superiors at CareFlight, Dr Walker and Ms Herring, who described her variously as a vivacious, hardworking, reliable, diligent, competent, professional and organised nurse. 3. Ms Casey was then also working casually in trauma nursing for Meditrack, at various race tracks, during high speed car races, as well as in intensive care at Nepean Hospital. She also worked part-time as an aerobics instructor. Ms Casey was also then pursuing a Post-graduate Certificate in Aeromedical Retrieval from James Cook University in Townsville, aiming in the future to work in that field overseas. She had an interest in motor racing driving and had taken flying lessons, another of her interests. 4. Ms Casey's description of her former work and interests was supported by the evidence of other witnesses. 5. There was no issue as to the nature of Ms Casey's horrific experience in the crash, one she was fortunate, indeed, to have survived, or the seriousness of the physical injuries and psychiatric injuries which she suffered, or the consequences of the crash on her life. 6. Ms Casey lost the ability to undertake her former work, to pursue her interests and to function normally in her day-to-day life, as the result of the injuries which she suffered. She has never recovered her health. She has not been able to return to nursing or any other work since the crash, despite having attempted to return to work on a number of separate occasions, before her employment was terminated by CareFlight. She has also considered, but not been able to pursue, other work. One of her daughters is now her full-time carer. 7. Dr Walker, now a senior emergency medical specialist at Nepean Hospital and CareFlight's specialist retrieval physician, was its Medical Director at the time of the crash. His evidence was unchallenged. He described his observations of Ms Casey's marked physical alteration after the crash; the pain she appeared to be in; her ongoing depressed state; her difficulty in walking, sitting and moving; and what he had observed of her during his frequent telephone conversations with her, when she was often incoherent and difficult to follow. 8. Dr Walker explained the differences in Ms Casey's functioning, before and after the crash, as well as the nature of his long held concerns for Ms Casey, given what he had observed when on duty in hospitals, when she had been repeatedly admitted. Dr Walker considered it impossible and indeed futile, given the complex nature of her injuries, to attempt to distinguish the interaction between her physical and psychological injuries. 9. At the time of the crash, Ms Herring, who corroborated Dr Walker's evidence, was CareFlight's National Nurse Manager. She shared an office with Ms Casey and worked closely with her, in her role as nurse educator, before the crash. She also gave unchallenged evidence of Ms Casey's competence and professionalism at work, before the crash. 10. Ms Herring was one of those despatched to bring Ms Casey back to Australia. She described Ms Casey's then state; her unsuccessful, ongoing efforts to recover and return to work; and the ongoing pain, distress, fatigue and anxiety her injuries caused her. Ms Herring described occasions she had been called by Ms Casey's children to provide assistance, including when Ms Casey required urgent hospitalisation. 11. Ms Casey has not been able to recover from her injuries, with the result that she has not been able to pursue her former work, studies, physical activities, or interests. Nor has she been able to care for her children as she did beforehand. Instead, she has required their considerable day-to-day care and support, as well as that of her mother, stepfather and friends. On the unchallenged evidence she, her children, mother and stepfather gave, that has required very considerable efforts on their part, reflective of the pitiable state Ms Casey has at times been reduced to. 12. Despite this, Ms Casey has attempted to pursue her obligations to her children, other studies and interests. She has had limited success, because of the nature of the ongoing problems caused by her injuries, which amongst other things have interfered significantly with her memory and ability to concentrate. 13. The injuries which Ms Casey suffered as the result of the crash were physically and psychologically devastating. They included damage to seven of her teeth; neural irritation; disc bulges to the right of midline at C3/C4 and C4/C5; injury to the facet joint at C2/C3; injury to the right knee; PTSD; a co-morbid depressive disorder, generalised anxiety disorder; chronic pain and a complex regional pain syndrome. 14. Ms Casey's teeth required extensive specialist dental treatment. She also had to undergo a series of procedures to manage her cervical and right upper limb pain, including facet joint injections, nerve root blocks and insertion of a spinal cord stimulator, to help manage her considerable pain. The stimulator became infected and later had to be removed. Another stimulator was inserted in June 2011 and remains in place. 15. In 2014, Ms Casey underwent spinal surgery which helped reduce the number of severe and debilitating headaches from which she suffers, but was not successful in improving other aspects of her painful conditions. They led to increased weakness in her right arm, which has interfered with her ability to write and play a guitar, an activity she sought to pursue after the crash, in order to help strengthen her arm. 16. Ms Casey continues to require injections in her cervical spine and to receive other treatment from pain specialists, which includes considerable medication, to manage her ongoing pain, as well as physiotherapy and other treatments. 17. Ms Casey has also been hospitalised on a number of occasions for treatment of her psychiatric conditions. She continues to receive ongoing treatment from her psychiatrist, Dr Rastogi. She has also received treatment from psychologists on an individual basis, as well as undertaking group therapy. She also continues to receive considerable medication for her psychiatric conditions. 18. Ms Casey sleeps poorly, suffers ongoing nightmares and resulting fatigue, as well as drowsiness, caused by medication. Most understandably, she is distressed and frustrated by her situation and its consequences, for herself and her family, which she finds on occasions to be embarrassing and humiliating. 19. In her written evidence, Ms Casey described the nature of her physical injuries; her resulting limitations, the very considerable pain she has endured as a result; and the extensive treatment she has received, some of it distressingly unsuccessful. She described the increasingly severe and debilitating headaches she has suffered, other pain and other distressing symptoms, including hypersensitivity to touch; muscle spasms; difficulty with writing with her right hand and with other fine motor skills needed in order to pick up a cup of tea, or cut food; discomfort in sitting; problems with driving for longer than 30 minutes; problems with managing any heavy physical work; as well as problems with walking, because of the injury to her right knee. 20. Ms Casey also described the consequences of her pain syndrome and her psychiatric injuries and the ongoing problems they cause her, including problems with her memory; with sleeping; with managing simple routine tasks; repeated, extended hospital admissions for psychiatric treatment; feelings of anger, despair and lack of self-worth over the loss of her health, career and independence; flashbacks and fear of planes and flying; reduced social activities; and suicidal thoughts. 21. Ms Casey has also experienced some severe adverse reactions to certain medications. She described the large array of medication which she requires, some of their effects, including adverse ones, and problems she has experienced managing that medication. 22. Ms Casey explained occasions when symptoms of her physical and psychiatric injures interact and overwhelm her, to the point that she cannot get up and function, as well as days when she functions better and those when she was at her best and able to pursue activities designed to address her symptoms. 23. Ms Casey also described the physical tasks she could manage and how she accommodated her physical limitations. Ms Casey explained the assistance she had received managing her life at various times and her belief that with two hours assistance twice a week with domestic tasks, she could manage to keep her home in a proper state, as well as assistance which she thought she required with other activities, given her capacities, such as in relation to driving and gardening, for example. 24. On the evidence of other witnesses, despite all of her ongoing problems, Ms Casey appears to have remarkable determination, certain resilience and a drive to look after herself and her family. Despite her injuries and the considerable, ongoing limitations created by the chronic conditions which she suffers as a result of the crash, she persists in her ongoing efforts to deal with her difficulties. To her considerable advantage, her family continues to provide her with significant ongoing support. Despite these positive factors, the evidence provides no basis for any expectation that Ms Casey is likely to recover her health or ability to work. There is but little room for optimism as to Ms Casey's prognosis, given her history. 25. There are some further pain management treatments which might be of some benefit to Ms Casey and a view shared by certain of the experts who have examined and treated her, that if she was able to engage in work, it would be of assistance to her mental state. It is to be hoped that the conclusion of this litigation may also be of assistance to her. On the evidence there can, however, be no expectation of either recovery, or even considerable improvement in her present difficult physical and psychiatric conditions. Even if there is improvement, they will require considerable ongoing treatment in the future. The orthopaedic evidence 1. In their joint report, the treating orthopaedic surgeons, Dr New and Dr Machart, who had also examined Ms Casey agreed that, as well as the physical injuries she had suffered, Ms Casey was suffering from complex pain syndrome. This prevented her from working as a nurse, or performing any other work for which she is reasonably experienced, qualified and educated (see Q4 of the Joint report). 2. That she was totally incapacitated as a result, unable ever to perform any kind of work, was not entirely there agreed (see Q6 of the joint report). On all of the other evidence, I have concluded, however, that there is simply no foundation for the conclusion that Ms Casey will ever be able to work again. 3. Reports of specialists who had treated Ms Casey for her ongoing pain were in evidence. In his July 2010 report, Dr Bodel explained the decision to trial a permanent spinal cord stimulator, to attempt to control the pain in Ms Casey's shoulder and upper limbs. In her October 2010 report, Associate Professor Sandaraj explained that the device had assisted with severe shooting pains Ms Casey had experienced and that it had later been converted to a permanent device. 4. In her December 2010 report, Dr Sandaraj explained the distressing consequences of the infection which Ms Casey had suffered, resulting in the removal of the stimulator, after which her upper limb pain had again increased. 