Office of the Health Services Commissioner Annual Report 2008

HERE FOR ALL VICTORIANS 

Office of the Health Services Commissioner 

2008 

Annual Report

Current and former staff of the OHSC at the twentieth anniversary celebrations. 

 

Robyne Schwarz, President HSRC and the 

Honourable Andrea Coote MLC former President 

of the HSRC 

 

Vivienne McCutcheon and Liza Newby former HSC, Beth Wilson 

current HSC and Ian Siggins inaugural HSC together at the twentieth 

anniversary celebrations 

 

The Honourable Daniel Andrews MP, 

Minister for Health and Laurie Harkin, Disability 

Services Commissioner 

 

The organising committee of the twentieth anniversary celebrations 

Robyne Schwarz, Julie-Anne Balash, Beth Wilson, Jacqui Hoepner 

and Jill Aitken 

 

"The Disinfectors" comprising Paul Nisselle, Louise 

Johnson, Beth Wilson and Justin Brady who performed 

their popular song "There ain't no bugs on me"

Contents 

Glossary of Abbreviations 

ATSI Aboriginal & Torres Strait Islander 

CALD Culturally and Linguistically Diverse 

CLO Complaints Liaison Officer (Hospitals) 

FOI Freedom of Information Act 1982 

HPPs Health Privacy Principles 

HPRA Health Professions Registration Act 2005 

HRA Health Records Act 2001 

HSC Health Services Commissioner 

HSCR Health Services (Conciliation & Review) Act 1987 

HSRC Health Services Review Council 

OHSC Office of the Health Services Commissioner 

Commissioner’s Summary 2 

Health Services Review Council: President’s Report 5 

The Council 6 

Membership 7 

Statutory Functions 9 

The Role of the Commissioner 10 

Guiding Principles 10 

Expectations and Standards 10 

Health Records Act 2001 10 

Other Statutory Roles 10 

Liaison, Training and Promotion 10 

Public Interest Issues 11 

Cancer Treatments 11 

Lasers 11 

Health Privacy 11 

Storage and Disposal of Medical Records 11 

Analysis of Complaint Trends 12 

2007/2008 Summary 13 

Enquiries 13 

Who Complained 14 

How Complaints Are Managed 15 

How Were the Complaints Resolved? 16 

Seriousness 16 

Seriousness Rating 16 

Assessment Report 17 

Conciliation Report 18 

Aboriginal Liaison Officer's Report 19 

Registrar’s Report 20 

Health Professional Registration Act 2005 and 

and Investigation Review Panels 21 

Prisoner Complaints 22 

Reasons For Complaints 23 

Primary Issues in HSCR Complaints 24 

Primary Issues in HRA Complaints 26 

Complaints Against Health Services Providers 27 

Medical Practitioners 28 

General Practitioners 28 

Dentists 29 

Hospitals 29 

Psychiatric Services 30 

Hospital Complaints Data 31 

Executive Services 35 

Appendices 44 

Office of the Health Services Commissioner | Annual Report 2008 1

Commissioner’s 

Summary 

2 

Office of the Health Services Commissioner | Annual Report 2008

Beth Wilson 

Victoria’s Health Services Commissioner 

This year the Office of the Health Services 

Commissioner (OHSC) celebrated its 

twentieth anniversary at a reception 

attended by the Minister for Health, the Hon. 

Daniel Andrews MP. The guests in 

attendance were many and varied and bore 

witness to the fact that the work of the OHSC 

covers a broad spectrum of the community. 

It was not possible to invite everyone who 

has made a contribution over the years, but 

we could have easily invited many, many 

more. To all interested parties who have 

made a contribution to the work of this 

Office, my heartfelt gratitude. 

Within the OHSC, the management 

structures continue to be reviewed and 

strengthened. We have an excellent 

management team who take responsibility 

for their team members and who meet 

regularly with me so that I am kept up to 

date with what is happening in the office. 

Promotion of the work of the Health Services 

Commissioner (HSC) continues with 

consumer and provider groups and this 

means a very busy public speaking program. 

Consideration is being given to limiting 

community based presentations by the 

Commissioner to one per week because of 

the pressure of work. We continue to target 

culturally and linguistically diverse (CALD) 

communities in our promotion and in the 

year under review presentations were given 

to organisations such as the Federation of 

Chinese Association. 

Cooperation with the Victorian Quality 

Council and the Australian Commission on 

Safety and Quality in Health Care as well as 

six monthly meetings with all health 

complaints commissioners from Australia 

and New Zealand, continue to be 

constructive and important initiatives. The 

open disclosure project, implementation of 

the State Disability Plan and the Charter of 

Human Rights and Responsibilities, are 

important parts of OHSC involvement. The 

national initiative to set up new health 

professions registration boards is 

progressing well and the OHSC has 

continued to work with the project team and 

the registration boards. 

I was pleased to be appointed to the 

Disability Services Board to assist with 

providing advice to the Minister for 

Community Services and the Disability 

Services Commissioner. I have also given 

advice and made a submission to the 

Victorian Law Reform Commission’s inquiry 

into Abortion law reform. 

I was also an Advisory Committee member 

of the Australian Law Reform Commission’s 

Review of the Privacy Act 1988. This led to 

an extensive and detailed three volume 

report on privacy which was released in 

May 2008. 

Lunch time meetings with ombudsmen 

including the State Ombudsman, 

Telecommunications Industry Ombudsman, 

Banking and Financial Services Ombudsman 

and the new commissioners such as the 

Disability Services Commissioner and Public 

Transport Commissioner, are important 

forums for discussion of our mutually 

complex work. I am pleased to be able to 

provide some advice and cooperation to 

other commissioners and in return to benefit 

from their wisdom and ideas. 


The OHSC has continued to have a most 

constructive working relationship with 

the Minister for Health and the Secretary 

and staff of the Department of Human 

Services. Preparations are underway for a 

review of the OHSC budget formula and I 

welcome this. 

The Health Records Act 2001 (HRA) 

complaints indicate an increased community 

awareness of health information rights 

issues. Most complaints are about failures 

by health service providers to provide access 

to health records and health privacy issues. 

HRA staff have been faced with some 

perplexing and complex areas, particularly 

where health service providers have 

abandoned their records or where they 

have retired, given up practice or have been 

imprisoned. 

The President of the Health Services Review 

Council (HSRC), Robyne Schwarz, and the 

other members of the HSRC continue to be 

a source of support, expertise and 

constructive criticism. This is appreciated. 

During the year under review officers from 

the OHSC presented de-identified case 

studies to Council members so they could 

become more aware of the complexities of 

the work we do. These presentations were 

very well received by HSRC members. 

There were some changes to the 

membership of the HSRC in the year under 

review. Marcia Coleman and Dr Andrew 

Rothfield completed their terms and I thank 

them for the expertise and interest they 

brought to the Council. Chris Altis and 

Roslyn Glow also joined the HSRC. 

Unfortunately because of better 

opportunities elsewhere we were not able to 

work with Chris as long as we would like to 

have done. 

As in previous years I take the opportunity 

to thank the hardworking staff of the OHSC. 

Mark McPherson, a senior conciliator, left 

us to join the Medical Practitioners Board of 

Victoria and we thank Mark for his 

contribution to our work and his warm 

sense of humour. 

The HSC continues to be grateful to people 

who provide expertise in the form of expert 

clinical and other information. Without 

them our work would be much more difficult. 

In conclusion, I also thank the many 

complaints officers who work in our 

hospitals and other health services assisting 

with health complaints resolution. Their 

peak body, the Health Services Liaison 

Association (HSLA), meets at the OHSC on 

a monthly basis and these meetings are 

attended by Lynn Griffin, Manager, 

Assessment and Investigation. The OHSC 

also provides a venue for HSLA seminars. 

Any complaints officer who has not done so 

should avail themselves of orientation 

sessions with the OHSC and all are urged to 

join HSLA which can provide information and 

support to complaints officers in their 

difficult work. The HSLA website is 

www.hsla.com.au. 

Beth Wilson 

Health Services Commissioner 

4 


Health Services 

Review Council 

President’s 

Report 

Victoria was the 

first State to set up an 

independent health ombudsman 

to act as an impartial mediator 

and conciliator of complaints by 

users of health services. 


Robyne Schwarz 

President 

This year’s highlight was the twentieth 

year anniversary of the creation of the 


and the Health Services Review Council 

In March a cocktail party was held in the 

magnificent Sir Redmond Barry Room to 

celebrate this important milestone. 

The Minister for Health, the Hon. Daniel 

Andrews MP addressed the audience which 

included many past Commissioners and 

Council members. 

The Minister acknowledged the key role the 

Health Services Commissioner plays in 

ensuring an independent review of public 

concerns that arise from the provision of 

health services in Victoria. 

Health services legislation introduced in 

Victoria in 1988 heralded a new era in 

health complaints resolution. Victoria was 

the first State to set up an independent 

health ombudsman to act as an impartial 

mediator and conciliator of complaints by 

users of health services. Twenty years on 

Victoria, through its Office of the Health 

Services Commissioner continues to take a 

lead role in its conciliatory approach to 

individual complaints resolution as well 

as its commitment to address the 

systemic issues that often underpin 

individual complaints. 

Victoria is fortunate to have a Health 

Services Commissioner whose creative 

and entertaining style ensures the profile of 

her office remains high in the community. 

It is also a credit to her and her dedicated 

staff that providers and users of health 

services alike are confident that they will be 

treated fairly and respectfully in all their 

dealings with the Office. 

The year 2008 is the centenary of women's 

right to vote in Victoria. It is therefore 

appropriate that I congratulate the HSC 

on being inducted onto the Victorian 

Women's Honour Roll for her services to 

women's health. 

The Health Services Review Council which 

comprises members representing the views 

of providers and users and those who are 

fully independent continues to play an 

important role twenty years on in promoting, 

supporting and advising the Commissioner 

and her staff. Council members enjoy an 

open and constructive relationship with 

the Commissioner and her staff and it is in 

this environment that we all strive to ensure 

that the citizens of Victoria have access to 

a high quality, effective health complaints 

resolution system. 

I thank all Council members for their 

genuine commitment to grapple with the 

varied and complex issues we are presented 

with and in particular, I would like to 

recognise the valued contribution retiring 

members Marcia Coleman and Andrew 

Rothfield made to the work of the Council. 

Both Marcia and Andrew were always 

willing to take on extra tasks as required and 

we wish them both well in the future. 

Robyne Schwarz 

President 

The Council 

Under the Health Services (Conciliation and Review) Act 1987 (HSCR), the Council has the following functions: 

1. To advise the Minister on the health complaints system and the operations of the Commissioner; 

2. To provide expertise, guidance and advice to the Commissioner; 

3. To promote the Commissioner, the operations of the Commissioner and the guiding principles in the Act; 

4. To advise the Minister and Commissioner on issues referred to the Council by the Commissioner; 

5. With the Minister’s approval, to refer matters relating to health service complaints to the Commissioner for inquiry. 

6 


Membership 

Council members are representatives of providers, users and independent people in relation 

to the health system. The Council includes a representative with experience in matters 

affecting the privacy of individuals in relation to health information, representing both 

interests of organisations that handle information as well as consumers. 

The current membership is listed below. 

Robyne Schwarz (President) 

Robyne joined the Council in 2003 as an 

independent representative. She has 

both Physiotherapy and Social Work 

qualifications and was a senior practitioner 

at the Royal Children's Hospital for 15 

years. Robyne has been a National 

Director and State President of the 

Australian Association of Social Workers 

and has lectured in Social Work at the 

University of Melbourne. She is currently 

President of Jewish Care and a member 

of the Victorian Psychologists and 

Osteopaths Registration Boards. Robyne 

brings to the Council experience as a 

health services practitioner, along with 

expertise in quality improvement and 

community participation in healthcare and 

clinical governance system development. 

Susan Bunting 

Susan is a member of the Human Research 

Ethics Committee, RMIT, Melbourne and a 

consumer advocate in healthcare. 

She is also a lawyer, policy analyst and 

applied bio-ethicist with over 20 years 

experience in healthcare, including 

extensive experience in policy, governance 

and legal issues affecting the delivery of 

safe and quality healthcare. 

Judith Congalton 

Judith has been a member of Council since 

2005 and is currently Strategic 

Planner/Manager, Southern Melbourne 

Integrated Cancer Service. Her previous 

experience includes Chief Executive at 

MECWA and a number of other leadership 

positions across both public and private 

acute hospital sector over the past 25 

years. Judith is committed to continuous 

improvement and has been instrumental in 

creating and progressing the development 

of clinical governance programs throughout 

her career. 

Judith is a Director of the Nurses Memorial 

Centre, a Fellow, Royal College of Nursing 

Australia, Associate Fellow College of 

Health Service Executives and Member 

Australian Institute of Company Directors. 

Professor Albert Frauman 

Albert is the Head of Clinical Pharmacology 

& Therapeutics at Austin Health/University 

of Melbourne, Co-Director of the Victorian 

Toxicology Service and Head of the Drug 

Evaluation Unit of the University of 

Melbourne. Albert has longstanding 

activities in clinical medicine, teaching and 

research as a hospital and academic 

physician. He has expertise in 

pharmaceutical evaluation for the 

Therapeutic Goods Administration and 

strong interests in quality use of medicines 

and pharmacoeconomics. He chairs the 

Drug Utilisation Sub-Committee and sits on 

the Drug Trials Subcommittee and Drug 

and Therapeutics Committee of Austin 

Health. He sits on a number of key State 

and Commonwealth therapeutics 

committees as a clinical pharmacologist, 

including the Poisons Advisory Committee 

of DHS and the PBAC (Pharmaceutical 

Benefits Advisory Committee) (Department 

of Health and Ageing). He is also actively 

involved in professional advisory roles, 

sitting on the Royal Australasian College of 

Physicians’ Victorian State Committee. 


Jamie Gardiner 

Jamie is a human rights advocate. He has 

long been on the executive of Liberty 

Victoria, of which he is now a Vice- 

President. Since 2000 he has been a parttime 

Equal Opportunity Commissioner, and 

a Member of the Mental Health Review 

Board. As a gay activist Jamie has been 

campaigning for an end to discrimination, 

both in the law and under the law, for over 

30 years. He was a founding member of the 

Victorian AIDS Council, and took part in 

the mostly successful campaign in the 

1980s to have a health policy for HIV/AIDS 

that respected human rights, in a public 

health model. 

Ms Susan Healy 

On retirement from the State Library Sue 

decided that her efforts should be devoted 

to a positive view of ageing. She became 

chair of Residential Care Rights (now Elder 

Rights Advocacy) and joined the Consumers 

Health Forum (CHF). With CHF she was 

involved in a review of hospital quality and 

safety, a campaign for the safe use of 

medicines and the creation of software 

standards for General Practitioners 

medication management. She is currently 

involved in a pilot project of e-health records 

and in the use of online health information 

through HealthInsite. 

Dr Paul Nisselle AM 

Paul has been a provider representative on 

the Health Services Review Council since 

1994. He was in general practice in Elwood 

for 18 years before entering the medical 

indemnity industry in 1989. He is now 

General Manager, Clinical Risk 

Management for the Avant Mutual Group 

Limited. He is a past President, past 

Chairman and past Federal Councillor of 

AMA Victoria and has served on the Medical 

Practitioners Board of Victoria. 

