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3.4.4 Establishing the clinical onset and/or worsening
The process of investigating and determining a liability claim requires knowledge about the clinical onset and/or worsening of the claimed condition. Clinical onset refers to the time where relevant symptoms, signs or other evidence of a condition were first present, thus enabling an appropriate medical practitioner to say that the condition first manifested at that time. The date of clinical onset must be supported by medical evidence.
Clinical onset is not necessarily the date the condition was diagnosed.
Clinical onset and diagnosis are two different concepts, however in some cases it may be that these dates coincide or are close together. For example, dates may coincide when there are criteria or thresholds to be met, but can also happen with an acute injury (such as a fracture) or acute event (such as a stroke or a heart attack). Each case and each disease or injury needs to be considered on its merits.
In Re Robertson v Repatriation Commission  AATA 127, the time of clinical onset is said to be when:
- A person becomes aware of some feature or symptom which enables a doctor to say the disease was present at that time; or
A finding is made on investigation which is indicative to a doctor of the disease being present at that time.
Ideally, the medical records and/or reports that form part of the evidence should contain this information. However, some conditions may be claimed many years after service and/or the contended causal or aggravating factor. In some cases, due to an absence of contemporaneous evidence, a retrospective diagnosis may be sought.
Case study – retrospective diagnosis
A diagnosis for a specified condition is confirmed by a test result. However, symptoms consistent with the diagnosis have been present in the claimant in the three months prior to the test. Based on this information, the date of clinical onset would be three months prior to the test.
In some circumstances, backdating the date of clinical onset before the time of confirmation of the diagnosis may not always be possible. The presence of symptoms/signs does not necessarily allow a diagnosis to be made at that time. However, once a diagnosis is made, they may allow the onset to be dated from that time symptoms/signs were present. There may be situations where the symptoms or signs are not sufficiently specific to the disease or injury in question to allow the onset to be backdated to when the symptoms/signs began.
A retrospective diagnosis requires consideration of the history of the injury or disease and when it was manifested and/or was aggravated in order to establish the clinical onset and/or worsening of the relevant condition. The Federal Court decision in Repatriation Commission v Cornelius  FCA 750 established the need for material pointing to signs and symptoms of the injury or disease such that enables a medical practitioner to say the condition was present at a particular time. This principle was endorsed by the Full Federal Court decision in Lees v Repatriation Commission  FCAFC 398.
Certain SoPs have diagnostic thresholds or criteria that need to be met before the SoP can be applied. Where this is the case, in applying any SoP factors, clinical onset will be when there was first evidence that those thresholds had been reached, or the criteria were satisfied. This may be some time after the first symptoms were experienced.
Case study – diabetes mellitus
Clinical onset of diabetes mellitus can be said to have occurred when the required plasma glucose concentration levels were first demonstrated. If earlier testing has indicated elevated levels, but not to the required level for diagnosis, then the date of clinical onset cannot be retrospectively ascribed to that time. The onset date in such a case would be the date when a medical practitioner is able to say that diabetes was present at that time.
Clinical worsening is the time when a disease itself has worsened and is more than just a temporary change or natural progression of the injury or disease. Clinical worsening SoP factors apply only in relation to aggravation of, or material contribution to an injury or disease that was suffered or contracted before or during (but not arising out of) the person’s relevant service. In applying the SoPs, clinical worsening means aggravation of the underlying pathology of the injury or disease. This requires an increase in the gravity of the disease beyond its natural progression as endorsed by the High Court in Johnston v Commonwealth  HCA 54. It excludes aggravations of signs or symptoms which relate to decisions made under sections 29 or 30 of the MRCA and any deterioration that is part of the normal course of the disease. Unless the SoP specifically requires permanent aggravation, it may be permanent or temporary, in accordance with the Federal Court findings in Repatriation Commission v Yates  FCA 1234.