5. In March 2011, the specialist rehabilitation physician Dr Bowers considered that Ms Casey had been unfit for work for six weeks after the crash, but that she should have been fit to return to "any type of work suitable for a woman of her age over a period of three months after that", depending on the adverse effects of her non-organic conditions. He also considered that her physical symptoms should resolve, so that her pain would be ameliorated within six months. 6. Dr Bowers' views cannot be given much weight. They did not accord with Ms Casey's evidence, her ongoing medical history, or with the views of other examining and treating doctors. Nor were Dr Bowers' expectations realised. 7. In his April 2011 report, Dr Bodel considered Ms Casey's prognosis to be guarded; her ability to eat had been significantly impaired; and a return to work severely compromised by her pain syndrome. Unless that altered, he considered that Ms Casey would have great difficulty returning to any form of paid employment. Such an alteration has never eventuated and is not likely, in the future. 8. In his first April 2012 report, Dr Machart considered that Ms Casey's ongoing symptoms required neurological assessment, the severity of her pain and limitations of movement and weakness, not in keeping with other objective signs. In his second April 2012 report, Dr Machart said that Ms Casey's diagnosis was not clear and that it was more of neurological nature than orthopaedic, given the location and severity of her symptoms. A neurologist's opinion was recommended. 9. In his January 2013 report, the neurologist Dr Robin Fitzsimons described Ms Casey's then current symptoms, pain and how the pain syndrome was then affecting her, including by preventing her return to work. She discussed the help which suitable employment might be able to provide Ms Casey, which she considered would require substantial support, but which she hoped might help prevent a vicious cycle of depression and hopelessness. Ms Casey has, however, never been able to pursue such employment. 10. In Dr New's March 2013 report, he explained Ms Casey's ongoing problems with walking, sitting, standing, sleeping, personal relations, social life and travel by car. He then considered her prognosis poor, particularly given her ongoing complex pain and psychiatric issues; that she was unable to work and unlikely to return to her former work; and that she required substantial assistance with domestic and recreational activities. 11. The reports of the neurosurgeon, Dr Timothy Steel, outlined the circumstances in which the decision to pursue spinal surgery was made, given Ms Casey's ongoing pain and other debilitating symptoms, despite the treatment she had earlier received. 12. In his December 2013 report, Dr Steel explained the purpose of the surgery to have been to decrease Ms Casey's ongoing pain, by rectifying structural problems, which would alleviate symptoms and improve her functional capacity. In his April 2014 report, Dr Steel described significant improvement in symptoms after the surgery, but her readmission following right arm weakness and the development of other symptoms. He considered Ms Casey's prognosis to be guarded, it being impossible to be certain as to what other structures might have been damaged, such as ligaments and musculotendinitis insertions. He considered a return to nursing unrealistic and while he hoped for Ms Casey's recovery of normal activities, noted the risk of further degeneration and the need for further surgery. 13. In his May 2014 report, Dr New noted a dramatic deterioration following the surgery to Ms Casey's spine, with increased pain in her neck and arm, but 50% improvement in headaches. 14. In June 2014 another neurologist, Dr Paul Darveniza, reported Ms Casey to have been very distressed and hardly able to give a coherent history. He found her disabilities to be stable and permanent; that she was only fit for light sedentary duties, where she was relatively free to move; and that she was permanently unfit for any duties involving repetitive lifting, bending, stooping or maintenance of any one posture for any length of time. In the result, he considered that she would find it hard to obtain any gainful employment in the open labour market. 15. There is no evidence that this situation has altered, or is likely to improve; that Ms Casey is fit for any employment; or that there is any employment realistically available to her, now or in the future, given her ongoing problems and limitations. 16. Dr Machart examined Ms Casey again in September 2014. He found her history of injuries and diagnostic features consistent and considered that she was unable to work as a result. He considered that her physical injuries were not responsible for the totality of her disability, which was contributed to by her chronic pain and psychological position. He also noted worsening clinical features after recent spinal surgery and considered her prognosis to be guarded. 17. All of this evidence simply provides no basis for any positive conclusion as to likely improvement in Ms Casey's physical condition, or the considerable pain and pain syndrome which she continues to suffer. On the evidence, it must be concluded that she is unlikely ever to be able to successfully pursue employment in the future, given her physical injuries. The psychiatric evidence 1. In evidence are clinical records, as well as reports of psychologists and psychiatrists who have treated Ms Casey and others who have examined her over the years. There was no evidence from a neurologist or MRI scans of Ms Casey's brain undertaken. As Lord Hobhouse discussed in King, the evidence of the damage to Ms Casey's brain and the other parts of her body on which its normal functioning depends, came from clinical observation, including by psychiatrists, who attempted to treat that damage. 2. The documents show that Ms Casey's conditions and their ongoing treatment present significant ongoing challenges, given the nature and severity of her various conditions, the ineffectiveness of available treatments and her ability to tolerate particular drug treatments. Those problems mean that it is likely that she will require further hospitalisation in the future and is unlikely to be able to work again, as a result. 3. In various documents, in the March 2010 report of the psychologist, Mr Zuessman, for example, Ms Casey's resilience, active pursuit of recovery, in order that she could resume her former employment and personal life are referred to. Despite that admirable approach, Ms Casey has not been able to recover her health. 4. The psychiatrist Dr Bruce Westmore examined Ms Casey in February 2011. He considered her psychiatric condition to have stabilised, with the result that she was then moderately to severely disabled and that it was uncertain that she could return to nursing. He noted that she was considering alternative roles. 5. In March 2011, Dr Rastogi reported that, in her opinion, given the level of Ms Casey's irreversible impairment, she would never be able again to work as a nurse and would need to consider another profession. She has never recovered sufficiently to permit her to do so. 6. In his April 2012 report, Dr Klug considered Ms Casey required intensive ongoing psychiatric treatment for severe and chronic PTSD and a chronic major depressive disorder. 7. On a number of occasions Ms Casey has been admitted for treatment in crisis situations, described in Dr Rastogi's October 2012 report to have been triggered by her chronic pain, inability to return to work and ongoing intrusive thoughts and images, with the result that sighting and noises of air carriers causes sudden relapses and acute deterioration. Dr Rastogi also reported a significant deterioration in Ms Casey's health, despite intensive and ongoing treatment and supportive therapy. This was consistent with the other ongoing serious physical problems with which Ms Casey was continuing to contend. 8. In Dr Rastogi's then opinion, Ms Casey had a complex disorder with chronic and permanent damage, which had clinically deteriorated over the last three years and led to dangerous situations, following her realisation and awareness of losses from her premorbid functioning. She concluded that Ms Casey's prognosis was very poor and unlikely to change, given her physical challenges. She considered her pain to be of utmost concern and that her inability to do things, would possibly worsen given that she had been non-responsive to treatment. Worsening symptoms despite intensive treatment was possible. 9. Dr Rastogi then considered that Ms Casey required home care help on a daily basis, contact with services which offered 24 hour crisis intervention, as well as overnight supervisory care, the level of which might need to increase in intensity, during relapse periods. 10. Dr Rastogi also considered that Ms Casey was unlikely to carry any vocational goals in future, given her physical incapacitation, inability to sit or concentrate and the instability of her psychiatric condition. Vocational retraining was considered to be a significant stressor and indicator of a relapse, with any impairment dependent on pain management and ability to use her limbs effectively. 11. In her May 2013 report, Dr Rastogi noted Ms Casey's cooperation with treatment and compliance with management offered to her, including by hospitalisation. She reported, nevertheless, that further deterioration had occurred, with relapses of PTSD symptoms and resulting unpredictable behaviours, despite intensive treatment. 12. Dr Rastogi observed that Ms Casey's ongoing pain had caused permanent limitation of movement, permanent and functional decline, reinforcing her feelings of hopelessness and despair, with the result a chaotic lifestyle, self-neglect and inability to take needed medications. Distressingly, Ms Casey's desire to recover had led her to try harder, causing further physical damage, worse pain and depressive relapses. 13. In the result, Dr Rastogi considered that Ms Casey had become incapable of managing her affairs, due to the acute symptoms of her psychological conditions. She recommended the appointment of a tutor, which later occurred. She also considered that Ms Casey required long term care and supervision during the day and evening, as well as overnight care during periods of acute crisis. These needs could continue indefinitely, given her complex condition, with irreversible physical deterioration, treatment resistant psychological distress and high risk of further relapse. 14. In her June 2013 report, Dr Rastogi considered that Ms Casey required supervisory care for four hours a day, six days a week, with telephonic support on call at other times to provide supportive treatment, intimate crisis management and scheduled activities. 15. Dr Phillips examined Ms Casey in September 2013 and considered various medical reports, including those of Dr Rastogi. In his report of 19 September, he observed that he had found no evidence that Ms Casey was overstating the magnitude of her experiences, that she had given her history in a self-serving manner, or had exaggerated her symptoms. He considered her psychological status before the crash to have been one of normal emotional fortitude. She had not been predisposed to the development of serious psychological illness, but had been faced with a stressor of overwhelming magnitude, which was sufficient to have caused any person of normal constitution to decompensate with the development of a trauma related psychiatric disorder. 16. Those disorders included anxiety spectrum syndromes, depression spectrum syndromes and PTSD, which was a relatively low prevalence disorder, which generally emerged within the first three months after the trauma. 