Dr Roslyn Glow OAM 

Roslyn joined the Council in 2008 as an 

independent member. She is a retired 

Clinical and Child Psychologist with 

interests in practice, research and teaching. 

She was a member of the Psychologists’ 

Registration Board of South Australia, for 

twelve years, and was the Volunteer 

Researcher for Palliative Care Victoria for 

eleven years. Currently she is a member of 

the Research Ethics Committee of the 

Department of Justice. 

Dr Geoff Markov 

Geoff is a Consultant Physician and 

Rheumatologist working in both private 

practice and public hospital settings in 

suburban Melbourne. Having trained in 

Australia and the United States, he has 

considerable experience in issues 

concerning patient care, medico-legal 

affairs and clinical governance. He is a 

member of the Medicare Participation 

Review Committee, the Social Security 

Appeals Tribunal and Hearing Panels 

established under the Victorian Health 

Practitioners Registration Act 2005. 

He has provided expert opinion on cases 

brought before courts in Federal and 

State jurisdictions, and is a lecturer and 

examiner for the Medical School at the 

University of Melbourne. 

Dr Penny Weller 

Penny is currently the Postdoctoral 

Research Fellow with the Rethinking Mental 

Health Laws project in the Faculty of Law 

at Monash University. She previously 

lectured in Human Rights Law at Victoria 

University, and has a background in primary 

health care nursing and public health 

practice. As an academic she has continued 

research and teaching in health law, public 

health law and human rights. She has 

contributed a socio-legal perspective to 

projects in public health law and policy 

including research ethics for young people, 

young people in the criminal justice system, 

national prevention policy for drug related 

harm, and public health emergency powers. 

8 


Statutory 

Functions 


The Role of the 

Commissioner 

The OHSC was established in Victoria in 

1988 by the HSCR. The Commissioner's role 

is to receive, investigate and resolve 

complaints from users of health services, to 

support health care services in providing 

quality health care and to assist them in 

resolving complaints. The legislation also 

requires that information gained from 

complaints should be used to improve the 

standards of health care and prevent 

breaches of these standards. 

The HSCR states that the Commissioner is to: 

a. Deal with users' complaints; and 

b. Suggest ways in which the guiding 

principles may be carried out and help 

service providers to improve the quality 

of health care. 

The purposes of the Act include: 

a. To provide an independent and 

accessible complaint mechanism for 

users of health services; and 

b. To provide a means for reviewing and 

improving the quality of health service 

provision. 

Guiding Principles 

The guiding principles of the HSCR promote: 

a. Quality health care given as promptly as 

circumstances permit; and 

b. Considerate health care; and 

c. Respect for privacy and dignity of 

persons being given health care; and 

d. The provision of adequate information 

on services provided or treatment 

available in terms which are 

understandable; and 

e. Participation in decision making 

affecting individual health care; and 

f. An environment of informed choice in 

accepting or refusing treatment or 

participation in education or research 

programs. 

Expectations and 

Standards 

The guiding principles establish the range 

of responsibilities for health services 

and the basis for a complaint when a 

breach of these responsibilities has 

occurred. They establish a framework for 

the HSC to become involved in improving 

health services and report on problems 

identified and improvements made. 

The Commissioner also has the overall 

function of suggesting ways of improving 

the quality of health services. 

Health Records Act 

The HSC is also responsible for the 

administration of the legislation dealing with 

the privacy of health information and an 

individual’s right to have access to health 

information about them. The Health 

Records Act (HRA) commenced on 1 July 

2002. The purpose of the HRA is to promote 

fair and responsible handling of health 

information by: 

a. Protecting the privacy of an individual's 

health information that is held in the 

public and private sectors; and 

b. Providing individuals with a right of 

access to their health information; and 

c. Providing an accessible framework for 

the resolution of complaints regarding 

the handling of health information. 

Organisations holding health information 

must manage the health information, 

which relates to individuals, in accordance 

with the Health Privacy Principles (HPPs) 

in the HRA, subject to any specific 

provisions about the management of health 

information in any other Act. 

Individuals are able to seek access to health 

information about them held by any person 

or organisation in the private sector. 

The Freedom of Information Act 1982 (FoI) 

continues to provide a mechanism for 

individuals to seek access to their health 

information held by public sector 

organisations. However, in the event of a 

refusal of access to health information 

under the FoI Act, the HRA also provides an 

avenue for these refusals to be conciliated. 

Individuals can complain to the HSC when 

their health information has not been 

managed in accordance with the HRA, or 

where they have experienced difficulties 

accessing their health information. 

The HSC assesses complaints and, 

if a complaint is accepted, it may be 

conciliated, investigated or dismissed. 

At each stage the individual has the right to 

request referral of their complaint to the 

Victorian Civil and Administrative Appeals 

Tribunal (VCAT). 

Other Statutory 

Roles 

The OHSC provides training to a wide range 

of health service users, providers and 

organisations that hold health information. 

This is in accordance with the functions 

as outlined in section 9 of the Act. 

A cooperative working relationship exists 

between the OHSC and the complaints 

liaison officers at public hospitals and with 

many other health services in Victoria. 

Consultation with consumer organisations 

can be direct or through “umbrella” 

organisations like the Health Issues Centre. 

Liaison, Training 

and Promotion 

The OHSC consults regularly with the 

12 professional Registration Boards 

about complaint handling in accordance 

with section 19(6) of the HSCR. Regular 

meetings between the OHSC and the 

Boards are held to determine the most 

effective and efficient ways of handling 

complaints about registered practitioners. 

This process avoids double handling and 

ensures the legislative requirements are 

met. The HSC also discusses relevant 

issues with the Ombudsman, the Mental 

Health Review Board, Disability Services 

Commissioner, the Office of the Public 

Advocate, the Coroner, the Privacy 

Commissioner, Victorian Equal Opportunity 

and Human Rights Commission, the 

Infertility Treatment Authority and other 

relevant authorities. These links assist our 

work, especially where the management of 

complaints involves more than one Office. 

The Commissioner places strong emphasis 

on promotion and training to improve 

accessibility of the OHSC to the public and 

health service providers. During the year 

under review the HSC has been represented 

at many conferences and venues to 

promote the work of the Office. During the 

2007/08 financial year the HSC gave 

128 presentations and 18 lectures; 

participated in two hypotheticals and 

two panel discussions; attended four 

seminars and one workshop and gave 

many media interviews. 

10 


Public 

Interest 

Issues 

Cancer Treatments 

The HSC continues to be concerned about the nature and practice 

of some clinics and individuals that advertise and provide alternative 

treatments for cancer and other life threatening conditions. I 

acknowledge the right of people to seek alternative treatments for 

their health, however it is always incumbent upon providers to 

behave ethically and to make sure that fully informed consent is 

given. This includes advising members of the public if there is no 

scientific evidence base for treatments. The HSC continues to work 

with the DHS in this area to determine whether any further 

regulation is required. 

Lasers 

As noted in the Public Interest Issues section of the 2006/07 OHSC 

Annual Report the use of lasers by some beauty therapists who 

provide skin treatments and hair removal treatments is of concern. 

The lack of regulation in this area has allowed some providers to 

use these devices even though they have minimal training. The HSC 

is pleased to note that the DHS has called for tenders to investigate 

this area. Members of the public who are using these services 

should question therapists about the training that has 

been provided to them and what safeguards might be in place to 

protect clients. They should also ask about costs, risks and 

whether the treatments are suitable for their skin type. It is very 

important that people with fair skin are not exposed to unsafe laser 

treatments. Checks can also be made with a general practitioner 

and/or referral. 

Storage and Disposal of 

Medical Records 

A meeting was held at the office of the HSC on Wednesday, 

7 May 2008 to discuss issues arising from the storage, retention 

and disposal of medical records. Present at the meeting were 

representatives of the HSC, HSRC, Royal Australian College of 

General Practitioners, Avant Mutual Group Limited, AMA (Vic) and 

the Medical Practitioners Board of Victoria. 

While the issues are relevant to all health professionals, it was 

decided to have the first meeting restricted to issues relating to 

doctors because it would then be possible to extrapolate from these, 

issues concerning all health professionals. 

At the meeting examples were provided of the types of situations 

where handling of medical records is problematic. These included 

where a doctor has died, been in prison, where records have 

been abandoned, where the medical practice may have been 

sold and where doctors have gone overseas leaving the medical 

records behind. 

While doctors have an obligation to make proper arrangements for 

their medical records under the HRA and other legislation or 

contractual arrangements, this is not always complied with. 

It was decided the preferred option was the regulatory status quo 

and more education and training is vital. The doctors’ organisations 

present were keen to provide further training and education for their 

members about their obligations. 

Health Privacy 

The HSC is concerned about some corporatised services who are 

entering the health field and who take an aggressive and 

uncooperative approach to complaints handling, particularly about 

health privacy matters. Of particular concern is the closure of 

general practices without sufficient notice to patients as required 

under the Statutory Guidelines on Transfer or Closure of the Practice 

or Business of a Health Service Provider issued for the purposes 

of Health Privacy Principle 10.2. 


Analysis of 

Complaint 

Trends 

12 


Throughout this Report anecdotal 

information has been used to illustrate 

the type of complaints received. 

Details have been altered to 

protect confidentiality. 

2007/2008 Summary 

When complaints are received in writing or 

by telephone and they appear to be within 

HSC jurisdiction the details of the complaint 

are recorded on the database and a file 

number assigned. These complaints are 

shown in Table 1 as Complaints Lodged. 

Complaint forms are then sent to the 

complainant for completion and return. 

If these are not returned within one month, 

the file is closed on the database. 

These complaints are shown in Table 2 as 

Single Contact Complaints. 

When a complaint form is returned and the 

matter is within jurisdiction the case 

becomes an Accepted Complaint and is 

assigned to an assessment officer for 

management. These complaints are shown 

in Table 3 as Accepted Cases. 

Summary complaint data from the past year 

is shown in Tables 1, 2 and 3. 

While the overall number of complaints 

lodged appears to have decreased this 

year, it may be due to an increasing number 

of complainants using the HSC Website to 

download complaint forms rather than 

telephoning to initiate their complaints. 

The number of accepted cases is similar to 

that of the past two years and so caseloads 

have not varied from the previous year. 

The proportion of HRA complaints in 

comparison to HSCR complaints remains 

around 10% as for previous years. 

2007 - 2008 2006 - 2007 

HSCR 1799 90% 1961 90% 

HRA 195 10% 211 10% 

Total 1994 2172 

Table 1 

New Complaints lodged with OHSC 

(Complaints received complaint forms sent out) 

2007 - 2008 2006 - 2007 

HSCR 754 88% 885 90% 

HRA 99 12% 93 10% 

Total 853 978 

Table 2 

Single Contact complaints 

(Complaints closed because no complaint 

form returned) 

2007 - 2008 2006 - 2007 

HSCR 1053 92% 1081 92% 

HRA 86 8% 89 8% 

Total 1139 1170 

Table 3 

Accepted cases 

(Complaint Forms received and 

approved for assessment) 

Enquiries 

The OHSC offers advice and assistance to 

callers who may wish to make a complaint 

or who seek information about a health 

service. In the past year there were 

approximately 5,500 calls recorded where 

advice and information was given but no 

complaint was recorded. This is similar to 

previous years. Approximately one in three 

calls were enquiries about access to health 

records or privacy matters under the HRA. 

HRA Issues 

Other Issues 

Access to records 15% Brochure 1% 

Fees 2% Fees 6% 

Privacy Information 3% Food & environmental health issues 7% 

FOI Requests 1% Health insurance 2% 

Presentation to a Group 1% Hospital waiting lists 1% 

Written Inquiry 2% Other 26% 

Telephone Enquiry 5% Referred elsewhere 28% 

29% 71% 

Table 4 

Enquiry types 


Who complained? 

A complainant is most often the user of the 

health service but could also be the next of 

kin or legal representative or a person 

appointed by the service user to complain 

on his or her behalf. Complaints can be 

accepted from third parties at the discretion 

of the Commissioner where a user is 

unable to complain on their own behalf. 

The complaints must always be made 

either by, or on behalf of, a user of a 

Victorian health service. 

636 

Female 

620 

534 

Male 

519 

Legend 

2007 - 2008 

2006 - 2007 

Figure 1 

Consumer Gender 

Fifty-five percent of complaints made were 

about health services received by women, 

the same as the previous year. There is also 

an age factor in complaints. For example 

there were almost double the number of 

complaints made in relation to care received 

by males in the 0 to 14 age group and 

just slightly more complaints in relation to 

care received by males aged over 75. 

In all other age/gender groups there were 

more complaints about the care received 

by females. 

Age Range Female Male Total 

0 - 01 2 7 9 

01 - 04 6 6 12 

05 - 14 11 21 32 

15 - 24 31 14 45 

25 - 34 78 39 117 

35 - 44 94 45 139 

45 - 54 82 55 137 

55 - 64 76 75 151 

65 - 74 44 31 75 

75+ 50 53 103 

Unknown 144 173 319 

Total 620 519 1139 

Table 5 

Consumer Profile 

14 


How 

Complaints 

Are 

Managed 

The enquiry telephone line operates from 9.00am to 4.45pm, four 

days a week and from 9.00am to 1.00pm on Fridays. At other times 

messages may be left on the answering machine or with reception. 

Assessment Officers are usually the first point of contact for 

members of the public and have a broad knowledge of health issues 

and, where appropriate, can provide referrals to other agencies if 

the enquiry does not come within the jurisdiction of the HSC. 

When enquiries are received by telephone, an Assessment Officer 

listens and assesses the issues the caller is presenting. As 

required by the legislation, the Officer advises and encourages 

callers, where appropriate, to make direct contact with the service 

provider as the first step in resolving the complaint. It is thought 

many of the unconfirmed complaints are resolved in this way. The 

OHSC accepts not everyone is able to do this for him or herself and 

assists whenever necessary. 

If the complaint is about a health service provider, and the 

complainant has been unable to resolve the matter directly, a 

complaint form is sent out. The service user is asked to complete 

the form, sign an authorisation and give details of the complaint. 

The legislation requires that complaints made on the telephone or 

in person are confirmed in writing. Staff can assist in this process. 

All potential complaints are recorded on the database as cases. If 

a complaint is not confirmed in writing, the matter is closed 

although complaints identified as serious may be followed up. If 

a complaint is from a person from a CALD background the officer 

may use interpreter services and assist the person to make the 

complaint. Assessment Officers are also available to talk with 

prospective complainants if they attend the office and appointments 

can be made by telephoning the Helpline on (03) 8601 5200. 

Confirmed complaints are entered on the database in detail, 

including a summary of the complaint. The complaint is then sent 

to the health service provider who is asked to respond within 14 

days. A written response will be sent to the OHSC and this is usually 

sent to the complainant for comment. This process resolves the 

majority of complaints. A clear explanation from the health 

service and, where appropriate, an apology continues to be the most 

effective means of resolving complaints. 

