Reference Determination Content
Suggested draft · fictitious patient
Head - Concussion
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 21 May 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 21 May 2025;
- A pre-deployment medical examination and baseline cognitive testing by the regimental medical officer, dated 20 August 2012;
- A casualty card and Military Acute Concussion Evaluation by the combat medic, Afghanistan, dated 17 March 2013;
- A role 2 medical record and CT brain report by the medical officer and radiologist, Afghanistan, dated 18 March 2013;
- A forward operating base treatment record by the combat medic, Afghanistan, dated 22 March 2013;
- A post-operational psychological screening by the psychologist, Garrison health centre, dated 11 June 2013;
- An outpatient health record and duty restriction by the medical officer, Garrison health centre, dated 4 September 2013;
- An MRI brain report by the radiologist, dated 28 January 2014;
- A specialist consultation by the neurologist, dated 30 January 2014;
- A neuropsychological assessment report by the clinical neuropsychologist, dated 12 February 2014;
- A medical employment classification review by the senior medical officer, dated 5 August 2021.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
3 February 2009 and 18 November 2021
Head - Concussion
You have stated that your condition was caused by:
- experiencing a specified event at the time of the clinical onset of concussion
Diagnosis: Concussion
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 21 May 2025, and is supported by a role 2 medical record and CT brain report by the medical officer and radiologist, Afghanistan, dated 18 March 2013.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Concussion (Reasonable Hypothesis) (No. 92 of 2018)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- experiencing a specified event at the time of the clinical onset of concussion
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with brief loss of consciousness, confusion and repetitive questioning, post-traumatic amnesia of about four hours, headache, dizziness, nausea, bilateral tinnitus and light sensitivity on 17 March 2013.
The diagnosis was made clinically by a medical officer at a role 2 facility on 18 March 2013 on the basis of a documented blast injury with the head striking the vehicle interior, loss of consciousness of about two minutes, confusion, post-traumatic amnesia of about four hours, a lowest Glasgow Coma Scale score of 14 and a Military Acute Concussion Evaluation score of 22 out of 30, with a normal CT brain. These findings meet the Statement of Principles definition of concussion: a mild traumatic brain injury from the transfer of kinetic energy to the brain from external physical forces, with a temporary disturbance of neurological function that does not meet the criteria for moderate to severe traumatic brain injury.
This has then led to further investigations and the diagnosis of your condition of Concussion. I have accepted your condition of Concussion.
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that this condition is related to your wartime service.
I have therefore accepted that this condition is related to your service with effect from 17 March 2013.
Head - Concussion (Worsening)
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 21 May 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 21 May 2025;
- A pre-deployment medical examination and baseline cognitive testing by the regimental medical officer, dated 20 August 2012;
- A casualty card and Military Acute Concussion Evaluation by the combat medic, Afghanistan, dated 17 March 2013;
- A role 2 medical record and CT brain report by the medical officer and radiologist, Afghanistan, dated 18 March 2013;
- A forward operating base treatment record by the combat medic, Afghanistan, dated 22 March 2013;
- A post-operational psychological screening by the psychologist, Garrison health centre, dated 11 June 2013;
- An outpatient health record and duty restriction by the medical officer, Garrison health centre, dated 4 September 2013;
- An MRI brain report by the radiologist, dated 28 January 2014;
- A specialist consultation by the neurologist, dated 30 January 2014;
- A neuropsychological assessment report by the clinical neuropsychologist, dated 12 February 2014;
- A medical employment classification review by the senior medical officer, dated 5 August 2021.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
3 February 2009 and 18 November 2021
Head - Concussion (Worsening)
You have stated that the worsening of your condition was caused by:
- inability to obtain appropriate clinical management for concussion
Diagnosis: Concussion (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 21 May 2025, and is supported by a role 2 medical record and CT brain report by the medical officer and radiologist, Afghanistan, dated 18 March 2013.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Concussion (Balance of Probabilities) (No. 93 of 2018)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- inability to obtain appropriate clinical management for concussion
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with brief loss of consciousness, confusion and repetitive questioning, post-traumatic amnesia of about four hours, headache, dizziness, nausea, bilateral tinnitus and light sensitivity on 17 March 2013.
The diagnosis was made clinically by a medical officer at a role 2 facility on 18 March 2013 on the basis of a documented blast injury with the head striking the vehicle interior, loss of consciousness of about two minutes, confusion, post-traumatic amnesia of about four hours, a lowest Glasgow Coma Scale score of 14 and a Military Acute Concussion Evaluation score of 22 out of 30, with a normal CT brain. These findings meet the Statement of Principles definition of concussion: a mild traumatic brain injury from the transfer of kinetic energy to the brain from external physical forces, with a temporary disturbance of neurological function that does not meet the criteria for moderate to severe traumatic brain injury.
After the condition arose, it was worsened during your service. After returning to Australia on 27 May 2013 you were referred on 11 June 2013 for neurological and neuropsychological assessment of persisting post-concussion symptoms during peacetime service, but the referral was not actioned by the garrison health centre for almost five months because of staff shortages and a backlog of post-deployment reviews.
This has then led to further investigations and the diagnosis of your condition of Concussion (Worsening). I have accepted your condition of Concussion (Worsening).
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that the worsening of this condition is related to your peacetime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 4 September 2013.