17. Dr Phillips noted the significant physical injuries which Ms Casey had suffered in the crash and her resulting pain. He accepted that: "… some small degree of the plaintiff's pain is likely to be made worse by her ongoing psychopathology, and conversely her ongoing physical pathology will be making some small contribution to her ongoing psychopathology." 1. Dr Phillips also considered that Ms Casey suffered anxiety spectrum symptoms and depression spectrum symptoms, co-morbid with chronic PTSD, which he considered could be subsumed within the single diagnosis of PTSD, which was treatment resistant. He then considered that her chances of recovery were diminishing rapidly, despite Dr Rastogi's careful treatment. All areas of her life were affected as a result. He noted that Dr Rastogi could not see her returning to nursing or any other career, although he considered that every attempt at vocational rehabilitation was worthwhile, because regular employment is a major protector against psychological disorder. Dr Phillips also suggested that a novel Eye Movement De-programming and rehabilitation treatment for Ms Casey's PTSD, might be of benefit. 2. In her April 2014 report, Dr Rastogi advised as to PTSD that: "Although Post traumatic stress disorder has been considered as a neuropsychiatry disorder, numerous studies and evidence based research have confirmed that complex traumatic experiences cause chemical changes in the brain which result in structural changes in brain and toxic changes as evident by neurotransmitter balance changes and physical defects in brain similar to other physical chronic disease and conditions. Posttraumatic stress disorder presents with a constellation of physical symptoms and somatic features with psychiatric co morbidity. This places Posttraumatic stress disorder categorically in chronic physical disorders with significant physical and psychological impairment, It is important to recognise the physical changes that occur in Posttraumatic stress disorder similar to any chronic physical disease which cause toxic milieu and cell death and damage which is irreversible. The areas of the brain where such changes occur are the hippocampus, amygdala and prefrontal cortex." 1. Dr Rastogi referred to the studies which supported this and expressed the opinion that: "The above study is a reflection of close association of PTSD with chronic physical illness and disorders as well as the mechanisms associated with Complex PTSD such as changes in immunoglobulin's[sic], cortisol levels are similar to changes that are seen in cardiovascular disorders and auto immune disorders supporting that PTSD is in fact a physical disorder with psychological sequalae. These psychological sequalae have also been seen in chronic physical disorders such as Ischaemic heart disease, diabetes and hypertension explaining similar pathology." The psychiatrists' concurrent evidence 1. Dr Rastogi, who continues to treat Ms Casey, and Dr Phillips prepared a joint report. They there agreed, amongst other things, that Ms Casey's psychiatric diagnosis was that her functional impairment was in the severe range, with no likelihood that she would in future be able to function in her premorbid capacity. There had been minimal recent change, despite intense treatment, although there was hope for some improvement with further suitable treatment in future. It was agreed that Ms Casey was presently unable to perform any work, but again, there was some room for hope that she might in future be able to perform some kind of work. Given the other evidence which I have received, the room for this hope appears slim. 2. The experts were asked: "QUESTION 18 Assuming that the plaintiff's bodily injuries suffered in the accident are: a) fractures to porcelain veneers of teeth 22 and 23 and cracks at teeth 17,36 and 37; b) C3/C4 and C4/C5 disc bulging to the right of midline; c) Full-thickness chondral fibrillation (grade 3) chondral wear patellofemoral joint; and d) Low-grade synovitis involving the facet joint region of C2/C3 on the right; ("bodily injuries"), to what extent, if at all, are the plaintiff's psychological injuries caused by her bodily injuries? Joint answer: On the assumption Ms Casey has physical injuries, involving a variety of body parts and bodily functions, there is a known association between physical injuries and the onset of major depressive disorder and generalised anxiety disorder. To the best of knowledge the link between pure physical injury and PTSD is less. PTSD and physical injuries interplay each other. Physical injuries are an exacerbation of psychological symptoms rather than the cause. There is evidence to link chronic regional pain syndrome and Major Depressive Disorder and General Anxiety Disorder. Dr Phillips notes that he finds it hard to speak with any certainty about the plaintiff." 1. In their concurrent evidence Dr Rastogi and Dr Phillips agreed that PTSD is primarily caused by an overwhelming psychological experience, which physical disability, acute or traumatic, can exacerbate and that there is a vague link between PTSD and physical injury per se. They were largely agreed about Ms Casey and her conditions, although there were some important differences between them. Both experts considered, however, that in Ms Casey's case, it was somewhat artificial to attempt to separate her PTSD from her other disorders. 2. The experts had also been asked when Ms Casey had first suffered her psychological injuries. The views recorded in the joint report were: "Dr Rastogi: It is hard to give an exact timeline of when the patient suffered these diagnoses. However, I am of the opinion that the Plaintiff suffered the co morbid disorders (Major Depressive Disorder and General Anxiety Disorder) as part of the PTSD. Dr Phillips: On the basis of his history with the Plaintiff in September 2013, the plaintiff started a process of psychological decompensation within days of the trauma with evolution of symptoms of PTSD early in the piece and a steady evolution of symptoms over a period of weeks and months, reaching a point where the 3 above mentioned diagnoses (PTSD, Major Depressive Disorder, General Anxiety Disorder) could be made." 1. The experts were asked their opinions as to Ms Casey's treatment and prognosis, if her PTSD was not taken into account. This was a difficult exercise in their view, given the nature and interaction of her various conditions. 2. It was agreed that Ms Casey was suffering severe treatment resistant major depressive disorder, which required intensive treatment and had poor outcomes. Her severe pain disorder was associated with it. She would experience that without the PTSD. It was difficult to predict the length of treatment she would require, if she did not have PTSD, but it was agreed that the core medication used to treat her various disorders were similar. 3. Dr Phillips considered that the acute phase of Ms Casey's depressive disorder had been caused by the experience of the ditching, escape and survival in the ocean and in the longer term, the disorder had been exacerbated by problems of ongoing physical pain. Likewise, acute anxiety was first experienced and then a chronic generalised anxiety disorder developed and persisted. The combination of physical and psychiatric injuries and ongoing pain made her recovery more difficult. Such severe, ongoing treatment resistant pain was also likely to cause some kind of associated psychological symptoms, not necessarily anxiety. 4. The experts agreed that if Ms Casey's PTSD was not taken into account, that she was also suffering two other major, treatment resistant disorders. While those disorders were generally easier to treat and had a better prognosis than PTSD, it was also necessary to consider that she suffered considerable pain, with the result that treatment of her other conditions was more difficult. In the result, they agreed that Ms Casey's prognosis would remain poor, even if she had not suffered PTSD. 5. The experts also explained that pharmacological treatments for Ms Casey's major depression, anxiety and PTSD were similar, involving differing doses and multiple medications, depending on intensity and severity of symptoms and multiple modalities of symptoms present. 6. They agreed that a particular alpha-androgenic blocking agent could be used to treat traumatic nightmares in PTSD, which don't exist to the same intensity in the other disorders. Different behavioural or psychotherapy treatments can be used for these disorders. In PTSD there is also a novel behavioural therapy, eye movement desensitisation therapy, directed at altering how traumatic memories are stored and accessed in the brain, which has not yet been attempted with Ms Casey. 7. The experts also agreed that generally, depression and anxiety do not take so long to treat as PTSD, which is a relatively rare syndrome. If Ms Casey had not suffered PTSD, she was still, however, likely to have suffered depression and anxiety disorders, particularly given her very severe pain. It was also agreed that vocational rehabilitation was a positive treatment for depression and has good outcomes. Dr Phillips deferred to Dr Rastogi's view, however, that given Ms Casey's physical impairments and their deterioration over time, and her ongoing pain, retraining and employment were not available to Ms Casey. 8. It was also agreed that the acute phase of Ms Casey's major depressive disorder was originally caused by the accident, escape and survival in the ocean, but that it had been added to and exacerbated by her ongoing pain. 9. Importantly, for the question of whether Ms Casey's PTSD was a compensable bodily injury, the experts also agreed that Ms Casey's disorders can intermittently and chronically lead to functional impairment, which reflects an alteration in a brain function, which was explained to be changed patterns of neurotransmitter activity and chemical changes in the brain. They agreed that the current state of scientific knowledge of brain functioning is greater in relation to depressive disorders than the other disorders which Ms Casey suffers, but that the physiological changes associated with the three disorders, depression, anxiety and PTSD, overlap. 10. The experts also agreed that as the result of developments in scientific research, it is also now known that there are a number of chemical neurotransmitting agents important in brain functioning. They relay signals which regulate mood states, appetite, emotional reserves and help with other bodily functions. 