The maximum time a complaint may remain in the assessment 

stage is 84 days. If a case is not resolved within this time the 

Commissioner can decide to refer the case to conciliation. 

The referral can occur earlier if the circumstances of the case 

warrant this. 

The conciliation process is quarantined from all other processes 

within the OHSC and its aim is to encourage settlement of the 

complaint by arranging informal, confidential discussions between 

the parties. 

Within two weeks of receiving the referral the conciliator writes to 

the parties giving details of the arrangements for the discussions. 

These proceedings are privileged and nothing said or disclosed 

during the conciliation may be admitted in any court action. 

The process is entirely voluntary; at any stage in the negotiations 

either party can decide not to proceed any further and this ends 

the matter n conciliation. 

Generally complaints in conciliation fall into two categories. 

One group requires further explanation as to what happened and 

expert advice or opinion may be used for this purpose. The other 

is a claim for damages, compensation or remedial treatment where 

there have been allegations or sometimes evidence of negligence. 

Often they involve elements of both. A claim for compensation is 

usually negotiated between the parties and their advisors, with the 

conciliator as the link, with or without a meeting. 

When there is a dispute about a health service provider's liability 

for a claim, with the agreement of the parties, independent 

expert opinion can be sought. The conciliator organises this from 

an expert in the relevant field. Copies of this opinion go to the parties 

who use it as a basis for further negotiations. 

If conciliation results in the payment of damages or compensation 

release documents are prepared and signed and that is the end of 

the matter. It cannot be pursued further. 


How were the complaints resolved? 

The complaints closed in enquiry are those 

that were not confirmed in writing. The 

resolution of these may be that the caller 

felt it was sufficient to tell someone why 

they were unhappy and to be heard, however 

they may also remain unresolved and the 

person may decide to proceed with the 

complaint at some time in the future. There 

is a one year time limit on complaints but 

the Commissioner has the discretionary 

power to extend this. 

The confirmed cases are resolved either in 

the initial assessment process or they are 

referred to conciliation. A very small 

number are referred for investigation but 

this only happens when mediation and 

conciliation or referrals to registration 

boards are not feasible options. This year 

approximately 81% of confirmed cases 

were resolved in assessment. 

The stages at which complaints were 

resolved can be seen in Table 6. 

Seriousness 

All new complaints are given a 

“seriousness” rating which depends upon 

the severity of the outcome for the 

consumer and the perceived level of risk of 

the incident. This rating is allocated initially 

Stage of Complaint Process HRA HSCR Total % 

Closed in Assessment 64 852 916 81% 

Closed in Conciliation 15 205 220 19% 

Closed in Investigation 0 2 2 0% 

Total Cases Closed 79 1059 1138 100% 

Table 6 

Resolution Stages 

HRA HSCR Total % 

0-3 Months 53 489 902 79% 

3-6 Months 10 45 55 5% 

3-6 Months 7 42 49 4% 

9-12 Months 3 36 39 3% 

12-18 Months 5 47 52 5% 

18-24 Months 1 20 21 2% 

24 Over 0 20 20 2% 

Total Cases Closed 79 1059 1138 100% 

The data in Table 6.1 illustrates the time 

taken to resolve and close confirmed cases. 

The first three months is, generally, spent 

in the assessment stage where 

approximately 80% of cases are resolved 

and closed. Legislated timelines require 

assessment to be completed within three 

months. 

on the basis of the complaint information 

and may be revised and changed during the 

course of complaint management as new 

information emerges. 

Table 6 .1 

Time till Resolution 

The next stage is usually conciliation (or, 

infrequently, investigation). For the cases 

not closed in assessment 60% were 

completed within twelve months, 30% in two 

years and the remainder in more than two 

years. This is often due to the complexity of 

the issues and the multiple complicated 

activities required to reach completion. 

Seriousness Rating 

1. Low: A phone call, letter or an 

explanation should easily resolve the 

problem. Included in this rating are 

complaints that are frivolous, vexatious, 

obviously misconceived or where an 

investigation is unwarranted. 

2. Medium: Frequently there has been a 

misunderstanding; issues involving access 

to records, disputes about costs, 

discourtesy, diagnostic or treatment errors 

or differences of opinion without serious 

consequences. 

3. High: There may be quality assurance 

implications, where changes in practice are 

needed to avoid a recurrence or there is a 

need for policy development. These also 

include complaints associated with 

allegations of negligence leading to 

personal injury, professional misconduct, 

unlawful or unethical acts, lack of informed 

consent with serious adverse outcomes. 

The seriousness rating of accepted cases 

closed in the past year is seen in Table 7. 


HRA Low Medium High Total % 

Access & Correction 22 15 0 37 4% 

Collection 2 1 1 4 0% 

Data Quality 1 3 0 4 0% 

Identifiers 0 1 0 1 0% 

Info Available to another HSP 6 1 0 7 1% 

Transfer/Closure of HSP 1 0 0 1 0% 

Use & Disclosure 7 15 1 23 2% 

None 1 1 0 2 0% 

Total 40 37 2 79 7% 

HSCR Low Medium High Total % 

Access 55 34 10 99 9% 

Administration 43 13 2 58 5% 

Communication 75 55 6 136 12% 

Cost 58 26 2 86 8% 

Not Specified 3 5 0 8 0% 

Rights 42 21 7 70 6% 

Treatment 178 328 96 602 53% 

Total 454 482 123 1059 93% 

Grand Total 494 519 125 1138 100% 

43% 46% 11% 100% 

Table 7 

Seriousness by Issue at Closure 

The majority of complaints received (89%) 

are rated as “low” or “medium” seriousness 

and this is consistent from year to year. The 

majority of these complaints can be resolved 

by further explanation by the health service 

for the complainant. 

16 


Assessment Report 

An Assessment officer is rostered 16 hours 

a week on the enquiry telephone line and 

manages a caseload of approximately 35 

files. The officer helps the complainant to 

identify the issues they wish to raise with the 

service and assists the complainant to 

present these issues in an objective manner 

conducive to mediation and conciliation. 

This is important not only because of the 

approach to complaint resolution taken by 

OHSC but also because experience shows 

this is the most effective way to ensure the 

complaint is given appropriate consideration 

in order to achieve resolution. 

The service is advised of the complaint in 

writing and asked to respond as soon as 

possible. The officer follows up overdue 

responses and can give assistance to 

services who ask for help in responding. 

Liaising between both parties and keeping 

everyone informed of potential delays is an 

important aspect of the role. Once the 

response is received and reviewed by the 

officer it is sent to the complainant with a 

request that they contact the officer to 

discuss. For complainants who remain 

dissatisfied the officer will work to assist 

them to clearly identify what issues remain 

Assessment Officer 

Jill Aitken 

unresolved and to articulate what they 

hope to achieve in pursuing their complaint. 

Most complaints are resolved in this process 

and those that remain unresolved may 

proceed to conciliation. 

Assessment Officer 

Piotr Nyczek 

HSCR HRA Total % 

Apology 90 1 91 8% 

Compensation 8 0 8 1% 

Declined 328 23 351 34% 

Explanation 345 9 354 35% 

Fees/Cost waived or reduced 44 3 47 5% 

Quality change 36 4 40 4% 

Referred Out 72 4 76 7% 

Service obtained 23 6 29 3% 

Withdrawn 12 7 19 2% 

HRA - Access to records 0 9 9 1% 

HRA - Action/compliance order 0 0 0 0% 

HRA - Dismissed 0 1 1 0% 

Total 958 67 1025 100% 

93% 7% 

Table 8 

Resolution in Assessment 

For those complaints not declined, the 

most frequent outcome (35%) was an 

explanation of the incident that led to the 

complaint. Quite often this is all that is 

needed to resolve the matter. The OHSC has 

monitored the recording of outcomes to 

complaints in the past year to ensure that 

all outcomes are recorded accurately. As a 

result of this, apologies have increased to 

8% from 4% in the previous year and the 

percentage of recorded quality changes 

has also increased from 1% to 4%. 

A complaint about a health service lodged 

under the HSCR or the HRA may be 

declined in assessment because it is outside 

jurisdiction, already determined by some 

other office or agency or for a number of 

other reasons as shown in Table 9a and 9b. 

HSCR 

19 (1) The complaint is frivolous, vexatious or trivial 34 10% 

19 (2) The complaint has been determined elsewhere 63 18% 

19 (3) The incident occurred more than 12 months ago 2 0% 

19 (4) (a) The complaint was not confirmed in writing 82 23% 

19 (4) (b) The complaint contains insufficient detail 61 17% 

19 (5) Reasonable steps not taken 26 7% 

19 (6) The complaint has been referred to a registration board 7 2% 

19 (7) The complaint has been referred to an external person, organisation or agency 13 4% 

19 (8) (a) The complaint was rejected (Outside of jurisdiction) 40 11% 

Total 328 92% 

Table 9a 

Reason given for Decline in Assessment 

As with telephone complaints, people who 

write to the HSC or contact us in some other 

way often decide not to take the complaint 

further. They may send in a copy of a 

complaint letter written to a health service 

or write only to the Commissioner about 

their concerns, however they then either do 

not complete or return the complaint form 

or they do not provide further information as 

requested. These complaints are declined 

under s19 (4) and this was the outcome for 

82 complaints in the past year. The HSC also 

does not accept complaints that have been 

determined by some other jurisdiction such 

as the Coroner and this applied to 63 cases. 


HRA 

HRA - 45 (4) Complaint not confirmed in writing 6 2% 

HRA - 51 1(a) Not an interference with the privacy of an individual 5 2% 

HRA - 51 1(c) Complaint not made to respondent by complainant 0 0% 

HRA - 51 1(f) Complaint is subject to another enactment, court or tribunal 1 0% 

HRA - 51 1(h) Respondent dealing/dealt with or hasn’t had opportunity to deal with complaint 5 2% 

HRA - 52 (1) Complaint referred to Registration Board 0 0% 

HRA - Complaint did not proceed 0 0% 

HRA - Outside jurisdiction 6 2% 

Total 23 8% 

Conciliation Report 

Keith Jackson 

Chief Conciliator 

The conciliation team deals with around 300 

new complaints each year. The complaint 

files vary in complexity with some major 

claims for compensation taking up to two to 

three years to conciliate. During the past 

year a number of these long-standing 

claims have settled, some for amounts in 

excess of $600,000. The majority of 

complaints are made under the HSCR 

while complaints lodged under the HRA, 

although less numerous, often involve 

unprecedented facts and dilemmas for the 

conciliators to work through. 

A young woman still living at home attended a 

radiology centre for an ultrasound that 

confirmed she was pregnant. The woman 

elected to have the pregnancy terminated. The 

outstanding account was handed by the centre’s 

receptionist to the complainant’s mother. The 

account stated the service provided to the 

daughter and the mother’s access to this 

information led to a breakdown of her 

relationship with her daughter. The 

complainant pursued a complaint under the 

HRA claiming that her private health 

information was disclosed to her mother 

without her consent. The disclosure was 

acknowledged by the radiology centre. The 

complaint was resolved in conciliation by way of 

a monetary settlement for the pain and 

suffering experienced by the complainant. 

Table 9b 

Reason given for Decline in Assessment 

Although the types of complaints referred 

to conciliation under the HSCR vary widely, 

at the most serious end of the scale there 

continue to be complaints about major 

medical misadventures. 

A woman underwent a varicose vein procedure 

during which the common peroneal nerve was 

mistakenly identified as a vein and severed. The 

immediate consequence was a condition known 

as foot drop, resulting in numbness and 

alteration to the gait. The injury was identified 

immediately. The hospital arranged for 

assistance to the woman and her family and 

referred her claim for compensation to its 

insurers. The complaint has been settled in 

conciliation. 

Conciliation continues to be regarded by 

health consumers and providers as a 

successful mechanism for the resolution of 

complaints, including matters that might 

otherwise have been dealt with by litigation 

before the courts. The level of co-operation 

continues to be high and there is recognition 

that the conciliation processes are impartial 

and fair. Many health service consumers 

express a preference for conciliation even 

though they have the option of litigation. 

Whilst the changes to The Wrongs Act 

1958 have made it more difficult to claim for 

general damages (pain and suffering etc.), 

in some cases the need for impairment 

assessments is waived and settlements can 

then be negotiated without undue delay. 

A woman underwent removal of her ovaries at 

her local rural hospital. Several days later the 

woman was found to have had a bowel 

perforation, septicaemia and subsequently 

suffered a stroke. The settlement of this claim 

was assisted by a high level of co-operation 

from the hospital, its insurer and solicitors and 

resulted in significant quality changes at the 

hospital. 

Although a collaborative and conciliatory 

approach is very much in the spirit of the 

HSCR, unfortunately there are examples of 

long-standing files closing because of a lack 

of co-operation on the part of the health 

service provider, their insurer and/or 

solicitor even though they had agreed to 

participate in the process. 

As for the HSCR some people may write to 

the Commissioner with complaints under 

the HRA but then do not complete and 

return the complaint form. This accounts 

for approximately 25% of declined HRA 

complaints. 

A man underwent a laparascopic 

cholycystectomy and suffered a major 

complication. With the consent of the parties an 

independent opinion was obtained in 

conciliation. The opinion was critical of the 

hospital’s management. Impairment 

assessments (both physical and psychiatric) 

were also obtained. The impairment 

assessments were referred to the Medical 

Panels and although the Panels agreed the 

injuries satisfied the Wrongs Act 1958 

thresholds there was no response from the 

respondent’s solicitor in relation to the 

complainant’s offer of settlement. The 

complainant has sought legal advice. 

The appointment of a Senior Medical Officer 

has produced immediate benefits for the 

whole office, and in particular for the 

conciliators. The availability of speedy 

advice and informal opinions on medical 

matters in conciliation, along with advice as 

to the appropriate specialties and 

consultants from whom we should seek 

opinions has facilitated the handling of 

complex complaints. 

There were 291 files referred for conciliation 

during 2007/08. The outcomes have varied 

as demonstrated by Table 10. 80% of 

complaints were resolved, 2% referred to 

registration boards from conciliation and the 

remaining 18% either withdrawn or were 

unable to be conciliated. 

18 


Lynn Buchanan 

Senior Conciliator 

HSCR HRA Total % 

Apology 71 5 76 23% 

Compensation 43 2 45 14% 

Explanation 107 4 111 34% 

Fees/Cost waived or reduced 9 0 0 3% 

Non-conciliable 30 2 32 10% 

Quality change 16 2 19 6% 

Referred Out 4 1 5 2% 

Service obtained 2 0 2 0% 

Withdrawn 20 7 27 8% 

HRA - Access to records 0 2 2 0% 

HRA - Action/compliance order 0 0 0 0% 

HRA - Dismissed 0 1 1 0% 

Grand Total 265 26 291 100% 

91% 9% 

Table 10 

Resolution in Conciliation 

Aboriginal Liaison Officer's Report 

Melanie Fraser 

Aboriginal Liaison Officer 

Back row L-R: Loretta O’Neil (Victorian Aboriginal 

Legal Service), Petra Jankulovski (Public Transport 

Ombudsman), Heather Venn (Privacy Victoria), Melanie 

Fraser (Office of the Health Services Commissioner), 

Lucinda Puls (Ombudsman’s Office), Nellie Flagg 

(Victims Support Agency), Candyce Presland (Energy 

and Water Ombudsman Victoria), 

Front row L-R: Kerri-Lee Harding (Consumer Affairs 

Victoria), Richard Frankland, Steven Tregonning 

(Dispute Settlement Service Victoria), Kellie Frankland 

(Dhau Wurd-Wurrung Elderly Citizens Association) 

The Aboriginal Liaison Officer (ALO) 

performs two important functions: 

• Responding to enquiries and complaints 

received from Aboriginal and Torres 

Strait Islander consumers about health 

services; and 

• Performing outreach activities 

promoting the services of this Office 

within indigenous communities in 

Victoria. 