11. Medication used to treat various psychiatric disorders, including depression and PTSD, for example, such as antidepressants, are now understood to work by altering neurotransmitter pathways. Research suggested that pharmacological therapies assist in increasing levels of chemicals such as serotonin and noradrenaline in the body, or allowing better use of those chemicals in the brain. Such chemicals, serotonin, for example, are produced both in the brain and elsewhere in the body. 12. The experts also did not consider it helpful to seek to distinguish between physiological changes in the brain associated with the event which had caused these changes, and the chronicity of that illness. Conclusion 1. It is on the basis of all of this evidence, that I have come to the conclusion that the PTSD which Ms Casey developed and continues to suffer is not merely the result of an injury to her mind, caused by the shock, fear and other emotional trauma caused by the crash. It must be concluded, on the balance of probabilities, that Ms Casey's PTSD also involves an injury to her brain and other parts of her body involved in normal brain function. This is a psychiatric injury caused by a physical route, as Lord Hope discussed in King. 2. During the crash Ms Casey's body was seriously injured when she was violently flung around, while restrained in her seat. She was further injured as she tried to escape, including when she was struck to the head by the wing of the sinking plane. Ms Casey suffered injuries to her head, brain, neck, nerves, teeth, spine, knee, leg, shoulder and was left in a state where her brain was no longer able to function normally, in various different ways. 3. Despite extensive treatment, neither her brain or the other injured parts of her body have recovered their normal functioning. Ms Casey not only suffered ongoing pain and physical limitations from those injuries, some of which have deteriorated over time, but she also developed complex regional pain syndrome and three treatment resistant psychiatric conditions, major depression, an anxiety disorder and PTSD. 4. The evidence is inconsistent with Ms Casey's PTSD, alone of her three psychiatric conditions, being caused only by the shock, fear and emotional trauma of the crash. On the evidence, its cause cannot be separated from the causes of the other two psychiatric conditions which she suffers and their consequences, including her ongoing problems with memory, concentration and other normal brain functions. The ongoing dysfunction of Ms Casey's brain, despite pharmacological and other treatment designed to treat all three conditions, is also consistent with chemical changes in her brain and body and alterations in her brain's neurotransmitter pathways, which have prevented a return to normal brain function, despite intensive treatment. As Lord Hobhouse discussed in King, this was treatment directed at a physical condition, which can be reversed or alleviated by physical means. 5. There have been adverse interactions between the physical injuries to her body and brain, the three psychiatric conditions and the pain syndrome from which she also suffers. This has also adversely affected Ms Casey's ability to respond to the treatments she has received for her three psychiatric conditions and her ability to cope with her physical injuries and the ongoing pain they cause her. 6. The conclusion that Ms Casey's PTSD, like her other two psychiatric conditions, has a physical cause and/or is a manifestation of the injuries to her body and brain and not simply the result of an injury to her mind, is also supported by the evidence that her memory has been adversely affected and that there is available a novel behavioural therapy treatment for her PTSD, eye movement desensitisation therapy, which is directed at altering how traumatic memories are stored and accessed in the brain. That treatment has not yet been attempted. 7. In the result, it must be concluded that the PTSD which Ms Casey suffers, like her anxiety and major depression disorders, is also a bodily injury compensable under Art 17 of the Montreal Convention and the Act. Ms casey's Damages 1. Ms Casey's case that the bodily injuries she has suffered were significant and serious, resulting in significant impairment of function, which had prevented her from working from November 2009 and made it unlikely that she will work again in the future, was established by the evidence I have discussed. One of the results was that Ms Casey could no longer manage these proceedings and her mother was appointed her tutor. That development has to be taken into account in assessing the damages. 2. But for her injuries Ms Casey would have continued functioning at a high level, pursuing her career, personal interests and family life, as she had done before the crash. 3. In the result she is entitled to damages assessed in accordance with the provisions of the Civil Liability Act. Non-economic loss 1. Ms Casey claimed non-economic loss calculated at 90% of a most extreme case. On Pel-Air's case, if her PTSD was compensable, this loss would be assessed at 70% of a most extreme case and if it was not, it would be assessed at 40% 2. Most regrettably, Ms Casey's prognosis is very poor. The evidence establishes that she will require extensive ongoing treatment for her physical and psychiatric conditions in future, including during further hospital admissions. To her ongoing embarrassment, she will require considerable care and is unlikely to be able to work in future. She has been deprived not only of fulfilling work and a long-term career, but her ability to care for her family and much of her enjoyment of life. She has been left by the crash in what must be described as a pitiable condition, the result not merely of her physical and psychiatric injuries, but also the pain which her physical injuries continue to cause, despite extensive treatment. The ongoing limitations which are the result are unquestionably difficult for her to bear. 3. I consider that fairly assessed Ms Casey must be assessed at 80% of a most extreme case. Given the nature of her injuries, her psychiatric conditions, the complex pain syndrome which she also suffers and their ongoing interaction and consequences, even if she was not suffering PTSD, her circumstances would not be considerably different. 4. In the result, even if the conclusions which I have reached as to Ms Casey's PTSD being compensable under the Civil Liability Act were incorrect, the result in my view would be that her non-economic loss would be assessed at 70% of a worst case. Economic loss Past economic loss 1. The parties were agreed as to the orders which would reflect Ms Casey's damages for past economic loss, other than in relation to PTSD. That issue has been resolved by the conclusion that I have reached, that in Ms Casey's case, that condition is also compensable. 2. Had I not arrived at that conclusion, there would have been no different result in relation to this head of damage. On the evidence, even if she had not suffered PTSD, Ms Casey's past economic loss would have been the same, given the consequences of her other injuries. 3. Pel-Air's case, that 20% should be allowed to reflect a residual earning capacity, which Ms Casey would have retained and which was only lost because of the PTSD which she suffered, is a conclusion simply not available on all of the evidence which I have already discussed. Given the ongoing consequences of her physical condition and her other psychiatric conditions, even without the PTSD she would not have had any residual earning capacity. Future economic loss 1. Pel-Air submitted that future economic loss should be calculated on a net figure of $1,098.387, referable to Ms Casey's pre-injury earnings. Ms Casey relied on evidence of the higher earnings she would have earned, had she continued in CareFlight's employ, as a Nurse Educator Year 2 under the Nurses Award 2010, revealed by a letter provided by CareFlight in December 2012. 2. On that evidence it must be accepted that Ms Casey would have achieved earnings at that level, but for the crash and that accordingly, her damages must be calculated by reference to the higher average figure for which she contended. 3. On all of the evidence I have already discussed, regrettably, there is simply no basis on which it is open to conclude, as Pel-Air submitted, that Ms Casey will ever recover her health to such an extent that she will work again, given her physical and psychiatric conditions. 4. A December 2009 workplace assessment report considered treatments which might be available to help Ms Casey recover from her symptoms and to manage her pain, particularly neck pain and what steps might be available to permit her to return to work as a care flight nurse. Her attempts to return to work failed, despite the extensive treatment, including physiotherapy treatment which she received, consistent with her ongoing disabling physical and psychiatric conditions and the results of her complex pain syndrome. 5. In a September 2010 report, the complications which prevented Ms Casey's return to work were considered. Later reports reveal that despite Ms Casey's desire to return to work and her pursuit of recommended treatments, she has never sufficiently recovered her physical capacities to permit her to perform even the part-time office-based duties initially in contemplation. 6. Even if Pel-Air's case in relation to PTSD had succeeded, a conclusion that Ms Casey will ever be able to work again, would not have been available on the evidence, as I have explained. Accordingly, its submission, that s 13 of the Civil Liability Act requires that an award for future economic loss should be reduced by 40%, rather than the usual 15% discount for vicissitudes, to reflect the loss of earning capacity purely attributable to her PTSD, must be rejected. 7. Further, contrary to the case advanced for Pel-Air, as discussed in Mead v Kerney [2012] NSWCA 215 at [25]- [27], Pel-Air had the onus of establishing that Ms Casey has a residual earning capacity, by adducing evidence of what work she was capable of performing, what jobs are open to a person with such capacity and what earning such work is likely to produce. It cannot simply be inferred from the fact that she is a highly trained nurse and that she is capable of further training, that, accordingly, there would be administrative work, of some kind, which she could perform. While that accords with the evidence of Ms Casey's past approach to her work and her resilience and determination, it pays insufficient attention to the evidence of the ongoing effects of her complex physical and psychiatric injuries and the impact of the pain which she suffers. 8. Further, even if Pel-Air's case that Ms Casey could recover to perform desk or administrative work could be accepted, there is simply no evidence that such work is practically available to her, or what earnings it would result in. 9. In the result, Pel-Air's submission that there should be a 25% deduction, to permit for the possibility that in future Ms Casey might be able to undertake some level of employment, rather than the usual 15% proposed for Ms Casey, also cannot be accepted. Superannuation 1. There was no issue between the parties as to how past and future loss of superannuation would be calculated. Out of pocket expenses Past expenses 1. There was, again, an issue lying between the parties in relation to the consequences of PTSD. Pel-Air submitted that if it succeeded, these expenses should be reduced by 25% to reflect PTSD treatment. That cannot be accepted. 2. Such a deduction would not reflect the evidence that psychiatric treatment would still have been required for Ms Casey's other conditions and that the same pharmacological treatments had been used to treat the three conditions she suffers. It also overlooks the evidence of the interaction between Ms Casey's conditions and the exacerbation which resulted from the impact of the pain syndrome on those conditions. 3. In my assessment, at most any reduction to exclude treatment of PTSD would be assessed at 10%. Future expenses 1. What lay between the parties included future psychiatric treatment costs. Pel-Air also challenged future treatment needs for pain management, treatment of other physical injuries, including to Ms Casey's teeth, knee, neck and arm, and a need for funds management in future. 2. It was conceded that medication would be required in the future, including for pain management. Psychiatric care 1. Ms Casey's claims for future psychiatric treatment rested on the evidence of Dr Rastogi, with whose past treatment Dr Philips agreed. They also agreed as to short-term treatment of all of her conditions. Pel-Air's case was that these future expenses would have to be discounted, if it succeeded on its PTSD case. It has not, but if it did, I consider that a reduction of only 10% in such costs would be a reasonable assessment on the evidence as to the consequences of Ms Casey's other conditions and their exacerbation by her complex pain syndrome, given the evidence that the same treatments are used for her various psychiatric conditions. 