Complaints 

Aboriginal and Torres Strait Islander 

complaints continue to revolve around 

issues of communication and access to 

services. 

The ALO can respond to non-complex 

complaints informally and quickly with the 

permission of both parties to the dispute 

and also resolving more complex 

complaints in conciliation. 

Assistance can be provided in the form of 

help formulating complaints, raising 

concerns with health care providers and 

arranging meetings between parties 

with a view to discussing concerns and 

resolving differences. 

An Aboriginal woman complained about 

the accuracy of health information in her 

medical file at an Aboriginal community 

controlled health organisation. She only 

became aware of this when she read 

information contained in a referral letter. 

She approached the service to have the 

information corrected and contacted the 

OHSC to ensure corrections were made in 

accordance with requirements under the 

HRA 2001. 

A meeting was held between the parties 

and the health service apologised for 

mistakes that had been made. Arrangements 

were made for the woman to go through her 

entire record with a staff member present and 

for her to be present when amendments were 

made to her record. It was important for all 

parties present that the relationship remain 

amicable and that the woman felt she could 

continue to use the service and this was 

achieved as a result of the meeting. 

Outreach 

The ALO has visited a number of regions in 

the past year liaising with various 

stakeholders. Most particularly, she has 

been actively involved with the Koories 

Know Your Rights campaign in partnership 

with Consumer Affairs Victoria and a 

number of other agencies. 

This campaign has worked towards creating 

awareness in Victorian indigenous 

communities of services available from a 

number of alternative dispute resolution 

agencies and government departments. 

Regions targeted over the past year 

included Gippsland and Barwon South West 

Regions, in addition to attendance at 

Crocfest in Shepparton and a number of 

events in the metropolitan region. 


Nature of Complaint 

HRA Issue 

Access & Correction 2 

Data Quality 0 

Use & Disclosure 2 

HSCR Issue 

Access 9 

Administration 2 

Communication 7 

Cost 0 

Rights 3 

Treatment 14 

Not specified 0 

Total 39 

Table 11 

ATSI Complaints and Enquiries 

Registrar’s Report 

Shiranee Sinnathamby 

Registrar 

The Registrar’s role of interacting on a 

regular basis with health registration boards 

and other agencies has continued to the 

mutual benefit of all parties. Assistance is 

provided to each other by providing and 

receiving advice and making decisions 

about the management of complaints and 

notifications, as and when they are received. 

Complaints which may be conciliated are 

addressed by the OHSC while matters 

pertaining to professional conduct issues 

are addressed by the registration boards. 

The implementation of the Health 

Professions Registration Act 2005 (HPRA) 

posed no difficulties and saw the smooth 

transition and continuation of business 

between the registration boards and 

the OHSC. 

During the year under review the OHSC 

received a total of 684 notifications from 11 

registration boards, for comment. Of these 

21 notifications were referred formally 

to the OHSC for attention. By comparison, 

413 OHSC matters were forwarded to the 

boards for comment and again, following 

discussion, 58 of these were referred 

formally for consideration by the boards. 

Of the 1,097 complaints/notifications 

discussed, 685 were about medical 

practitioners, 189 related to dental 

practitioners, 60 concerned pharmacists 

while 54 matters were complaints 

pertaining to psychologists. This meant 

that 988 complaints/notifications related 

to practitioners registered with four 

of the boards with 109 matters being 

complaints/notifications about practitioners 

registered with the remaining eight 

boards. Table 12 provides an analysis of 

these figures. 

Organisation 

Board complaints 

discussed with HSC 

HSC complaints 

discussed with Boards 

HSC complaints formally 

referred to Boards 

Board complaints formally 

referred to HSC 

Chinese Medicine Registration Board 19 1 0 0 

Chiropractors Registration Board of Victoria 9 2 2 0 

Dental Practice Board of Victoria 112 77 6 1 

Medical Practitioners Board of Victoria 406 279 34 15 

Medical Radiation Practitioners Board of Victoria 0 1 0 0 

Nurses Board of Victoria 29 9 3 2 

Optometrists Registration Board of Victoria 3 13 2 0 

Osteopaths Registration Board of Victoria 4 0 0 0 

Pharmacy Board of Victoria 49 11 4 3 

Physiotherapists Registration Board of Victoria 6 8 1 0 

Podiatrists Registration Board of Victoria 1 4 2 0 

Psychologists Registration Board of Victoria 46 89 4 0 

Total 684 413 58 21 

Table 12 

Dealings with Registration Boards 

The table below gives comparative figures 

of discussions and referrals between the 

registration boards and the OHSC over a 

four year period. There has not been a great 

deal of variance over the four year period. 

20 


Year 

Board notifications 

discussed with OHSC 

HSC complaints 

discussed with boards 

HSC complaints formally 

referred to boards 

Board notifications 

formally referred to HSC 

2005 708 390 57 18 

2006 585 365 45 20 

2007 695 435 63 20 

2008 684 413 58 21 

Table 13 

Comparison of total complaint numbers and those referred in the past four years 

The Office’s interactions with other agencies 

continued with Memorandums of 

Understanding being drawn up with the 

Office of the Chief Psychiatrist and the 

Aged Care Complaints Investigations 

Scheme, establishing protocols for the 

exchange of complaint related information 

between the OHSC and these organisations. 

Meetings were held with the State Coroner’s 

Office and the Disability Services 

Commissioner’s Office and protocols agreed 

to for the sharing of information. Regular 

interactions with other agencies have 

continued satisfactorily and to the mutual 

benefit of all concerned. 

During the year under review the OHSC 

referred five complaints to the Disability 

Services Commissioner and one complaint 

each was referred to WorkSafe Victoria, the 

State Coroner, the Office of the Chief 

Psychiatrist and Supported Residential 

Services, DHS. In terms of referrals in to the 

OHSC from other agencies, eight referrals 

were made by the Aged Care Complaints 

Investigations Scheme and six came from 

Consumer Affairs. The Ombudsman 

regularly refers matters to the OHSC and 

these are covered in the section pertaining 

to prisoner complaints. Apart from the 

prisoner complaints one other matter was 

referred to the OHSC by the Ombudsman. 

Under the Freedom of Information Act 

(FOI), nine FOI requests were processed 

during the year as opposed to three the 

preceding year. 

The Registrar’s role includes the approval 

and assessment of complaints, providing 

advice and support as a member of the 

assessment team, deputising for the 

Manager of Assessment and Investigation 

as required and participating in training 

activities the Office undertakes for external 

groups and individuals on an ongoing basis. 

Meetings are arranged between OHSC staff 

and registration boards’ complaint handling 

staff and with staff of other agencies. These 

have proven to be useful forums for the 

exchange of ideas, policy development, 

education and training, as are the regular 

meetings of CEOs/Registrars. 

The co-operation of the registration boards’ 

CEOs/Registrars and other staff of the 

boards, and all staff members of other 

agencies who work closely with the OHSC 

is greatly appreciated. 

Health Professions Registration Act 2005 

and Investigation Review Panels 

Following the Department of Human 

Services “Review of the Regulation of the 

Health Professions” conducted between 

2002 and 2005, the Health Professions 

Registration Act 2005 (HPRA) was passed by 

Victoria’s Parliament in November 2005 

and came into operation on 1 July 2007. It 

repealed the eleven separate health 

practitioner registration Acts and section 

108AL of the Health Act 1958 relating to 

medical radiation practitioners. The HPRA 

covers people who are or will be registered 

as Chinese medicine practitioners, 

chiropractors, dental care providers, 

medical practitioners, medical radiation 

practitioners, nurses, optometrists, 

osteopaths, pharmacists, physiotherapists, 

podiatrists and psychologists. 

The HPRA established a statutory merits 

review for complainants who are aggrieved 

by a registration board decision not to 

investigate their complaint, to close their 

complaint following investigation, or a 

decision to forward the complaint to an 

internal ‘professional standards panel’ 

of the board rather than to the VCAT 

for hearing. 

The right of review has been framed to 

respond to concerns of consumers, some of 

whom do not have confidence in the 

transparency and fairness of registration 

board complaints handling. It is designed 

to provide a better balance between the 

rights and needs of consumers, and those 

of practitioners. 

When a registration board receives a 

complaint about a registered health 

practitioner, the board has powers to 

appoint an investigator, conduct an 

investigation and then decide whether 

disciplinary action is required, and if so, 

what type and what sanctions should be 

imposed on the practitioner. 

Section 60 of the HPRA provides that a 

notifier (the term used in the HPRA to 

describe a person who makes a complaint 

to a registration board about a registered 

practitioner) may apply to a responsible 

board for review of an investigation decision, 

for example, if the notifier is dissatisfied with 

the decision. On receipt of such an 

application, the responsible board is 

required to establish an Investigation Review 

Panel (IRP). Schedule 2 of the HPRA sets 

out the requirements the board must 

comply with when convening an IRP. 

An IRP must be made up of a lawyer (who 

chairs the panel), a practitioner member, 

and a nominee of the HSC. The HSC is a 

statutory officer, with powers established 

under the HSCR. The intent is that a 

nominee of the HSC will bring a level of 

independent scrutiny to the review of a 

complaint by a registration board. 

As detailed in Section 60 of the HPRA, 

board decisions that an IRP can review 

include: 

• the decision not to investigate a 

notification; 

• the decision to close a matter following 

investigation, with no further action; or 

• the decision to refer a matter to an 

internally convened professional 

standards panel, rather than for external 

hearing by VCAT. 

An IRP has and may exercise all the powers 

of an investigator under the HPRA. 

After completing a review of a decision, 

the panel may: 

a. affirm the earlier decision of the 

responsible board, 

b. refer the matter to the board with a 

request for an investigation, 

c. refer the matter back to the board or the 

investigator for further investigation, 

d. in the case of the review of a decision to 

take no further action, it may substitute 

its own decision from the range of 

decisions originally available to the 

board following an investigation (such as 


conduct a health or performance 

assessment or a professional standards 

or health panel hearing, or refer the 

matter to an external body), 

e) in the case of the review of a decision to 

refer the matter to a professional 

standards panel rather than VCAT, 

request the board to refer the matter to 

VCAT for a Tribunal hearing. 

During the period under review, the HSC 

received 11 requests for participation on 

IRPs established to review a board decision. 

Prisoner Complaints 

The Office receives complaints from 

prisoners by letter and telephone calls. 

Complaints are also received from 

Ombudsman Victoria from prisoners who 

have telephoned them on their “prisoner 

free call service”. The OHSC refers 

complaints that either directly relate to 

correctional issues, or cross with 

correctional issues, to the Ombudsman 

for their attention. The OHSC continues to 

liaise with, and refer complaints to the 

Justice Health Unit at the Correctional 

Services Commissioner’s Office for their 

information. A poster campaign continues 

at all prisons. 

Generally the issues of complaint remain 

the same at each reporting period. 

Access to services, dissatisfaction with 

treatment and the provision of medication 

continues to dominate complaints. 

Once again a continuing concern for the 

OHSC, and the frequent subject of 

complaint from prisoners is, the 

inconsistency of prescribing by doctors. 

Prisoners see many different doctors 

throughout their incarceration and, 

while they may be prescribed a particular 

medication regime at one prison, this does 

not mean they will be prescribed the 

same medication when they are transferred 

to another location. This is a constant 

frustration to prisoners who believe they 

were stable on their medication before it 

was changed. While medication is a matter 

of clinical judgement it would assist 

communication and understanding if health 

services communicated with each other in 

these cases. 

The co-operative approach by the health 

service providers helps bring most 

complaints to a satisfactory resolution. 

Whilst some prisoners may not be satisfied 

with the outcome, the responses to their 

complaints would indicate they are mostly 

receiving satisfactory services. 

Registration Board 

Chinese Medicine Registration Board 0 

Chiropractors Registration Board of Victoria 0 

Dental Practice Board of Victoria 2 

Medical Practitioners Board of Victoria 9 

Medical Radiation Practitioners Board of Victoria 0 

Nurses Board of Victoria 0 

Optometrists Registration Board of Victoria 0 

Osteopaths Registration Board of Victoria 0 

Pharmacy Board of Victoria 0 

Physiotherapists Registration Board of Victoria 0 

Podiatrists Registration Board of Victoria 0 

Psychologists Registration Board of Victoria 0 

Total 11 

Table 14 

Investigation Review Panels held in 2007-2008 

A prisoner who suffers diabetes was prescribed multivitamins at one prison for a period of 12 months. 

He believed they assisted with his general wellbeing. He was transferred to a different prison where the 

doctor concluded that the multivitamins were of no benefit to the prisoner as he was not suffering from a 

dietary deficiency and his prescription was ceased. The health provider advised he could purchase them 

from the prison canteen if he wished to. 

HSC advised the prisoner that, apart from bringing the concerns to the attention of the prison health 

service, there was little more we could achieve as doctors are entitled to make their own clinical decisions. 

Legend 


2006 - 2007 

Access 

Administration 

Communication 

Cost 

Rights 

Treatment 

Access and Correction 

Not Specified 

1 

1 

2 

2 

1 

2 

0 

0 

0 

2 

0 

0 

HSCR Issues 

HRA Issues 

23 

37 

59 

69 

Figure 2 

Prisoner Complaints 

22 


Reasons 

For Complaints 

Complaints received by the HSC are classified according to their underlying issues. 

The broad categories are as follows: 

HSCR Issue Categories 

• Access Availability of services in terms 

of location, waiting times and other 

constraints that limit use of the service; 

• Treatment Diagnosis, testing, 

medication and other therapies 

provided; 

• Communication Manner of 

communication such as rudeness, 

disinterest, quality and quantity of 

information provided about treatment, 

risks, outcomes and prognosis; 

• Cost Information about costs and fees, 

discrepancies between advertised and 

actual costs, charges and rebates; 

• Rights Dignity, consent to treatment; 

• Administration Support services for 

providers such as reception, waiting 

lists, cleaning services, etc. 


HRA Issue Categories 

• Access and correction right of individuals 

to access and correct health information 

held about them, subject to certain 

criteria; 

• Anonymity right of an individual not to 

identify him or herself when it is lawful 

and practicable; 

• Collection how and when health 

information is collected; 

• Data quality how accurate, complete, up 

to date and relevant the health 

information is, having regard to the 

purpose for which it is held; 

• Identifiers the unnecessary use of 

identifiers, for example the use of a 

public sector identifier by a private 

sector organisation can only occur with 

the individual's consent or if it is required 

by law; 

• Information available to another health 

service one health service making 

information available to another; 

• Openness organisation’s policies on 

the management of health information 

and steps an individual must take to 

access their health information; 

• Transborder data flows the transfer of 

an individual's health information 

outside Victoria; 

• Transfer/Closure of a practice the 

process to be followed when a practice 

or business of a health service provider 

is sold or closed; and 

• Use and disclosure how an organisation 

has used or disclosed an individual's 

health information. 