2. Pel-Air did not accept Ms Casey's claims, which rested on Dr Rastogi's assessments explained in her November 2012, May and June 2013 and April 2014 reports, as to what she anticipated Ms Casey's complex and deteriorating conditions would require by way of future treatment. It argued that a further one to two years of intensive treatment should be provided for, but the evidence did not establish a requirement for a psychotherapy regime beyond that. In oral submissions it was accepted that the psychiatrists' silence on what might be required afterwards, was that there would be continued requirement for medication and ongoing consultation with a psychiatrist, psychologist and phone counselling, at a lower level of intensity. 3. By May 2013, Ms Casey had been admitted to a clinic on seven occasions, she attended a day clinic on a weekly basis and had regular fortnightly follow ups with Dr Rastogi, apart from periods of hospitalisation. Dr Rastogi had conferred with Ms Casey's mother and had considered Ms Luft's occupational therapist report. It is not necessary to further outline the sad circumstances described in her reports, which are also revealed by the clinical records in evidence. 4. Ms Casey's claims for weekly group therapy, reviews by a psychologist every three weeks, ongoing treatment by a psychiatrist, medication and hospitalisation, must all be accepted as reasonably necessary, given her past history, poor prognosis and the common views of Dr Phillips and Dr Rastogi, including in relation to the impact of ongoing pain on Ms Casey. 5. The claims for future hospitalisation was also supported by Dr Klug's evidence. He also envisaged various further treatments being necessary, including during hospital admissions and an inpatient adult trauma program, as well as indefinite treatment by a psychiatrist and further treatment by a psychologist, her prognosis being linked to her ongoing physical problems. He was not called and his opinions were unchallenged. Funds management 1. Dr Rastogi's opinion that Ms Casey is incapable of managing her future affairs must be accepted, consistent with her mother's appointment as her tutor, in June 2013 and with the evidence of other witnesses, as to the pitiable state to which Ms Casey has on occasions been reduced, by the pain she suffers and its interaction with her psychiatric conditions. Dental care 1. Ms Casey suffered immediate injury to her teeth during the high velocity crash, some of which was latent and has over the years materialised, requiring further dental treatment. 2. Her response to the ongoing chronic pain which she suffers has resulted in further damage, requiring other treatment. Dr John Wells' report of July 2013 identified her future needs, which were unchallenged, must be accepted. GP and pain management physiotherapy and hydrotherapy 1. Ms Casey's claims rested on reports of Professor Cousins, Dr Lam, a pain medicine specialist, Dr New and the joint report of Dr New and Dr Machart. The claim for painkillers was corrected to be $45 per month. 2. In his April 2013 report, Dr Lam diagnosed Ms Casey to be suffering Complex Regional Pain Syndrome Type 1 and described its symptoms, past treatment and future management. He said that there was no cure for her condition. He recorded Ms Casey then describing the pain she suffered to be constant, with paroxysmal attacks. It was variously described to be sharp, stabbing, dull, aching paraesthesia, hot, burning, throbbing, electrical and shooting. It was accompanied by discolouration, swelling, hyperhidrosis and her right arm feeling very cold. Pain also radiated from her right shoulder, down her right arm. It was associated with headaches, allodynia, hyperalgesia and dysaesthesia. It was exacerbated by use of the right arm 3. Dr Lam referred to the alternate pain treatments which Ms Casey had been receiving, including physiotherapy, hydrotherapy, acupuncture, spinal cord stimulator and nerve blocks, as well as pain killers and anti-inflammatory drugs. He described worldwide evidence that such a syndrome required an intensive multi disciplinary pain management program, including cognitive behavioural treatment, physical therapy, education in pain coping strategies and pain management skills. 4. He considered that healthcare professionals needed to provide Ms Casey with reassurance and encouragement, to work towards functional goals, rather than waiting for pain to be relieved. He also considered that Ms Casey would require analgesia prescribed by her GP every 3-4 months, an integrated treatment with a one off cost of $7,588, as well as changes to her spinal cord stimulator every 10-15 years, at a cost of $15,000. 5. In his December 2013 report, Professor Cousins, who had removed Ms Casey's spinal cord stimulator on referral for Dr Lam, took the view that Ms Casey's pain in the neck, shoulder and right upper extremity were all part of her complex pain syndrome, and that her symptoms were likely to persist for many years. He considered her current regime of medication to be reasonable, necessary and appropriate. 6. In their joint report, Dr New and Dr Machart also considered that Ms Casey would require ongoing treatment for her knee, which also required ongoing pain management by a pain management team. 7. Pel-Air noted that Dr Lam's report, which described the pain Ms Casey suffered, how it impacted her daily life and sleep, and the medication and other treatment she had received, but provided no details for the cost of analgesia or a basis for a claim for supplements. 8. I, however, am satisfied that all of the evidence as to Ms Casey's ongoing pain and its treatment, including that which I earlier referred to, provides a proper basis for an award for painkillers and other treatment calculated at $45 per month, together with six GP visits a year, as claimed. 9. The claim for physiotherapy was also not agreed. Ms Casey claimed $70 per week, $3,640 per annum. Pel-Air submitted that this should be assessed at $800 per year for five years. 10. Dr New and Dr Machart considered various treatment which Ms Casey would require, identifying particular treatment required for her neck and knee. There was also knee replacement at a future cost identified to be $20,000 by Dr Machart and possible extension to cervical fusion, at a cost of in excess of $50,000, physiotherapy and lifetime pain management, which was difficult to define, including psychological care. Dr Machart considered that physiotherapy would be required for five years, Dr New that it would be on an as needs basis, for an undefined time frame, during which there would be periods when less therapy would be required. 11. Pel-Air's case was that Dr Lam's report provides no reason as to why Ms Casey required this treatment or its cost and that in the circumstances, Dr Machart's opinion should be accepted. 12. All three doctors agreed that Ms Casey required ongoing physiotherapy treatment. Dr Lam's report explains why that will be needed in the long term, given that there is no cure for her complex pain syndrome and that it is best treated by a pursuit of functional goals, rather than simply waiting for pain to be relieved. There was also concern about dependence on pain medication. Dr New's observation that there will be times when Ms Casey needs more treatment than others, must also be accepted in the face of all of the evidence. 13. Accordingly, I am satisfied that a basis for the physiotherapy claim has been established, assessed at $3,000 per year. Hydrotherapy 1. The claim for hydrotherapy was also not agreed. Pel-Air did not call evidence from a pain management specialist. Dr Lam's unchallenged report refers to the hydrotherapy treatment which Ms Casey was receiving and explains the importance of the pursuit of functional goals, through treatment rather than reliance only on pain medication. 2. In his 28 May 2014 report, Dr New also referred to Ms Casey's ongoing need for pain management, including by hydrotherapy and physical therapy. 3. The orthopaedic surgeons, Dr New and Dr Machart, did not refer to hydrotherapy treatment in their joint report, but explained their difficulty in answering Pel-Air's question about Ms Casey's future treatment needs. Dr New explained that often, patients did not pursue physical treatment when there was active treatment for a mental issue in place. Dr Machart said that he was not a pain manager and could not discuss that treatment or its costs. 4. The evidence did not address the frequency of the hydrotherapy treatment or its cost. Pel-Air submitted that the lack of particulars ought to result in the claim being refused. That this claim was not so particularised, does not prevent such claims being pressed, if there is evidence to support it (see Dare v Pulham [1982] HCA 70; (1982) 148 CLR 658 at 664). Where evidence is admitted without objection, which tends to establish a claim for damages higher than claimed in particulars earlier provided, orders reflecting that evidence may be made. What will result in a particular case depends on the overriding principle said in Nestle Australia Ltd v McDougall [1998] NSWCA 158 (Beazley JA, Mason P and Powell JA agreeing) to be one of fairness. 5. Like in that case, here Pel-Air had the relevant information as to Ms Casey's past treatment, which included hydrotherapy. It was not suggested that what was claimed departed from what had been incurred in the past. Had there been any real issue about the cost of that treatment, or whether it was reasonably necessary in future, it could have been addressed when Ms Casey was cross-examined. It was not. 6. In the result, I am satisfied that Ms Casey's claim for weekly hydrotherapy, at a cost of $50 per week, must be granted. Knee, neck and arm 1. Ms Casey's claim was for $15,000. Pel-Air submitted that a buffer of $5,000 was appropriate. 2. Ms Casey has a life expectancy of some 40 years. In the joint report Dr Machart identified the treatment likely for Ms Casey's right knee to be physiotherapy, steroid injections, arthroscopy, arthroscopic realignment and a replacement knee as possible, but he could not say what was likely to be needed. Dr New considered that surgeons would be conservative and may steer away from arthroscopy, with more minor measures preferable in the more immediate future. They both considered a knee replacement to be possible, with that possibility being assessed by Dr Machart to involve a 25% chance. 3. In the result, having considered this and other evidence earlier mentioned, I consider a buffer of $10,000 to be appropriate. Past and future care 1. Pel-Air's case was that Ms Casey's disability to her right arm had necessitated some gratuitous domestic care in relation to heavier household duties, but it argued that the evidence as to how much assistance she had received in the past, was unclear. It conceded that objective evidence supported a conclusion that there had been approximately three hours per week of such care provided, consistent with her right arm not being completely disabled, as Ms Casey had acknowledged and the video evidence had confirmed. 2. Pel-Air's submitted that in the result, Ms Casey's care requirements did not meet the threshold specified in s 15(3) of the Civil Liability Act, of at least six hours per week, for at least six consecutive months. 