Most complaints identify only one of these 

as an issue but approximately one in three 

raises concerns about more than one issue. 

Primary Issues in HSCR Complaints 

During the past year 1053 complaints were 

accepted under the HSCR Act. The primary 

issues in these complaints are shown 

below. 

As in previous years treatment issues 

accounted for two thirds of complaints. 

604 

99 

55 

140 

87 

Legend 

Access 


Communication 

Cost 

Rights 

Treatment 

68 

Figure 3 

Issues Raised 

Access 

People complain when they are refused 

access to treatment or circumstances mean 

that treatment is not available for them. 

Access issues raised in complaints are 

shown in Table 15. 

Access 10% 

Communication breakdown 3 

Delay in admission 6 

Delay in treatment 24 

Discharge arrangements 14 

Discharge/Transfer 4 

No/inadequate service 29 

Non attendance 1 

Other 5 

Waiting list 8 

Refusal to refer 2 

Refused admission 3 

Total Access 99 

Table 15 

Access 

A man had been attending a public dental 

service as he had problems with a number of 

his teeth. His dental problems were such that a 

number of extractions were required. The man 

complained that the service refused to provide 

implants to replace these teeth although a 

private dentist was willing to do this. The 

service responded explaining it was policy not to 

provide high cost, high risk treatment to 

patients because of limited resources and the 

man had been identified as a high risk patient. 

Although he remained dissatisfied, the man was 

advised that this explanation was reasonable 

and nothing further could be done. 


Occasionally people complain about the 

administrative staff and policies of a health 

service. They might say they found the 

receptionist rude and uncaring, or that 

their messages are not passed to the 

health professionals in a timely manner. As 

for last year, one concern was the service’s 

failure to respond to letters or phone calls. 

The administration issues in complaints are 

listed In Table 16. 

Administration 5% 

Advertising 2 

Administration 15 

Failure to provide certificate 3 

Hygiene 5 

No/inadequate response 14 


Policy 4 

Total Administration 55 

Table 16 

Administrative Issues 

A woman requested her doctor provide her 

with a treatment plan so she could consult a 

psychologist under Medicare. The doctor agreed 

to do this and wrote a referral for the woman on 

the same day. Because of some communication 

problems the treatment plan was not written 

until after the woman had consulted the 

psychologist on three occasions. She then 

realised she could not claim for these costs on 

Medicare. The doctor apologised for the 

misunderstanding and contributed to the cost of 

the psychologist’s contributions. 

24 


Communication 

The sub-issues where communication was 

named as the primary concern of a 

complaint can be seen in Table 17, however 

experience shows communication is a 

feature of all complaints. Poor 

attitude/discourtesy is again the most 

frequent at 26% of all complaints about 

communication. 

Cost 

The most frequent cost issue in the past 

year (33%) related to billing practices with 

some service users receiving their first 

account two years after the procedure or 

complaining that an account was referred 

to a debt collector too quickly. People also 

complain about the overall cost of health 

services as they believe these should be 

regulated. The cost issues raised in 

complaints can be seen in Table 18. 

A family newly migrated to Australia 

were concerned about their infant daughter 

and called a local medical clinic to arrange 

an appointment for her. An appointment was 

Communication 13% 

Absence of caring 25 

Failure to consult 21 

Inconsiderate/undignified service 16 


Poor attitude/discourtesy 36 

Wrong/misleading Information 16 

Total Communication 140 

Table 17 

Communication 

Cost 9% 

Amount charged 23 

Billing practices 29 

Information on costs 21 


Over servicing/ unnecessary treatment 2 

Health Insurance 3 

Public/private election 1 

Total Cost 87 

Table 18 

Cost 

made for later that day, however when the parents 

arrived with the child they were advised the doctor 

was not seeing any more patients that day and they 

should take her somewhere else. When they 

enquired where else they might go, the receptionist 

suggested the nearest public hospital however the 

family expected they would need to wait a 

considerable time for attention there. They became 

angry and demanded to speak to the doctor who 

attended and simply told them to leave. They found 

another clinic where the child was seen and treated 

promptly. In response the doctor said she had been 

called to attend a patient in their home and there was 

no one else to attend the clinic or make the home 

visit. She apologised for the poor communication with 

the family and they were satisfied with the 

explanation and apology. 

A man was booked into a private hospital to have 

a day procedure; however he requested he be allowed 

to stay overnight as there was no one available to 

collect him on that day and he could not be 

discharged unattended. The Hospital agreed to this 

request and advised him to call his health insurer to 

check whether they would agree to cover this cost. 

The Insurer advised him they would discuss with the 

Hospital and let him know the outcome. After the 

procedure he received the account for the overnight 

bed but his insurance refused to pay claiming it was 

not necessary on medical grounds. The Hospital 

agreed they had failed to discuss this with him and 

waived the outstanding account as a gesture of 

good will. 

Rights 

Complaints about rights are shown in Table 

19. Twenty eight percent of these complaints 

made allegations of unprofessional conduct. 

If an allegation of unprofessional conduct is 

made against a provider who is registered 

by a board, the complaint will often be 

referred to that board for investigation. 

Where there is no registration board the 

HSC will deal with the complaint. If it is of 

a serious nature the Commissioner may 

decide to investigate. 

Rights 6% 

Access to records 9 

Accuracy of records 5 

Assault 6 

Discrimination 3 

No/insufficient consent 12 


Privacy/confidentiality 2 

Unprofessional conduct 19 

Discrimination public/private 1 

Refusal to treat 2 

Total Rights 68 

Table 19 

Rights 

A woman consulted a surgeon about plastic 

surgery to improve the appearance of her eyes as she 

felt loose skin made her look older then she was. The 

surgeon agreed to do the procedure and the woman 

signed the consent forms stating she did not want the 

change to be too noticeable to her friends and family. 

A few weeks after the procedure when the results 

were apparent and were noticed by her friends, she 

was distressed as she felt that more had been done 

to her face than requested. The surgeon explained 

that one additional procedure had been done as it 

was clear during surgery that the procedure 

requested would be inadequate to achieve any 

improvement. He said he would not charge her for 

the additional procedure however she was upset and 

felt she had not consented to this. The matter could 

not be resolved and an expert opinion concluded she 

had a very good outcome. The woman decided she 

would then take her complaint to the Medical 

Practitioners Board of Victoria. 

Treatment 

The most frequently cited issues in 

complaints relate to aspects of treatment. 

Most frequently service users complain 

when they perceive the treatment 

to be inadequate in some way (34%). 

The Treatment issue categories are shown 

in Table 20. 

Treatment 57% 

Inadequate diagnosis 76 

Inadequate treatment 207 

Medication 55 

Negligent treatment 141 


Rough treatment 18 

Unskilful/incompetent treatment 33 

Wrong diagnosis 22 

Wrong treatment 13 

Total Treatment 604 

Table 20 

Treatment 

A man living in a rural area called an ambulance 

as he was having severe chest pains and thought he 

may be having a cardiac arrest. The ambulance 

attended promptly and advised him they would take 

him to the nearest hospital although the man was 

concerned that the Hospital could not treat him 

adequately. When he arrived at the hospital the 

nurse called the local doctor who examined the 

patient and decided he needed to be transferred to a 

tertiary hospital for further tests. He was transferred 

the following morning and tests showed some heart 

damage. The man complained that an earlier 

transfer could have minimised the harm to his heart 

however an expert opinion stated that the damage 

had occurred at the time of the initial arrest and all 

possible treatment had been provided at the rural 

hospital. The man accepted this advice and was 

happy to close his complaint. 


Primary Issues in HRA Complaints 

Complaints under the HRA continue to 

account for approximately 10% of all 

accepted case. 

These complaints are most frequently about 

the refusal of access to private health 

records about the complainant (45%) and 

breaches of privacy (37%). 

32 

39 

Legend 

Access & Correction 

Anonymity 

Collection 

Data Quality 

Identifiers 

Info available to another HSP 

Use & Disclosure 

4 

1 3 

6 

1 

Figure 4 

Breakdown of Issues - HRA 

A woman had been on leave from her job for a number of months related to a physical condition as 

well as a psychological condition. She had recovered from her physical condition and was ready to return to 

work. She was directed by her employer to undergo an assessment with an independent psychiatrist to 

determine her fitness to return to work. 

She attended the appointment with the psychiatrist, who explained to her the purpose of the 

examination. The psychiatrist had received a letter from her employer, which the woman had not seen, 

setting out the reasons for the fitness for duty assessment, and requesting the psychiatrist provide the 

employer with a report. The session was lengthy and required the woman to discuss her family history, 

personal relationships, her medical conditions and issues in her workplace. The psychiatrist told the 

woman at the end of the session that he would be informing the employer she was fit to return to work. 

Angela Palombo and Jesinder Bhullar 

Legal and Policy Officers 

The woman obtained a copy of the psychiatrist’s report and discovered he had written a lengthy report 

covering all aspects of her life, which had been sent to her employer. The woman returned to work but was 

distressed that her employer had been told details about her life that the employer did not need to know. 

She was expecting the psychiatrist would merely be writing a short report and stating she was fit to return 

to work. 

The woman lodged a complaint against the psychiatrist for disclosing unnecessary information to the 

employer, and to the employer for collecting information they did not need to know. The complaint was 

conciliated by the HSC. The psychiatrist agreed that in the future, he would discuss with patients the nature 

of the report that would be sent to the employer in the case of fitness for duty assessments, and he would 

use his professional judgement, in consultation with the individual, as to how much information it was 

necessary for the employer to know. The employer agreed that when requesting a fitness for duty 

assessment from a psychiatrist or psychologist, they would ensure the health professional only release to 

them information it was necessary to know for managing the employee’s performance in the workplace. A 

monetary settlement was negotiated for the distress and humiliation suffered by the woman. 

The major issues in HRA complaints 

can be seen in Table 21 below. 

Access & Correction 

Info available to another HSP 

Access refused 36 Information refused 3 

No written reason for refusal 2 Unreasonable time in delivery 1 

Correction refused 1 Excessive fee 2 

39 6 

Anonymity 

Use & Disclosure 

Refusal of anonymity 1 Disclosure - Inadequate consent 29 

Collection Disclosure - Inadequate disclosure 3 

Breach of in-confidence details 2 32 

Unnecessary collection 1 Data Quality 

Unlawful/Intrusive collection 1 Data inaccurate, incomplete or out of date 2 

4 Unsatisfactory protection 1 

3 

Identifiers 

Misuse 1 

Total 86 

Table 21 

HRA Issues 

26 


Categories of 

Accepted Complaints 

Against Health 

Service Providers 


Categories of Accepted Complaints Against 

Health Service Providers 

Doctors and hospitals were again the 

largest group of respondents to complaints 

about health services. This is consistent 

with previous years and, to be expected, 

given the large number of health services 

they provide. 

Please refer to Appendix 1 for a list of 

providers by type and medicical practitioner 

specialities. 

Medical Practitioners 

The category of medical practitioners 

includes specialist service provision 

but not doctors who are employees of 

public hospitals. 

The most frequently named issues in 

relation to treatment are inadequate 

treatment and diagnosis and negligent 

treatment (approximately 66%). These 

issues are those outlined in the complaint 

statement and, in reality, there is little to 

separate “negligent treatment” from 

“inadequate treatment” and they could be 

viewed as one group. In most of these 

cases there will be no evidence of 

negligence found in the complaints process; 

however the patient often will believe this 

is the case if communication about risks 

has not been sufficiently communicated 

or understood. 

403 

18% 

367 

22% 

Inadequate 

Diagnosis 

26% 

33% 

290 

Inadequate 

Treatment 

2% 

0% 

Medication 

Information 

Used 

10%10% 

Negligent 

Treatment 

76 

Dentists in Private Practice 

Hospitals 

Medical Practitioners 

Remaining Providers 

Figure 5 

Categories of complaints against health service providers 

22% 

20% 

5% 

2% 

Other 

3% 2% 

7% 

5% 5% 

3% 

Rough 

Treatment 

Unskilful / 

Incompetent 

Treatment 

Legend 


2006 - 2007 

Wrong 

Diagnosis 

2% 3% 

Wrong 

Treatment 

Figure 6 

Treatment Issues - Medical Practioners 

General Practitioners 

The number of complaints against General 

Practitioners could be seen as quite low in 

comparison with the number of patient 

contacts in a year. The relationship between 

doctors and their patients is very important 

and mediation can serve to mend this 

relationship in many cases. Other patients 

may move frequently from one doctor to 

another and it can be more difficult to 

develop the rapport necessary for good 

communication and to foster trust. 

The widow of a man who had died of bowel cancer complained that his general practitioner had 

been ignoring his complaints of abdominal pain for the past two years and had only referred him to a 

gastroenterologist a short time before his death. In response the doctor explained that the man had 

undergone several screening procedures and tests over the last three years and had been closely 

monitored by the general practitioner and the specialist. In the end the cancer that had developed was 

very fast growing and did not respond to treatment. The woman and the two doctors met in conciliation 

to review the records and the woman was satisfied that all possible care had been provided. 

HSCR issues 

57% 

4%4% 4%5% 

53% 

5% 4% 

HRA issues 

Legend 


2006 - 2007 

13% 14% 8% 8% 

7% 

5% 

0%0% 0%0% 0%0% 1%1% 0%0% 4% 2% 

Access Administratioication 

Commun- 

Cost None Rights Treatment 

Access 

& Correction 

Collection 

Data 

Quality 

Info 

Available 

to 

Another 

HSP 

Transfer/ 

Closure of 

HSP 

Use & 

Disclosure 

Figure 7 

Issues in GP Complaints 

28 


Dentists 

Most complaints made about dentists refer 

to treatment issues. While most dentists 

advise patients of treatment options, risks 

and costs there are still a few complaints 

each year about lack of adequate informed 

financial consent for dental procedures. This 

may in part be due to the complications 

which can arise in dental treatment which 

may not have been anticipated when 

treatment commenced. 

A woman complained that orthodontic treatment provided to her daughter could not be completed 

because it had taken far longer than anticipated and the dentist had now retired. The dentist had referred 

the patient to another practitioner however the costs were anticipated to be much higher than that agreed 

to in the original contract. As a gesture of good will the retiring dentist agreed to refund some of the fees 

to assist with the cost of completing the treatment with the new dentist. 