3. Pel-Air also argued that with adjustments to suit her physical limitations, Ms Casey could cook, shop, carry loads and drive for limited journeys, but it was accepted that heavy housework and gardening would be beyond her. Given that she could not work and the evidence she tried to do as much as she could herself, Ms Hammond's assessment that she had required assistance of three hours per week, in the first year after the accident and then from 3 September 2012 to 25 July, 1.08 hours, would be accepted. 4. Those submissions cannot be accepted. Ms Casey has in the past received voluntary care in excess of the statutory requirement and will in future require considerable ongoing care, given all that she continues to suffer. Her needs cannot justly be assessed by reference only to her physical injuries, as Dr Rastogi and Dr Phillips agreed. Past care 1. Attendant care services are defined in s 15 of the Civil Liability Act to mean: "(a) services of a domestic nature, (b) services relating to nursing, (c) services that aim to alleviate the consequences of an injury." 1. The evidence well establishes that since the crash Ms Casey has received such care, in excess of the statutory requirement from her parents and children, particularly as they grew older. She received ongoing assistance with domestic tasks which she undertook previously for herself and her family, as well as assistance which she herself required, to alleviate not only the serious physical consequences of her injuries and the pain which they caused her but also the consequences of the psychological conditions which she suffered. 2. Ms Casey, her children and parents gave evidence about these matters, which is not open to doubt, consistent as that evidence was, not only with that of other witnesses, but with Ms Casey's medical history. That history includes repeated hospital admissions for various treatments. It is not necessary to refer to all of that evidence. It is sufficient to refer to that which Ms Casey gave and that which her daughter, Jemma, and her mother gave. I have no doubt that their evidence was honestly and frankly given. It was supported by and consistent with evidence given by other of Ms Casey's family members. 3. Ms Casey was cross-examined as to the type of light activity that she was now capable of undertaking, in relation to what she could be seen doing on the video in evidence, which included taking down tinsel Christmas decoration from a veranda at the front of her home and minimising use of her right arm when carrying shopping, and on one occasion, a roll of shade cloth. She explained how she had dispensed with some past commercial care she had been provided, because of embarrassment at her need for help, which she found difficult to accept. 4. Ms Casey's daughter, Jemma, who was aged 15 at the time of the crash, was required for cross-examination. In her first statement, Jemma said that before the crash Ms Casey had looked after her children and the house. Afterwards she was in a lot of pain and kept to her room. After she had recovered from the initial effects of the crash, Ms Casey gradually tried to do a bit more, but tended to start, but not finish things. Over time, Jemma came to realise her mother would not get better. She described her spending a lot of time lying down and telling her that she could not escape the pain, which was with her all of the time. On occasions she was in so much pain she needed her help to do her hair or dress, but she was very independent and did not like to ask for such help. 5. Ms Casey's parents had visited regularly, doing the cleaning, cooking and shopping. Jemma described the house often to be in chaos. When it was tidy, she knew her grandparents had been there. Often they were still there when she came home from school. She and her brother Jesse had helped with cooking and after a long time, Jesse had taken over the shopping. She described her mother seeming to be "out of it" a fair bit of the time, spending a fair bit of time in hospital in 2011, when she would have to look after the house and her siblings at home. Her father would come over then and bought them food. 6. When her grandparents were not there, her mother often wasn't able to cook and on occasions there was not enough food in the house and they went to eat at their grandparents' home. She was the one who ended up doing most of the cooking, although her sister Amy helped, but she was not at home as much. In 2010 she was making dinner three or four times a week. She was missing a lot of school. In 2011, she was spending an hour cooking three or four days a week and two hours a day on other forms of housework. 7. Since she had returned home in 2013, Jemma cooked most meals and did as much of the housework as she could, as well as keeping her mother company, to distract her from her problems and checking on her medication. On average she was spending two hours a week on actual physical work. 8. In her second statement, Jemma said that even while living away from home between January and November 2013, she was going home nearly every day, to keep her mother company and help with chores. She found her mother on occasions unable to look after herself, slow in her movements and speech, sleepy, unkempt and still in her pyjamas. 9. After her return home she took on various household tasks, shopping and the heavy washing. Her mother tried to do what she could with household work and cooking, because it made her feel better 10. Jemma agreed in cross-examination that she had assisted with chores, such as dishwashing, vacuuming, mopping, cleaning, work of a kind she had helped her mother with before, but which had increased after the accident. Afterwards she also helped with cooking, three or four nights a week. Her grandmother then quite frequently also helped. She also confirmed that she could not recall the frequency with which she had performed various tasks on which she estimated on average having spent two hours per day. When giving her evidence she was receiving a carer's allowance. 11. In her first statement, Ms de Brouwer described Ms Casey having been overwhelmed by what had happened to her. Until the beginning of 2010 she was very confused and bewildered, functioning at a very low level. She and her husband had to be with Ms Casey almost every day. She tried to be there in the afternoons, when the children came home, when she attended to housework, Ms Casey's personal needs and cooking a meal. Up to March 2010, Ms de Brouwer estimated spending eight hours a day, seven days a week on these activities. 12. From that time Ms de Brouwer said Ms Casey gradually became more involved, really trying to overcome her ongoing problems. When the nerve blocks were inserted in her neck, first in October 2010, she had some relief, but only for a few days. Ms de Brouwer continued her almost daily visits to help Ms Casey with the children, cooking and housework, but for shorter periods. Often things were left undone and she would try to catch up, unobtrusively. She and her husband also did the shopping. Ms Casey tried, but often said "it's overwhelming me". 13. Ms Casey could manage to get to her nearby GP, physiotherapist and hydrotherapy, but Ms de Brouwer and her husband also had to transport Ms Casey to her various other medical appointments, which never took less than three hours. Ms de Brouwer estimated otherwise spending on average two hours a day, five days a week helping Ms Casey and six hours a week shopping. 14. This pattern continued until the end of 2011, with periods of improvement, when Ms Casey could manage more herself, and then periods when she could do nothing and periods when she required hospitalisation. Over time the children were able to do more and in October 2011 the shopping had come to be managed by Ms Casey with Jesse's assistance. Still Ms de Brouwer was calling in most days. To October 2011 Ms de Brouwer estimated spending one hour a day, four to five times a week, with an additional hour spent providing care such as checking medication and trying to reassure Ms Casey, as well as additional time spent taking her to medical appointments. 15. During 2012, Ms de Brouwer tried to step back, but Ms Casey was still struggling, contending with depression and unrelenting pain. During 2011 and 2012, she estimated having spent 250 hours taking Ms Casey to medical appointments. She and her husband had also assisted when twice she had to move homes. 16. There were also times when Ms de Brouwer took the children to her home, to give Ms Casey a break and being concerned that there were occasions when they were not having meals at home. On occasions they had brought Ms Casey home to care for her, when she had resisted hospital admissions. 17. In 2013, Ms de Brouwer had restricted her visits to once or twice a week, but still spoke to Ms Casey every day. Her ex-husband had also rented a house nearby, to spend more time with the children and to assist Ms Casey. Her son was providing her with more assistance, after her two daughters had moved out of home. Ms Casey had hospital admissions in 2013, including for further spinal surgery, which was hoped would give her pain relief, which did not eventuate. 18. In Ms de Brouwer's second statement, she referred to Ms Casey undergoing further surgery to her neck in March 2014. She described her being in an awful state beforehand, lying down, unable to tolerate light, not functioning and unable to look after herself, or her house. She then obtained some relief from unremitting headaches, but not with pain in her neck, arm and shoulder. 19. Ms de Brouwer also described Jemma's almost full-time care for Ms Casey allowing her and her husband to be less involved in her care, but she still called in three or four times a week and rang Ms Casey everyday. She described ongoing problems, including with weight loss. If Ms Casey was low and Jemma was not there, Ms de Brouwer went over. 20. In the face of all of this evidence, I am satisfied that the claims finally pressed for Ms Casey by reference to the submissions marked mfi 7, which had regard to the differing times at which care was provided and by whom, should be allowed, from 18 November 2009. 21. Reference was made to the observations of Hodgson JA in relation to similar provisions of s 72 of the Motor Accidents Act 1988 (NSW) in Matchan v Lyons [2003] NSWCA 384; (2003) 40 MVR 466 at [5] that: "[5] ... a plaintiff seeking compensation for unpaid domestic care should prove what domestic tasks he or she previously did and does not now do, that this is due to the relevant injuries and disabilities, and that these tasks are now done for the plaintiff otherwise than as part of the fair give and take of family life." 1. I am satisfied that Ms Casey has met that onus. Further, there is ample evidence that attendances on Ms Casey included attendances by her mother in order to comfort her in ways reasonably necessary for the alleviation of her pitiable conditions. This must be taken into account on this head, given the provision made in s 15(3). Future care requirements 1. The parties also differed as to the cost of self-care, Ms Luft assessing the cost at $234.57 and Ms Hammond $249. Ms Casey's submission that the average figure should be used, should be accepted. 2. Contrary to Ms Hammond's assessment, the evidence establishes that Ms Casey is only able to drive short distances to shop and attend medical appointments and needs to be driven for medical appointments further away. A claim for one hour a week, with an allowance for mileage calculated at a cost of $50, should be accepted as reasonable on all of the evidence. 3. Ms Casey pressed a figure of 6.7 hours per week domestic care in future, in accordance with Ms Luft's assessment. I consider that this reflects a reasonable assessment of Ms Casey's needs, having regard to the evidence I have referred to. 4. Pel-Air contended that Ms Hammond's assessment of 1.5 hours per week, plus assistance with lawns and car cleaning should be accepted. For reasons already explained in relation to the past care which Ms Casey has received, I have concluded that Ms Hammond's assessment cannot be accepted as properly reflecting all the assistance which Ms Casey reasonably needs in future. It does not accord even with Dr Philips assessment of four to six hours per week, given her psychiatric condition. 5. There was also a claim for assistance with leisure. Ms Luft assessed this at two hours per week. This was supported by Dr Rastogi and Dr Phillips' agreement in the joint report that Ms Casey would be assisted by pursuing physical exercise. Ms Hammond considered that the psychiatric nurse could provide such assistance. On the evidence, I am satisfied that these claims should also be allowed. 6. Dr Rastogi and Dr Phillips also agreed with desirability of the continuation of the regular contact with Ms Casey arranged by the insurer. This should be allowed at a cost of $30 per week. 7. The evidence also establishes a need for overnight supervision which has been provided by family members, who will not in the future always be available to provide such care for Ms Casey. I consider that a basis for the claim for seven nights per year has been established on the evidence I have discussed. What is claimed is reasonable and must be allowed. Dr Helm's injuries 1. Dr Helm swore two affidavits, the first in September 2013 and the second in January 2015. Pel-Air did not dispute his description of the difficulties he encountered from the injuries which he suffered in the crash. It served a report from Dr Lindsay, an anaesthetist, who described ways in which an anaesthetist may avoid pressure on his back. He was not finally called, Dr Helm's evidence as to these matters being accepted as sufficiently joining issue on the matters dealt with by Dr Lindsay. 2. Dr Helm was a qualified doctor training in anaesthetics and intensive care specialties in the United Kingdom, when he took a break from his studies and pursued a 12 month appointment with CareFlight in Australia. Dr Helm's evidence was supported by that of his wife, Ms Stacey Sharman and Dr Christopher Jones, with whom Dr Helm worked at CareFlight. They were not required for cross-examination. 3. At the time of the crash Dr Helm was 32, a very fit and active man, who ran marathons, skied, raced mountain bikes, cycled road bikes almost daily and played competitive rugby league. He was not suffering any pre-existing conditions. Dr Helm was then engaged to Ms Sharman. They have since married, have two children and live in the United Kingdom. 4. Dr Helm was planning to return to the United Kingdom to finish his specialty studies in anaesthetics and intensive care and then to work in the British NHS medical system, at a hospital, as well as a specialist in private practice, after his CareFlight appointment. He there intended to pursue a similar career path to that which Dr Jones described in his evidence. 5. Dr Helm was also considering the possibility of returning to Australia to practise his specialty here in the future. At the time of the hearing he was in Australia undertaking further studies, as part of his specialty training. He and his wife proposed to purchase a house on their return to the UK, when he will complete his studies and begin his work as a specialist. 6. Dr Helm was much less seriously injured in the crash than Ms Casey. He suffered scratches, bruising and multiple soft tissue injuries, as well as an injury to his spine. Dr Helm had some weeks off after the crash, during which he sought treatment, which included seeing a psychologist. He then returned to work where he performed modified duties for CareFlight with some discomfort, for which he was treated. He did not consider that he had suffered any permanent psychological problem, but the pain in his back has not gone away and has gradually become worse. 7. Dr Helm has still not completely recovered from his injuries and never will. He suffers ongoing, fluctuating pain in his lumbar spine, thoracic spine and cervical spine, which has worsened over time. As a result, he has not been able to return to his former very active lifestyle and has had to stop various physical activities, such as jogging and rugby, which he found aggravated his back. His ability to pursue his studies and perform his work have also been adversely affected, as has his physical interaction with his children, which can result in back pain, from bending, twisting or stooping. His physical exercise is now largely restricted to bike riding. Understandably, Dr Helm finds his ongoing restrictions distressing. 8. By the time he swore his January 2015 affidavit, Dr Helm's back pain had altered, extending from the low back into his buttocks and thighs. He was then finding that he was generally slow and stiff, especially in the mornings, with even simple movements causing him pain, which he described as mild, but constant. Awkward movements increased the pain, which on occasions became severe. There had been several occasions on which it had become excruciating. 9. Dr Helm had earlier found that certain postures and positions which he has to adopt at work aggravated his pain, which was coming on more easily over time and had resulted in him getting more restricted. He has had muscle spasms, with no obvious cause, which resulted in him being unable to manage patient lifting. He had also experienced a pattern of flare up in pain, from which he does not recover to the position he had before. 10. In June 2013, he sought a specialist opinion and was advised to persevere, being cautious and using analgesics, aiming to avoid a spinal fusion. His work involves a lot of physical activity, which he found uncomfortable. Dr Helm gave examples of particular anaesthetic and ICU work which he has to perform and how he manages work which causes him particular problems, including by seeking assistance with lifting and avoiding bending over, stooping and twisting. 11. By January 2015, he was finding the pain a distraction at work on a daily basis, with long procedures when he could not change his position, difficult to manage. He described how he attempted to manage challenging work he had to perform, but that sometimes he had to force past pain, in order to complete the task at hand. 12. The orthopaedic experts Dr New and Dr Vote were not required to give oral evidence in relation to their joint report. It was their joint view that Dr Helm's physical condition will require ongoing treatment; it will deteriorate over time, with the result a curtailment of the amount and type of work that Dr Helm will be able to perform. These problems will also continue to affect the other activities he is able to pursue. 13. Both experts considered that Dr Helm ought not to attempt any heavy lifting and that he is susceptible to further injury to his spine. They also considered that it was possible that he might require surgery in the future. Dr New considered it likely that Dr Helm would not be able to persist with his work after age 50 and Dr Vote that there was a better than even chance that he could continue to age 60. If his condition requires treatment with opioids, it was possible, however, that his working life would cease sooner. 14. Normal retirement age in the UK NHS system is 68, with an extension to age 70 possible. Dr Helm's evidence was that he hoped that he would be able to manage his work for longer than Dr New predicted, but with recent exacerbations he had experienced, feared that Dr New might be correct, given that he had very specific technical skills which would not readily translate into other areas of medicine. 15. In the result, the parties agreed that Dr Helm's earning capacity had been reduced. Dr Helm's damages 1. The parties agreed that Dr Helm was entitled to an order for damages. There was no issue as to various of the matters by reference to which those damages must be calculated. 2. There was no issue, for example, that Dr Helm was a fit, active and healthy man before the crash. His most likely future circumstances, but for the injury, his potential earnings and the way in which his gross earning per year should be calculated, were all not in dispute. 3. There was also no dispute about the nature of the injury Dr Helm suffered and that it will have an increasing impact upon him over time, something that he would not have experienced, but for the crash. 4. What was in issue included retirement age, the impact of Dr Helm's deteriorating condition, the weekly figure by reference to which his damages should be calculated and the periods to which certain rates should apply; rates for commercial assistance; various care requirements and future treatment expenses. Future economic loss 1. Dr Helm expects to complete his specialist studies in anaesthetics and intensive care in the United Kingdom in August 2015. He will then seek appointment to an NHS Trust hospital, where he will be paid a salary. He expects there to work in both anaesthetics and intensive care. How much work he would perform in the two fields is job specific. He described what such work involves. He also gave evidence as to how that work differed from the views expressed by Dr Lindsay, as to what anaesthetic work in a hospital in Australia involves. He also explained why he disagreed with various opinions Dr Lindsay expressed, as to steps available to him to take, to accommodate the problems which his injury causes him. 2. It is sufficient to give two examples. Dr Helm referred to Dr Lindsay's view that electric beds could be utilised to minimise the amount of bending which Dr Helm had to do. Dr Helm said that anaesthetists work as part of a team and that bed height has to be at a level which suits all team members, who might have to work together in emergency situations. Dr Helm is six feet in height and given the height of other team members, he said that there had to be compromise, so that in some cases bed height adjustments which would suit him, could not be made. 3. Dr Helm agreed with Dr Lindsay that the actual placing of an intubation tube normally took about 30 seconds, but said that the entire intubation process took up to three minutes. He agreed that this did not involve bending for a long period. Where intubation was not straight forward, however, it could take considerably longer and require positions which were not optimal for his back. 4. Dr Helm was cross-examined as to his work as an anaesthetist and as an intensivist. He said that he would not be able to restrict his practice to purely anaesthetic work, because of requirements to be on call for emergency work, which requires performing work on patients in intensive care beds, inside and outside the emergency department. He also described the circumstances in which it was not possible to control anaesthetic work to positions which he found comfortable, because of various patient needs. He agreed that intensive work exposed him to such situations more frequently, as did paediatric work and work with obese patients. 5. I accept Dr Helm as a witness of truth. His evidence as to these matters, the impact of his injuries on his work and the pain and limitations which have resulted must be accepted. 