39% 

50% 

33% 

Legend 


2006 - 2007 

12% 

17% 

16% 

10% 

2% 

2% 0% 

5% 

2% 2% 2% 

4% 2% 

Inadequate 

Diagnosis 

Inadequate 

Treat ment 

Medication 

Negligent 

Treatment 


Rough 

Treatment 

Unskilful / 

Incompetent 

Treatment 

Wrong 

Treatment 

Figure 8 

Treatment Issues Dentists 

Hospitals 

Complaints Made to the HSC about Hospitals 

Most of these complaints are made in 

relation to public hospitals (90%). This is 

because public hospitals treat more 

patients each year and also because 

complaints about treatment in a private 

hospital will frequently need to be made 

against the admitting doctor rather than 

the Hospital. There is a general lack of 

understanding in the community about the 

relationships that exist between private 

specialists and private hospitals and the fact 

that many smaller private hospitals do not 

employ their own doctors as staff. 

409 

Legend 

362 


2006 - 2007 

41 

23 

Private Hospital 

Public Hospital 

Figure 9 

Public/Private Hospital Comparisons 

Public Hospital Issues 

The majority of complaints about public 

hospitals, as for all health services, are 

made in relation to treatment issues 

(approximately 60%). Other complaints 

relate to administration problems such as 

appointment times (5%), delays in treatment 

(13%) and other resource issues as well as 

failures of communication (12%). Issues 

about public hospitals are set out in 

Figure 10. 

HSCR issues 

49 

Access 

19 

3 

Cost 

45 


Communication 

28 

212 

Rights Treatment 

HRA issues 

1 1 1 3 

Access & 

Correction 

Info Available 

to another 

HSP 

Data 

Quality 

Use & 

Disclosure 

Figure 10 

Public Hospital Complaints 

A woman was admitted to a hospital for abdominal surgery. She was in considerable pain on recovery 

but was advised this was normal and was discharged to her home. As she felt very unwell she called a 

friend to come and stay with her and the friend was sufficiently concerned to take her back to hospital. 

The doctor in the emergency department examined her, told her the pain was to be expected and sent her 

home again telling her to return if she did not feel better in the morning. Later that night her friend took 

her to another hospital where she was admitted and had surgery for a perforated bowel. The Hospital 

stated they had examined her and acted reasonably in their care of her as there were no signs of sepsis on 

discharge or on her re attendance. They suggested her bowel perforation may have occurred or worsened 

dramatically subsequently. An expert opinion concluded the perforation was most likely to have occurred 

in surgery however the indications that this had happened may have been difficult to detect and diagnose. 


Private Hospital Issues 

The numbers of complaints against private 

hospitals are comparatively few as any 

complaints about treatment decisions and 

outcomes would usually be made against 

the admitting doctor rather than the 

Hospital. Complaints might be made 

against a private hospital for nursing or 

communication issues. 

Although some larger private hospitals 

have emergency departments and doctors 

on staff, many smaller private hospitals do 

not employ their own doctors. This is 

frequently a cause of misunderstandings 

and it needs to be made clear to prospective 

patients by the service in advance if this is 

the case. 

HSCR issues 

2 

Access 

5 5 

Administration Cost Communication Rights Treatment 

Figure 11 

Private Hospital Complaints 

A woman was booked to have her baby at a small private hospital. She had indicated she wanted to 

give birth with as little intervention as possible however after being in labour for more than 24 hours she 

requested an epidural to manage her pain. The Hospital contacted all the anaesthetists listed as on call for 

that period of time however as it was a holiday weekend no one was available to attend as the situation 

was not considered to be an emergency. The woman was very angry she had not been able to receive the 

pain management on request. She considered the Hospital should have advised her when she made the 

booking that they may not be able to provide this service. The Hospital agreed to revise the information 

brochures provided to new prospective patients. 

6 

1 

22 

Psychiatric Services 

There was a 8% decrease in complaints 

about psychiatric services and services 

provided by psychologists this year. 

The numbers of complaints made against 

each type of service is shown in Figure 13. 

Legend 


2006 - 2007 

98 

45 

90 

27 18 

2007-2008 2006-2007 

Public 

Hosptials 

Psychiatrists 

Psychiatric 

Health Service 

Figure 12 

Psychiatric Services Complaints 

Figure 13 

Types of Service 

Issues in Psychiatric Service Complaints 

The most frequent complaint is that 

the patient’s involuntary status is 

unwarranted and these matters are referred 

to the Mental Health Review Board. 

There are also complaints about treatment 

and communication issues and access 

to services. 

HSCR issues 

18 

42 

HRA issues 

7 

3 

11 

5 4 

Access Administration Communication Rights Treatment Access & 

Correction 

Use & 

Disclosure 

Figure 14 

Issues in Psychiatric Complaints 

A young woman complained she had been admitted to psychiatric care and made an involuntary 

patient without any thought about whether she could be cared for in any other way. She complained she 

had been handled roughly and had some bruises from being restrained and injected with medication. She 

also complained she had been left in seclusion for too long without access to toilet facilities. She agreed 

she had been depressed and potentially suicidal however she believed the treatment provided had made 

her feel worse, not better. The Hospital responded to her explaining why she had been made an involuntary 

patient and offering to meet with her to discuss her concerns however she did not want to do this and the 

complaint was closed. 

30 


Hospital 

Complaints 

Data 

Complaints Made at Public Hospitals 

Information contained in this section has 

been compiled from complaints lodged 

directly with the Complaint Liaison Officers 

(CLOs) (or patient representatives) of public 

hospitals and provided by them to the HSC 

in an aggregated form. Some hospitals 

utilise the Health Complaints Information 

Program (HCIP) to record and monitor 

complaints handled locally within the 

Hospital. These complaints are separate to 

those lodged directly with the HSC. 

The following trends comprise data 

provided by 48 health services over the 

reporting period. Some of the services 

reported every quarter whereas others 

may have only reported once during the 

year. It should also be noted that the 

services reporting this year are not 

necessarily the same as those who 

reported in previous years. Therefore 

anyone doing trends analysis comparing 

years needs to take this into account. 


Who Complained and How? 

Thirty Nine percent of complainants were 

female and 25% male and in 36% of cases 

the gender was not stated. As expected, 

public patients comprised the largest group 

(74%) of patients who complained. 

The majority of complaints were made via 

telephone call (51%) or letter (24%), 11% by 

personal visit and 14% by other means. 

The age and patient type of consumers are 

shown in Table 22 and 23. 

25% 

36% 

39% 

Legend 

Male 

Female 

Not Specified 

Figure 15 

HCIP - Gender 

Consumer Profile 

Age 

Total 

Under 1 29 

1 – 4 52 

5 – 14 148 

15 – 24 334 

25 – 34 361 

35 – 44 280 

45 – 54 79 

55 – 64 287 

65 – 74 208 

75+ 415 

Not Specified 1191 

Total 4184 

Patient Type 

Total 

Public Patient 3102 

Private Patient 0 

Dept of Vet Affairs 0 

Not Specified 1082 

TAC 0 

Ineligibe Patient 0 

WorkCover 0 

Total 4184 

Table 23 

HCIP - Patient Type 

What Was the Complaint About? 

During the period under review the 

reporting Hospitals received, and dealt 

with, 4184 complaints. A complaint may be 

multi-faceted, for example it may be 

concerned not only with poor 

communication but may also be about 

inadequate treatment, however the analysis 

in this report is based on the primary issue. 

The diagram below shows the primary 

issues in complaints. CLOs are not 

constrained by legislation and may deal with 

any issues brought to their attention. This 

gives them flexibility and every year they 

resolve many complaints promptly and 

effectively. The HSC supports them through 

their organisation the Health Services 

Table 22 

HCIP - Age Analysis 

Liaison Association and by providing 

orientation training and support. 

Nineteen percent of complaints concerned 

communication issues. Treatment issues 

were 20%, while Access issues remained 

steady at (37%) and cost issues (7%), rights 

issues (11%) and administration (6%). 

Hospital services can be complex and 

sometimes, clinical sections may not 

communicate well with, for example, 

administration. This can result in problems 

and distress for patients and their families. 

A more specific analysis of issues forms 

Appendix 2. 

11% 

Legend 

6% 

20% 

20% 

Access 


Communication 

Figure 16 

HCIP - Issues 

37% 

6% 

Cost 

Rights 

Treatment 

Site and Service at Time of Complaint 

1636 

1162 

550 

343 

152 

86 

32 

137 

41 45 

Admission Aged Care Day 

Procedure 

Unit 

Emergency 

Department 

Hospital 

Grounds 

Intensive 

Care Unit 

Operating 

Theatre 


Outpatient 

Clinic 

Ward 

Figure 17 

HCIP - Site 

32 


2006-2007 2007-2008 

Admissions 236 152 

Age Care 41 86 

Day Procedure Unit 70 32 

Emergency Department 567 550 

Hospital Grounds 247 137 

Intensive care 57 41 

Operating Theatre 121 45 

Other 1065 1636 

Outpatient Clinic 496 343 

Ward 998 1162 

Total 3898 4184 

Table 24 

HCIP - Site 

Services 

Figure 18 shows 13% of complaints were 

made about services provided in the 

emergency department, orthopaedic 

surgery 8%, gynaecology 3%, aged care 2%, 

general medicine 4%, general surgery 3% 

and outpatient clinic 2%. A more specific list 

of services forms Appendix 3. Figure 18: 

HCIP – Services 

59% 

13% 

8% 

3% 

2% 

3% 

4% 

4% 

Legend 

Emergency 

Obstretrics 

Gynaecology 

Aged Care 

General Surgery 

Unknown 

General Medicine 

Outpatient Clinic 

Orthopaedic Surgery 

Remaining Providers 

2% 

2% 

Figure 18 

HCIP - Services 

How Serious Were the Complaints? 

Thirteen percent of complaints were 

categorised as serious or substantial and 

35% as routine. The remaining 52% were 

listed as either minor or trivial. All 

complaints are treated seriously by the 

Complaints Officers as patterns of minor 

complaints can still reveal systemic 

problems that need to be addressed. 

If complaints are not resolved internally the 

complainant may be advised of the right to 

take the complaint to the HSC or the 

appropriate registration board. 

Please refer to Appendix 4 for a full 

categorisation of complaint outcomes. 

Minor Routine Substantial Serious Total 

Access 902 516 139 5 1562 37% 

Administration 111 76 59 0 246 6% 

Communication 499 212 105 1 817 19% 

Cost 151 87 38 0 276 7% 

Rights 156 185 108 5 454 11% 

Treatment 387 376 51 15 829 20% 

Total 2206 1452 500 26 4184 100% 

52% 35% 12% 1% 100% 

Stage of Complaint 

Process 

Table 25 

Seriousness of Complaints 

Number of 

Complaints 

Resolved 3847 

Lapsed 887 

Not Upheld 188 

Remedial 156 

Referred 118 

Change in Policy 76 

Total Number of Complaints 5272 

Table 26 

Outcomes of Complaints 


Executive 


34 


Manager, Executive Services 

Michael McDonald 


Manager, 

Executive Services 

Legal & Policy Officer x 2 

Angela Palombo (.6) 

Jesinder Bhullar (.4) 

Education Officer 

Susan Joseph 

Corporate 

Services Officer 

Joe Barczak 

Information Systems 

Officer 

Colin McKnight 

Funding 

The OHSC is an independent statutory 

authority and receives its funding through 

the Department of Human Services. 

In developing funding requirements and key 

performance indicators for the delivery of 

services, the parties agreed to the following 

general principles: 

• The Department recognises and 

respects the independent status of the 

OHSC; 

• all dealings between the parties are 

based upon a cooperative partnership; 

• all services will be provided in a timely 

fashion, with skill, care and diligence, 

according to statutory requirements 

and to service delivery targets; and 

• communication between the parties 

will be transparent, direct and timely. 

Negotiations with DHS over funding are 

conducted by the Commissioner and 

Manager, Executive Services annually. 

Receptionist x 3 

Dianne Rutkowski (.6) 

Sarah Whitehead (.2) 

Kay Rouse (.2) 

Figure 19 

Executive Services – organisational structure 

HRA 

The HRA, protects the privacy of health 

information and establishes standards 

through eleven health privacy principles 

(HPPs). These principles regulate the 

collection, use, disclosure, quality, 

security, access, retention and transfer 

of health information in the public and 

private sectors. 

The HSC and staff of the Executive Services 

Unit continue to provide training, education 

and support to holders of health information 

and consumers on their respective 

responsibilities and rights under the 

legislation. These include health services 

providers, government departments and 

agencies, local government, employers and 

many other holders of health information. 

During the reporting year the HRA team 

gave over 65 presentations attended by a 

total of over 1400 people, answered over 300 

telephone enquiries and responded to 83 

written inquiries. We also provided two 

joint training sessions with Privacy Victoria 

on Information and Health Privacy to staff 

of public sector agencies. 

We also ran a ‘train the trainer’ session in 

November 2007 where representatives from 

organisations received HRA training so 

they could then train their staff. The package 

is available on our website and the offer for 

training is open to any organisation with 

HRA responsibilities. 


Vision Australia Launch 

A campaign to inform Victorians with print 

disabilities of their Privacy rights regarding 

their personal and health information was 

launched on Thursday 17 April, with 

Graeme Innes, Australian Human Rights 

and Equal Opportunity Commissioner as 

guest speaker. The communications 

campaign is a joint initiative of Privacy 

Victoria and the OHSC working with 

Vision Australia. 

Privacy Victoria and the OHSC are keen to 

ensure that Victorians with a print disability 

(and their families, friends and colleagues) 

are aware of their privacy rights and the 

remedies available if those privacy rights 

are breached. 

Gerard Menses, Vision Australia CEO, Beth Wilson, Health Services Commissioner, 

Graeme Innes, Australian Human Rights and Equal Opportunity Commissioner, and 

Helen Versey, Privacy Commissioner at the campaign launch. 

Charter of Human Rights and Responsibilities 

The HSC is a statutory partner with the 

Victorian Equal Opportunity and Human 

Rights Commission in promoting and 

considering the Charter of Human Rights 

and Responsibilities Act 2006 in assessing 

complaints it receives. The Charter creates 

a legal obligation on Public Authorities to 

"act in a way that is compatible with human 

rights and take human rights into account 

when making decisions." 

Human rights belong to all Victorians and 

the OHSC is aware of the Charter when 

considering complaints against any health 

service provider who has, among other 

things, failed to provide satisfactory care or 

denied a patient their respect, dignity or 

privacy. All OHSC employees have 

completed an e-learning program which 

was developed to assist them in meeting 

their obligations under the Charter, Code of 

Conduct and Public Sector Values. They are 

aware they should actively: 

• encourage actions which are compatible 

with the Charter 

• support others to act compatibly with the 

Charter 

• respect and actively promote the Charter 

to clients, external service providers 

• and other staff 

Culturally and Linguistically Diverse Communities (CALD) 

Since the introduction of the HRA in 2002 

the OHSC has made a concerted effort to 

increase the awareness of the office to 

Victoria’s diverse community. In September 

2007 the OHSC had a stand at the Moon 

Lantern Festival which falls on the 15th day 

of the eighth Chinese Lunar Calendar. 

The Asian Moon Lantern festival is the 

most important date in the second 

half of the Lunar year and has been 

celebrated for 5000 years. It draws in 

audiences from all Asian backgrounds 

and is celebrated by Chinese, Vietnamese, 

Thais, Laotians, Cambodians, Koreans, 

Japanese, Indonesians, Malaysians and 

Singaporeans. 