6. Dr Helm will also have a right of private practice in the United Kingdom. He intends to practice in anaesthesia, pursuing the career path about which Dr Jones, who is several years ahead of him, gave evidence. Retirement age 1. Pel-Air accepted that the evidence supported a finding that Dr Helm would lose eight years of his full-time earnings, from age 60, calculated by reference to probable retirement at 68. 2. The current retirement age under the NHS system is 68 years. An extension to age 70 is available. There is no evidence of any retiring age for private practice. 3. Dr Helm is a highly motivated man. The experts agreed that he had downplayed his symptoms and that his survival, while in considerable pain from multiple soft tissue injuries, scratches, bruising and injury to his spine, reflected his CareFlight pre-induction training, which was military in rigour. Dr Vote considered his return to work after only a few weeks off, while still in considerable pain and keeping pain medication to a minimum, to have been amazing. 4. On Dr Helm's unchallenged evidence, he intended to work to age 68, if not beyond. On that evidence and the evidence of his health and approach to fitness prior to the crash, I consider that Dr Helm would have worked until age 70, but for his injuries. His damages must be calculated by reference to that age. Dr Helm's likely future circumstances 1. It was the common view of the orthopaedic experts that the nature of Dr Helm's condition was such that he will suffer increasing adverse effects over time and that he will not be able to pursue his work beyond the age of 60. 2. Dr Vote agreed with Dr New, who expected that Dr Helm would have significant pain by age 50 and retirement at that age might be taken out of his hands by the NHS, if it was felt that he was not then up to the job. If he began suffering sciatic pain before then, that would also affect what he could do. It was agreed that there was also a possibility of spinal fusion surgery, if Dr Helm's pain became considerable. Still Dr Vote considered that given his fitness, Dr Helm had a better than even chance of working to age 60. 3. Pel-Air contended that this aspect of calculation should thus be approached on the basis of a diminished capacity to work from age 55, rather than age 50. 4. Given the evidence of Dr Helm's past approach to his injuries and his evidence as to the deterioration he explained that he has experienced and its impact, I am satisfied that submission cannot reasonably be accepted, notwithstanding Dr Vote's views. 5. I have earlier discussed Dr Helm's evidence of his worsening condition, its impact on his work and his concerns for the future, particularly given that working despite the impact of his condition is not a matter only within his control. Resilience and determination alone are not likely to be enough, given the nature of the injuries which Dr Helm has suffered. When all of that evidence is considered, it must be concluded on the balance of probabilities, that Dr Helm's capacity to work will diminish from age 50, as he contended. 6. A calculation of this aspect of his damages, on the assumption that he would progressively lose one third of his income from his private practice, is a reasonable basis upon which to calculate this loss. Section 12 of the Civil Liability Act 1. There was a disagreement over the impact of s 12 of the Civil Liability Act. It relevantly provides: "12 Damages for past or future economic loss - maximum for loss of earnings etc ... (2) In the case of any such award, the court is to disregard the amount (if any) by which the claimant's gross weekly earnings would (but for the injury or death) have exceeded an amount that is 3 times the amount of average weekly earnings at the date of the award. (3) For the purposes of this section, the amount of average weekly earnings at the date of an award is: (a) the amount per week comprising the amount estimated by the Australian Statistician as the average weekly total earnings of all employees in New South Wales for the most recent quarter occurring before the date of the award for which such an amount has been estimated by the Australian Statistician and that is, at that date, available to the court making the award, or (b) if the Australian Statistician fails or ceases to estimate the amount referred to in paragraph (a), the prescribed amount or the amount determined in such manner or by reference to such matters, or both, as may be prescribed. " 1. It was agreed that the figure representing three times the relevant average weekly earnings was $3,354. 2. Originally Dr Helm's damages were calculated by reference to his estimated gross weekly salary of $3,580 (see paragraph 8 of mfi 6). Accepting the figures at paragraph 8 of mfi 6, Pel-Air calculated that his net salary, after deduction of British tax, was $3,614 and submitted that, accordingly, s 12 required that his loss from age 60 be calculated by reference to $3,354 (paragraph 1 of mfi 10). 3. Dr Helm then conceded that in accordance with s 12, these damages had to be calculated by reference to the figure of $3,354 per week (see mfi 13 and 14). 4. Pel-Air then submitted in response to mfi 13 and 14, that these damages should be calculated by reference to a net figure of $2,314, said to have been calculated in accordance with paragraph 1 of mfi 10. No reference was made to such a figure in mfi 10. How that figure was calculated is not revealed by what was submitted there. Reference was also made in Pel-Air's response to ABS statistics and an average weekly earnings table attached to the submission. How those documents relate to the calculation of the figure of $2,314, is not apparent. 5. I consider that the submissions advanced for Dr Helm as to the proper construction of s 12 of the Civil Liability Act are correct. In calculating these damages s 12 requires any amount by which Dr Helm's gross weekly earnings would, but for his injuries, have exceeded $3,354, be ignored. That is a figure less than Dr Helm's net salary would be, after tax, but for his injury. Accordingly, $3,354 is the figure by reference to which these damages must be calculated. Non-economic loss 1. The issue between the parties was whether the assessment of this loss under s 16 of the Civil Liability Act falls at 25% of a worst case, or 35%, given the evidence of Dr Helm's pain, discomfort, loss of enjoyment of life and ongoing restrictions. 2. I have already discussed the evidence as to the impact of the crash on Dr Helm's health, on his working life and the loss of his ability to pursue an active private life in which he successfully pursed a wide range of physical interests and pursuits. There is also evidence that it has had an adverse impact on various aspects of his personal life, another relevant consideration (see Linsell v Robson [1976] 1 NSWLR 249). 3. Dr Helm's account of the difficulties he has suffered were not disputed by Pel-Air. It was supported by Ms Sharman's evidence, Dr Helm is plainly a stoic man. His evidence of a condition worsening more than he had expected, must be accepted, consistent as that is with the experts' evidence. That evidence does not permit the conclusion that what he has suffered was quite moderate, as Pel-Air submitted. 4. On all of that evidence, I am satisfied that a reasonable assessment of his non-economic loss is 35%. Care 1. There was no claim for past voluntary care, which it was accepted fell below the statutory threshold. The rates at which future needs should be calculated were agreed. 2. It was not in issue that Dr Helm has future care needs. 3. Dr Helm submitted that they should be awarded from age 40 , increasing from age 50, again from age 60 and then ceasing at age 75, it being accepted as a matter of common experience that assistance is required at that age. Pel-Air's case was that his needs would be assessed at no more than two hours per week, as a realistic average of needs which it was accepted would increase, beginning at age 50 and ceasing at age 70. It was argued that an assessment that his needs over time would increase to nine hours per week was, however, unrealistic. 4. In his January 2015 affidavit, Dr Helm assessed that from age 40 he would require two hours domestic assistance a week, six hours from age 50 and by age 60, nine hours per week. He also there described the nature of his worsening symptoms and their effects. 5. His evidence was supported by Ms Sharman's affidavit evidence, where she described the effects of Dr Helm's ongoing back problems on his ability to pursue his sporting interests, to interact with his children and to perform housework and other things such as gardening. She described the ongoing impact of his problems on his mood and ability to cope with his work and life. She also explained why it would be necessary for them to obtain help to perform outside work when they buy the home they plan to purchase and how they currently paid for assistance, when funds were available, to avoid Dr Helm undertaking tasks which already aggravate his back. She assessed that they then needed about three hours a week paid assistance for domestic and inside home maintenance tasks and two hours for paid assistance outside. 6. None of this evidence was challenged. 7. The evidence well establishes that Dr Helm has future care needs which will increase over time. Calculating those needs at two hours per week from age 40 is consistent with the evidence of Dr Helm's current condition and the evidence that it will deteriorate over time. That his needs will increase to six hours per week by age 50, is consistent with the conclusions which I have reached as to the likely deterioration in his condition by then. That they will have increased further by age 60 to nine hours per week, when Dr Helm is unlikely to be able to continue work at all, is also, I am satisfied, a realistic assessment of his needs at that time. 8. I do accept Pel-Air's submission that the calculation should reduce at age 70. While increasing longevity and working life is common, it must be accepted that from that age, assistance with heavier tasks are generally required. Dr Helm will, however, require more assistance than normal and so to age 75, he should have an award of five hours per week. Treatment expenses 1. Past treatment expenses were agreed. 2. Future expenses were calculated by reference to treatment needs to age 85, including medication, physiotherapy, hydrotherapy and surgery. 3. The difference between the parties reflected that the cost of surgery had been calculated by Pel-Air on the basis that there was a 25% chance of surgery, deferred for some 15 years, so that it was calculated on a net present value basis, which seems reasonable in the circumstances. Orders 1. For the reasons given, I find for Ms Casey and Dr Helm. 2. The usual order as to costs is that they follow the event. In these proceedings that would result in orders that Pel-Air bear their costs, as agreed or assessed. I will hear the parties if any of them seek any different order. 3. The parties are directed to confer and to file short minutes of proposed orders, reflecting the conclusions which I have reached and indicating any remaining areas of disagreement, within 21 days. 4. The matter will be listed for mention on 10 June 2015 at 9:30am. ********** Amendments 11 June 2015 - typographical error in [363] - 'collected' amended to 'calculated' 02 October 2015 - typographical error on coversheet and in paragraphs [38] and [40] - the word "Lexus Nexis" corrected to "LexisNexis" 08 March 2016 - minor corrections throughout decision 08 March 2016 - amendment to coversheet DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated. Decision last updated: 08 March 2016