People at the 2007 Moon Lantern Festival obtaining information from the OHSC stand. 

36 


Human Research Ethics Committees (HREC) 

The HSC developed statutory guidelines 

which relate to the collection, use and 

disclosure of health information for 

research purposes. The Guidelines allow an 

organisation to collect, use or disclose 

health information in the circumstances 

contemplated in HPPs 1.1(e) & 2.2(g) with 

the approval of a properly constituted 

HREC. The HREC which should have regard 

to the matters listed within the guidelines. 

The task for the HREC is to decide whether 

the public interest in the research 

substantially outweighs the public interest 

in the protection of privacy, in relation to the 

Royal Melbourne Show 

Once again the OHSC joined resources 

with Privacy Victoria in 2007 to provide our 

message to some of the 500,000 visitors 

who visit the show each year. We did this by 

the distribution of a souvenir Chinese 

Horoscope and ‘Privacy’ handprints where 

children placed there unique handprint on 

a card. Both of these popular handouts had 

our contact details on them. 

Without the support and help of Darryl 

Rogan, Manager, Community Liaison from 

Information Victoria this would not have 

been possible. 

use of information or recruitment to a 

research project. If the HREC, having 

considered all the matters as required by 

the guidelines considers that such a test 

has been met, then the researchers 

have complied with the legal requirements 

of the Act. 

The guidelines require HREC to report on 

the use of the HSC guidelines for the 

purposes of HPP 1.1(e)(iii) & 2.2(g)(iii) of the 

HRA. For the reporting year 47 out of a 

possible 61 HREC reported to us that they 

utilised the guidelines. 

47 

Number of HREC Reports 

Returned to HSC 

61 

Number of HREC 

Committees 

Figure 20 

HREC returns 

Photos from the 2007 Royal Melbourne Show showing the OHSC, Privacy Victoria floor tile and the Chinese 

Calligrapher completing a horoscope for one of the many children who visited our stand. 

InfoMed 

As part of our commitment to inform 

Victorians of the role of the OHSC we 

utilise the services of InfoMed which 

displays our brochure in over 450 medical 

centres throughout Victoria. This has 

resulted in over 7000 of our brochures 

being taken by patients while they were 

waiting to see their doctor. 

Month Year Uptake Number of patients Number of doctors 

July 2007 671 966,000 2112 

August 2007 581 963,000 2101 

September 2007 726 967,000 2110 

October 2007 606 997,000 2182 

November 2007 673 992,000 2170 

December 2007 506 1,011,000 2208 

January 2008 447 1,009,000 2205 

February 2008 485 1,009,000 2205 

March 2008 687 1,009,000 2202 

April 2008 529 1,004,000 2198 

May 2008 563 1,004,000 2194 

June 2008 573 996,000 2178 

Total 7047 

Table 27 

InfoMed 

Human Resources 

This financial year saw us farewell Mark 

McPherson, Senior Conciliator, who was 

successful in obtaining a position at the 

Medical Practitioners Board and Dr Vinay 

Rane, Conciliator whose fixed term contract 

expired. We express our appreciation to 

both Mark and Vinay for their contribution. 

We welcomed back Dr Jacqueline Smith as 

a part time Senior Medical Adviser; Jacqui 

had previously worked with us on 

placement during her sabbatical leave. 

Another former staff member Kay Rouse 

commenced work with us working one day 

per week on reception and Jacqui Hoepener 

the Commissioner’s Executive Assistant 

was successful in obtaining the position on 

an ongoing role after being employed from 

an agency. Bonnie Owusu-Afriyie 

commenced as a new member of the 

Conciliation team after working with the 

Victorian Equal Opportunity and Human 

Rights Commission. 


Staff of the OHSC as at 30 June 2008 

Position Staff Member(s) Responsibilities 

Manager, 

Executive Services 

Manager, Assessment 

& Investigation 


Lynn Griffin 

Manage the operations of the HRA and corporate support 

services. 

Manage the assessment, acceptance, resolution and referral 

of all new complaints received under the HSRC. 

Chief Conciliator Keith Jackson Manages the conciliation unit. 

Senior Medical 

Adviser 

Jacqui Smith 

Provide authoritative and strategic specialist advice to 

Providers, Complainants and OHSC staff on clinical aspects 

on the various complaints received. 

Senior Conciliators 

Orysia Ckuj 

Lynn Buchanan 

Koula Louras 

Supervise conciliators in their casework and conciliate the 

more complex cases. 

Joe Barczak 

Corporate Service Officer 

Conciliators 

Aboriginal Liaison 


Lisa Graham 

Susan Kennedy 

Christine Lalor 

Bonnie Owusu-Afriyie 

Maree Wilson 

Melanie Fraser 

Assist parties with a complaint to reach a resolution in a 

confidential and privileged setting. 

Liaises and conducts outreach work with Aboriginal and 

Torres Strait Islander communities in Victoria. Performs 

conciliation functions and responds to inquiries on matter 

involving these communities. 

Conciliation 

Administration Officer 

Julie-Anne Balash 

Maintain the conciliation waiting list and provide 

administrative support to the conciliation team. 

Registrar 


Liaise with the professional Registration Boards, assist the 

Manager, Assessment & Investigations and co-ordinate all 

Freedom of Information requests. 

Assessment 

Officers 

Heather Andrew- 

Rieper 

Jill Aitken 

Kate Kennedy 

Piotr Nyczek 

Receive inquiry calls, case manage and assist resolution of 

complaints and provide advice to health service users and 

providers. 

Legal & Policy 


Angela Palombo 

Jesinder Bhullar 

Provide advice to health service users and providers and 

case manage complaints received under the HRA. Provide 

legal and policy advice to the Commissioner and oversees 

Freedom of Information requests. 


Susan Joseph 

Educate and train health service providers and holders of 

health information about the HRA. 

Corporate Services 


Joe Barczak 

Provide corporate support services 

Information Systems 


Colin Mcknight 

Provide IT support and assistance to staff and hospitals. 

Executive Assistant 

Jacqui Hoepner 

Provide executive and administrative support to the 

Commissioner including the Investigation Review Panel. 

Receptionist 

Dianne Rutkowski 

Sarah Whitehead 

Kay Rouse 

Support receptionist duties were provided by staff from other 

tenants on Level 30 of 570 Bourke Street in the 2007/2008 

financial year. 

Classification Male Female Full Time Part Time Ongoing Fixed Term EFT 

Executive Officer 1 1 1 1.0 

Senior Medical 1 1 1 0.2 

VPS 6 2 1 3 3 3.0 

VPS 5 12 6 6 10 2 9.4 

VPS 4 2 5 7 6 1 7.0 

VPS 3 1 2 2 1 2 1 2.6 

VPS 2 2 2 2 0.4 

Total 5 24 19 10 22 7 23.6 

Table 28 

Staffing profile at 30 June 2008 

38 


Merit and Equity Employment 

The OHSC supports specific initiatives of the 

State Services Authority in managing 

diversity and employment equity goals. 

The Office follows equal employment 

opportunity policies when recruiting. 

Staff by gender at 30 June 2008 was 24 

women and 5 men. 

Performance Management 

The Office utilises the DHS Progression, Performance and Development performance 

management system, which provides a framework to manage and develop staff to achieve 

corporate objectives. The scheme provides for regular and formal assessment of an 

employee's work performance and allows for access to training and skill development with 

a greater emphasis on career progression. 

Training 

Staff of the OHSC are encouraged to expand 

their knowledge and skill base through 

various learning and development 

opportunities including attendance at 

forums, seminars, conferences, performing 

higher duties, secondments and 

undertaking external training courses. 

During 2007-2008 staff attended various 

training activities including: 

• Human Rights Charter seminar 

• Investigation training 

• Grief Awareness Forum 

• Power of Apology symposium 

• Legal Professional development 

• Mental Health Review Board seminar 

• Law Institute of Victoria Medicine and 

Law Conference 

• Receptionist seminar 

• Injury in indigenous populations 

workshop 

• Statute of Limitations Post Tort Law 

reform 

• Credentialing and defining the scope of 

clinical practice for Medical 

Practitioners in Victorian Health 


The CEO of the State Coroner’s Office 

provided staff with a presentation on the 

role of the Coroner and how it interacts with 

the OHSC. Mia Campbell from law firm 

Slater and Gordon discussed with staff 

reforms to the Wrongs Act 1958 and the 

Limitation of Actions Act 1958. 

Website 

The website (www.health.vic.gov.au/hsc) is 

featured prominently in all of the Office 

promotional material. It is a source of 

information for the community on the role 

of the OHSC and includes publications 

produced by the office, appropriate links 

and information. We use ‘Nielsen 

Netratings’ to measure our website traffic 

which is the official measurement tool 

across Victorian Government websites. 

Month Page Impressions Browsers Sessions 

July 5,681 1,724 1,429 

August 7,230 2,192 1,848 

September 6,345 1,866 1,555 

October 6,602 2,075 1,790 

November 5,615 1,702 1,462 

December 3,920 1,802 1,525 

January 4,755 1,439 1,197 

February 5,671 1,658 1,369 

March 5,218 1,667 1,411 

April 6,297 1,744 2,016 

May 8,154 2,121 2,499 

June 5,424 1,632 1,839 

Total 66,454 18,622 21,927 

Average 5,538 1,552 1,827 

The following table is for the period 1 July 2007 to 30 June 2008. 

Table 29 

Website 


Customer Feedback 

Evaluation Survey 

At the conclusion of a complaint the 

OHSC sends with the closure letter an 

evaluation survey form to complainants 

and providers. The information returned 

provides the OHSC with indicators on 

how we are performing and often 

contains useful suggestions for further 

improvement, and where follow up action 

may be required. This year for the first time 

the evaluation survey has also been sent to 

complainants and providers at the 

completion of the conciliation process. 

The form lists six questions: 

1. OHSC staff were helpful in explaining the complaints process 

2. I was able to speak to OHSC staff when I needed to 

3. OHSC staff returned my calls within 24 hours 

4. I felt OHSC staff listened to what I had to say 

5. I was satisfied with the way the complaint was handled 

6. I was satisfied with the outcome of the complaint 

Respondents are asked whether they strongly agreed, agreed, disagreed or strongly 

disagreed with the question. 

Complainants 

Over eighty per cent of complainants, both 

in Assessment and Conciliation, who replied 

to the survey agreed the staff were helpful, 

they were accessible and they listened 

to them and their calls were returned 

within 24 hours. Seventy five percent were 

pleased with the way their complaint was 

handled and 58% were satisfied with the 

outcome of the complaint. Of the 191 

evaluations received 70 (37%) disagreed or 

disagreed strongly with the outcome of 

their complaint. 

70 

60 

50 

40 

30 

Legend 

Missing 

Disagree strongly 

Disagree 

Agree 

Agree strongly 

Conciliation Assessment Conciliation Assessment Conciliation Assessment Conciliation Assessment Conciliation Assessment Conciliation Assessment 

Outcome 

Handled Listen Calls Access Helpful 

20 

10 

0 

Response Total Assessment = 120 from 918 (13% return) 

Response Total Conciliation = 71 from 220 (32% return) 

Figure 21 

Complaint’s Evaluations 

40 


Providers 

Last year’s report indicated 90% of providers 

who responded were satisfied with the 

outcome and the way the complaint was 

handled. These figures were repeated again 

this year and 94% of providers in both 

conciliation and assessment agreed their 

complaints were handled appropriately. 

Only 5% of providers disagreed with the 

outcome of the case. 

70 

60 

50 

40 

30 

Legend 

Missing 

Disagree strongly 

Disagree 

Agree 

Agree strongly 

Conciliation Assessment Conciliation Assessment Conciliation Assessment Conciliation Assessment Conciliation Assessment Conciliation Assessment 

Outcome 

Handled Listen Calls Access Helpful 

20 

10 

0 

Response Total Assessment = 131 from 918 (14% return) 

Response Total Conciliation = 62 from 220 (28% return) 

Figure 22 

Provider's Evaluations 

Finance 

For the 2007/08 financial year the OHSC 

was allocated $2,161,515 and expended 

$2,230,473 being 103% of its total allocation 

resulting in a deficit of $70,000. As occurred 

last year the deficit was due to staff salaries 

exceeding salary allocation, despite 

transferring $75,000 from the operating 

expenses budget to the salaries budget. 

As would be expected of a health services 

complaints body over 40% of our operating 

expenditure was on telephony services, 

medical reports requested in conciliating 

complaints and providing information to 

the public. 

Allocated 

Actual 

Operating Expenses $267,695 $258,287 

Salary Oncosts $256,636 $251,201 

Salaries $1,637,184 $1,720,985 

Total $2,161,515 $2,230,473 

Expenditure 

Salaries $1,720,985 

Salary Oncosts $251,201 

Administrative stationery & operating supplies $11,925 

Advertising, publicity & information $32,880 

Books/publications/subscriptions/memberships $14,413 

Catering 4,282 

Furniture, fittings & equipment 8,024 

General consulting fees 16,073 

Graphic design & editing 8,127 

Interpreter Services 8,103 

IT 14,767 

Medical reports 36,044 

Miscellaneous 5,251 

Postal /courier 1,791 

Printing 21,908 

Staff development, seminars & training 18,120 

Telephones 36,859 

Travel-Airfares, taxis, personal expenses 13,855 

Venue Hire 5,865 $258,287 

Total $2,230,473 

Table 30 

Financial Statements 


Compliance and Accountability 

Whistleblowers Protection Act 2001 

Section 104 of the above legislation requires public bodies to prepare an annual report of operations 

including a copy of current procedures for dealing with disclosures under the Act. (see Appendix 6) 

For the year under review the OHSC reports: 

a. Number of Disclosures 

No disclosures of any type were made 

to the Office. 

b. Public Interest Disclosures Referred 

to the Ombudsman 

No disclosures of any type were referred 

by the Office to the Ombudsman for 

determination as to whether they were 

public interest disclosures. 

c. Disclosures Referred to the Office 


to the Office by the Ombudsman. 

d. Disclosures of Any Nature Referred to 

the Ombudsman 


by the Office to the Ombudsman to 

investigate. 

e. Investigations Taken Over by 

Ombudsman 

No investigations of disclosed matters 

of any type were taken over from the 

Office by the Ombudsman. 

f. Requests Under Section 74 

No requests were made under section 

74 to the Ombudsman to investigate 

disclosed matters. 

g. Disclosed Matters declined to be 

investigated 

There were no disclosed matters of 

any type that the Office declined to 

investigate. 

h. Disclosed Matters Substantiated on 

Investigation 

No disclosed matters of any type were 

investigated, or substantiated on 

investigation. 

i. Recommendations by Ombudsman 

No recommendations were made by the 

Ombudsman under the Whistleblowers 

Protection Act relating to the Office. 

Information Privacy Act 2000 

The OHSC is an organisation covered under section 9 of the above legislation. We comply 

with the Act in our collection and handling of personal information. 

42 



Joe Barczak 

Information 

Systems Officer 

Colin McKnight 

Receptionist x 3 

Dianne Rutkowski (.6) 

Sarah Whitehead (.4) 

Kay Rouse (.2) 

Organisational Structure as at 30 June 2008 

Health Services Commissioner 

Beth Wilson 

Executive Assistant 

Jacqui Hoepner 



Chief Conciliator 

Keith Jackson 

Senior Medical Adviser 

Jacqui Smith (.2) 


Susan Joseph 

Legal and Policy Officer 


Angela Palombo (.6) 

Joe Barczak 

Jesinder Bhullar (.4) 

Senior Conciliators x 3 

Orysia Ckuj 

Koula Louras (.6) 

Lynn Buchanan (.6) 

Conciliators x 5 

Lisa Graham 

Susan Kennedy 

Maree Wilson 

Bonnie Owusu-Afriyie 

Christine Lalor (.4) 

Aboriginal Liaison Officer 

Melanie Fraser (.6) 

Administrative 

Support Officer 

Julie-Anne Balash 

Manager, Assessment 

and Investigation 

Lynn Griffin 

Registrar 


Assessment Officers x 4 

Heather Andrew-Rieper 

Jill Aitken 

Kate Kennedy 

Piotr Nyczek 

Figure 23 

Organisational Structure 


Appendices 

44 


Appendix 1 

Providers by Type and Medical Practitioner Specialities 

Dentists in Private Practice 76 

Dental Surgery 15 

Dentist 61 

Hospitals 403 

Hospitals 403 

Private 41 

Public 287 


Psychiatric 21 

Specialist 33 

Womens 2 

Medical Practitioners 367 

Medical Clinic 59 

Group Practice 19 

Laser Eye Clinic 0 

Men’s Health 2 


Medical Practitioner 308 

Anaesthetist 7 

Cardiologist 4 

Dermatologist 8 

Ear, Nose and Throat 5 

Gastroenterologist 2 

General Practitioner 143 

Locum 0 

Medico-legal Examiner 0 

Neurologist 6 


Obstetrician/Gynaecologist 18 

Oncologist 3 

Ophthalmologist 4 

Paediatrician 3 

Psychiatrist 27 

Rehabilitation Medicine 1 

Radiologist 4 

Respiratory Medicine 1 

Rheumatologist 1 

Urologist 4 

Surgeon 47 

General 6 

Cardio-Thoracic 2 

Neurological 1 


Orthopaedic 7 

Plastic 19 

Vascular 4 


Remaining Providers 270 

Aged Care 1 

Alcohol & Drug Service 1 

Allied Health 1 

Alternative therapist 2 

Naturopath 2 

Ambulance Service 15 

Beauticians/ laser therapists 1 

Beauty Therapy Clinic 5 

Chiropractic Service 4 

Community Health Centre 25 

Corrections Health 85 

Counsellor 3 

Dental Prosthetist 1 

Diagnostic Service 33 

Diagnostic Imaging 10 


Pathology 13 

Dept of Human Services 9 

Education 2 

Health/Insurance 2 

Hostel 1 

Infant Welfare Centre 2 

Law Firms 1 

Not a health service provider (organisation) 2 

Employer 1 


Nursing Home 5 

Nursing service 4 

Occupational therapist 2 

Optical dispenser 13 

Optometrist 3 

Pharmaceutical supplier 6 

Pharmacist 6 

Physiotherapist 4 

Podiatrist 4 

Police 2 

Psychiatric Health Service 12 

Psychologist 9 

Radiographer 2 

Social Services 1 

Supported Residential Service 1 

Grand Total 1136 


Appendix 2: HCIP Issues 

Access 

Absence of caring (Access) 8 

Access - Other 959 

Delay in admission 38 


Discharge arrangements 88 

Discharge/transfer 33 

No/inadequate service 115 

Non attendance 1 

Privacy 10 


Service busy 28 

Transfer unsuitable 3 

Transport 3 

Waiting list 104 

Total 1562 

Rights 

Access to records 13 

Accuracy of records 5 

Assault 8 


Discrimination public/private 2 

Discrimination 10 

Failure to provide interpreter 1 

No/insufficient consent 8 

Other - Rights 202 

Privacy/confidentiality 36 

Property 129 


Refusal to treat 13 

Unprofessional conduct 9 

Total 454 

Treatment 


Inadequate diagnosis 59 

Inadequate nursing care 89 

Inadequate treatment 191 

Medication omission/error 44 

Negligent treatment 49 

Other - Treatment 189 

Rough treatment 33 

Unexpected outcome 52 

Unskilful/incompetent 17 

Wrong diagnosis 14 

Wrong treatment 14 

Total 829 

Communication 


Communication breakdown 164 

Conflicting information 47 

Failure to consult 27 

Inadequate information 139 

Other - Communication 114 

Poor attitude/discourteous/rude 218 

Undignified service 19 

Wrong/misleading info. 27 

Total 817 


Administration - Other 145 

Advertising 3 

Fail. provide certificate 8 

Incorrect documentation 23 

No/Inadequate response 38 

Policy 9 

Public health standards 8 

Treatment Cancelled 12 

Total 246 

Cost 

Amount charged 30 

Billing practice 26 

Information on cost 10 

Other - Cost 206 

Public/private election 3 

Unnecessary treatment 1 

Total 276 


46 


Appendix 3: HCIP Service provided at time of Complaint 

Accommodation Services 5 

Administrative Services 57 

Admissions 7 

Aged Care 91 

Anaesthetics 17 

Awaiting admission 2 

Car Parking 94 

Cardiac Surgery 10 

Cardiology 51 

Colorectal 18 

Day procedure 18 

Dentistry 63 

Dermatology 2 

Dietitian 1 

Ear, Nose & Throat 12 

Emergency 563 

Emergency Triage 39 

Endocrinology 5 

Environmental services 11 

Food Services 7 

Finance & Administration 16 

Gastroenterology 27 

General medicine 150 

General practice 4 

General surgery 141 

Gerontology 13 

Gynaecology 140 

Haematology 6 

Home Care 13 

Infectious diseases 13 

Intensive Care Unit 22 

Interpreter Services 4 

Liver Transplant 3 

Medical administration 19 

Neurology 35 

Neurosurgery 43 

Appendix 4: HCIP Outcomes 

Resolved 

Agreement reached 56 

Apology 1147 

Compensation Paid 39 

Explanation offered 1044 

Fee waived or reduced 7 

Fee refunded 39 

Frivolous/vexatious 15 

Information Provided 525 

Misunderstanding resolved 93 

No further action required 85 

Service/facility provided 393 

Users view acknowledged 398 

Waiting Time Reduced 6 

Total 3847 

Change of Policy 

Censure or Reprimand 15 

Policy change 5 

Procedural change 56 

Total 76 

Nursing Home 26 

Nutrition 2 

Obstetrics 255 

Obstetrics/Gynaecology 144 

Occupational Therapy 8 

Oncology 25 

Operating Theatre 4 

Ophthalmology 9 

Orthopaedic surgery 100 

Outpatients clinic 63 

Paediatrics 26 

Palliative care 2 

Pain Services 4 

Pathology 6 

Patient Services 57 

Pharmacy 22 

Physiotherapy 24 

Plastic surgery 28 

Podiatry 10 

Prosthetics/Orthotics 4 

Psychiatry 129 

Radiology 38 

Reception/Administration 2 

Rehabilitation medicine 21 

Renal/Nephrology 13 

Respiratory Medicine 24 

Rheumatology 6 

Social work 19 

Specialist Medical 5 

Specialist Surgical 48 

Speech therapy 4 

Spinal Injuries Unit 6 

Telecommunications 5 

Unknown 1254 

Urology 36 

Vascular surgery 33 


Remedial 

Caution or warning 1 

Censure or Reprimand 7 

Remedial action 148 

Total 156 

Referred 

Outcome in Referral 118 

Total 118 

Not Upheld 

Complaint not upheld 91 

No action possible 97 

Total 188 

Lapsed 

Allowed to lapse by user 47 

Insufficient detail 666 

Not confirmed 13 

Unsubstantiated 134 

Withdrawn by user 27 

Total 887 



Appendix 5: Reporting procedure guidelines 

under the Whistleblowers Protection Act 2001 

September 2003 

Contact 



Phone: 8601 5222 

Executive Approval 

9 September 2003 

Ombudsman Approval 

14 October 2003 

Guideline No. 0302 

Prepared by 


These guidelines are for all employees of the OHSC and are available to all members of the public 

free of charge. They can also be viewed at the OHSC website www.health.vic.gov.au/hsc 

Whistleblowers Protection Act 2001 

These guidelines are made in accordance with the 

Whistleblowers Protection Act 2001 (the Act), 

which came into effect on 1st January 2002. 

Consistent with the Act, the policy of the Health 

Services Commissioner is to encourage and 

facilitate the making of disclosures, where these 

are supported by reasonable grounds, related to 

alleged improper or corrupt conduct. 

A staff person or member of the public, who has 

reasonable grounds to believe improper or 

corrupt conduct has occurred, is occurring or is 

about to occur is encouraged to disclose this in 

accordance with these procedures. 

Introduction 

a. The aim of these procedures is to establish 

an objective system to encourage and provide 

support to persons making disclosures 

("whistleblowers"), to investigate disclosed 

allegations of improper conduct, or 

detrimental action against the person 

making the disclosure and to enable 

appropriate action to be taken. 

b. A disclosure may be made about improper 

conduct by a public body or public official. 

Improper conduct means conduct that is 

corrupt, a substantial mismanagement of 

agency resources or conduct involving 

substantial risk to public health, or to safety 

or to the environment. The improper conduct 

must be sufficiently serious to establish (if 

proved) a criminal offence or reasonable 

grounds for dismissal from employment. 

Corrupt conduct includes conduct by any 

person (not necessarily an employee) that 

adversely affects the honest performance of 

the functions of a public body or a public 

officer; an employee performing their 

functions dishonestly or with inappropriate 

partiality; conduct by an employee or a 

former employee that amounts to a breach 

of public trust, or a misuse of information or 

material acquired in the course of performing 

their official functions; a conspiracy or 

attempted conspiracy to engage in corrupt 

conduct. 

c. Detrimental action is action taken or 

threatened against a person disclosing 

alleged improper conduct and includes 

action causing injury, loss or damage, 

intimidation or harassment, discrimination, 

disadvantage, or adverse treatment to a 

person's employment, career, profession, 

trade or business and includes the taking of 

disciplinary action because of the fact of a 

disclosure of alleged improper conduct. 

Procedures for Handling Disclosures 

The OHSC has established the following 

procedures to facilitate the making of disclosures, 

investigation of disclosures, and for the protection 

of persons making disclosures from reprisals by 

the Health Services Commissioner, or any other 

employee of the OHSC. A disclosure may be made 

to the Manager, Executive Services of the OHSC 

or to the Victorian Ombudsman. 

The following procedures apply where a disclosure 

is made to the OHSC: 

1. A disclosure of alleged improper conduct 

shall be made direct to the Manager, 

Executive Services (or specifically nominated 

delegate). Alternatively, the disclosure may 

be made to the Ombudsman. 

2. On receipt of a disclosure, the Manager, 

Executive Services (or specifically nominated 

delegate) shall assume the role of the 

Protected Disclosure Coordinator (PDC) and 

shall promptly: 

a. Meet with the person making the disclosure 

(unless it is provided anonymously) to 

ascertain the details of the disclosed matter 

and invite the complainant to provide a 

detailed written statement on an "in 

confidence" basis. 

b. Impartially assess the disclosure to 

determine whether it amounts to a protected 

disclosure: 

i. If not, the PDC will explain to the 

complainant what other remedial action 

can be taken in the circumstances; 

ii. If so, the PDC will explain to the 

whistleblower the protections hat s/he 

receives under Part 3 of the Act and will 

offer the whistleblower welfare 

management. Thereafter, the PDC will 

move to step (c). 

c. Determine whether the protected disclosure 

amounts to a Public Interest Disclosure 

(PID) within Part 4 of the Act: 

i. If not, the PDC will explain what remedial 

action can be taken in the circumstances 

and that the whistleblower has the right 

to request that the protected disclosure 

be referred to the Ombudsman for a 

review of the PDC's determination. Where 

the whistleblower is satisfied with the 

proposed remedial action the PDC will 

give effect to such action subject to the 

protection, that the whistleblower enjoys 

under the Act; 

ii. If so, the PDC will refer the PID to the 

Ombudsman for a formal determination 

as to whether the protected disclosure 

amounts to a PID. 

d. If the Ombudsman determines that the 

disclosure is a protected disclosure, the 

Ombudsman may refer it back to the 

Manager, Executive Services to be 

investigated. 

e. If it is referred back to the Manager, Executive 

Services, the PDC shall promptly assign an 

investigator (who may be a senior employee 

or external solicitor/consultant) to investigate 

the disclosure and report direct to the PDC 

who will refer the report to the Ombudsman. 

3. If the disclosure relates to the Manager, 

Executive Services, the disclosure should be 

made directly to the Ombudsman. 

4. Disclosure and investigation material will be 

treated with the utmost confidentiality and 

security. Such material is only to be accessed 

by the Manager, Executive Services as the 

PDC or by the investigator. Disclosures made 

under this policy will be investigated swiftly, 

professionally and discretely. 

5. The OHSC is required to include in its annual 

reports material including the number (if any) 

and types of disclosures made to it. 

6. Where an investigation of a PID reveals that 

the improper conduct occurred, the PDC will: 

i. Report the findings of the investigation to 

the Minister; 

ii. Take all reasonable steps to prevent the 

conduct occurring in the future; 

iii. Bring disciplinary proceedings against the 

person responsible for the conduct; 

iv. Refer the matter to the appropriate 

regulatory body for further consideration. 

7. It is a criminal offence: 

a. For a person to take detrimental action 

against a person in reprisal for a protected 

disclosure ($6,000 fine or two years 

imprisonment or both) 

b. For a person to reveal confidential information 

received in the course of or as a result of a 

protected disclosure except as provided for 

under the Act ($6,000 fine or 6 months 


c. For a person to wilfully obstruct hinder or fail 

to comply with a lawful requirement of the 

Ombudsman ($24,000 fine or two years 


d. For a person to knowingly mislead or attempt 

to mislead the Ombudsman ($24,000 fine or 

two years imprisonment or both) 

e. For a person to knowingly provide false 

information to the OHSC's Manager, Executive 

Services intending it to be acted on as a 

disclosed matter ($24,000 fine or two years 

imprisonment or both). 

The OHSC is committed to the highest standards 

of ethics and probity in the performance of its 

duties and the delivery of its services to the 

community. 

The Ombudsman has published a set of detailed 

guidelines and the agency will follow these in 

dealing with a disclosure. A copy of these 

guidelines is available from the OHSC or can be 

downloaded from the Ombudsman's website 

www.ombudsman.vic.gov.au 

48 



Level 30, 570 Bourke Street, Melbourne VIC 3000 

hsc@dhs.vic.gov.au 

www.health.vic.gov.au/hsc 

Telephone: (61 3) 8601 5200 

Toll Free: 1800 136 066 

Fax No.: (61 3) 8601 5219 

Ausdoc: DX 210182 

TTY No. 1300 550 275

Office of the Health Services Commissioner Annual Report 2008

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