Introduction to Volume 6

This volume—Volume 6—focuses on children in Tasmania’s health system and how the Department of Health prevents and responds to child sexual abuse. The terms of reference for our Commission of Inquiry specifically require us to have regard to:

The adequacy and appropriateness of the responses of the Tasmanian Health Service and the Department of Health to allegations of child sexual abuse, particularly in the matter of James Geoffrey Griffin (deceased 18 October 2020).1

Health services, particularly hospitals, are often assumed to be inherently safe places for children and young people. They are imagined as busy places, humming with staff who have been professionally trained and rigorously screened by oversight bodies to confirm their suitability to work with children and young people. The public naturally assumes that those working in health services will place the best interests of patients at the centre of what they do.

There has been limited research to test the assumption that hospitals are inherently safe for children and young people, and there is little evidence available about the risks of child sexual abuse in health services. However, based on the available research and the limited evidence we heard, there are inherent risks posed to children and young people in health services.

Health workers can have intimate contact with children, sometimes without supervision. Children and young people who seek treatment often feel unwell or may have disabilities or mental health concerns that create a dependency on health workers for their care. Children and young people often have less social power than adults and are therefore less able to advocate for themselves. Parents and carers typically take for granted that they can safely leave their children unsupervised in the care of a health worker and that any intimate procedures are warranted or necessary.

The overwhelming majority of health workers do an outstanding job in providing safe, empathetic and high-quality care to children and young people. We met many such health workers across Tasmania during our Commission of Inquiry. We consider the trust and goodwill extended to health workers to be well founded. However, a significant reason that our Commission of Inquiry was established was the shocking and devastating revelations that James Griffin, who was a paediatric nurse on Ward 4K at Launceston General Hospital for nearly 20 years, perpetrated child sexual abuse inside and outside the hospital. Sadly, these revelations were not so shocking to those who knew of Mr Griffin’s abuses first-hand or had tried, with little success, to raise the alarm about his concerning behaviour over the years.

While it may be tempting to view Mr Griffin’s abuses as an anomaly, they are not. The risk of child sexual abuse in health services must be recognised and addressed. We heard from several people who had reported allegations of abuse within, or connected to, health services across Tasmania, including at Royal Hobart Hospital.2
However, our Commission of Inquiry received a substantial amount of evidence about allegations of child sexual abuse connected to Launceston General Hospital. For this reason, we focus primarily on Launceston General Hospital in this volume.

As part of our examination of Launceston General Hospital, we focused on three case studies—those of Mr Griffin and two other individuals who were accused of child sexual abuse at Launceston General Hospital prior to Mr Griffin’s employment there or before there were complaints about his conduct. Launceston General Hospital’s failure to identify and respond to the red flags raised about Mr Griffin over his long tenure at the hospital are indicative of an institution that did not learn from its previous experience in responding to allegations of child sexual abuse.

We do not discuss the first case study in our report because it is subject to a restricted publication order, which means it will not be made available to the public or media. We are committed to being open and transparent and have sought to examine the prevention, identification, reporting of and responses to child sexual abuse. During our Inquiry, we heard evidence that, too often, people, including victim-survivors, have felt silenced or unable to come forward and be heard. At the same time, we have sought to avoid prejudicing any current investigation or proceedings. Not only was this required by our terms of reference, but we are acutely aware of ensuring we did not prejudice the ability of victim-survivors to seek justice and ongoing attempts to keep children safe. It is in this context that we made a restricted publication order in relation to the first case study. We made this order because we were satisfied that the public interest in the publishing of evidence contained in the first case study is outweighed by relevant legal considerations, including avoiding prejudicing current investigations and proceedings.

Zoe Duncan (now deceased) alleged that she was sexually abused by Dr Tim (a pseudonym) as an 11-year-old in 2001.3 Her incremental disclosures were met with scepticism and disbelief from the hospital, which set in train a sequence of wrongful assumptions that neither she nor her parents could overturn, despite their best efforts. Zoe remains deeply loved and missed by her family, who were generous in giving us an insight into her life and the abuse she suffered, as well as the disbelieving responses to her allegations by the hospital and other investigatory agencies. The agreement of Zoe’s parents to allow us to consider her experience in more detail reflects their desire for Zoe’s legacy to be one of protecting other children and young people from abuse and ensuring they are believed when they report concerns. We document the case study relating to Dr Tim in Chapter 14.

Because previous matters, such as Dr Tim, did not act as ‘wake-up calls’ to the hospital and broader Department of Health, Mr Griffin tested and overstepped boundaries early in his tenure at the hospital and continued to do so until a victim-survivor eventually reported him to police in 2019.

We were overwhelmed by the extent of Mr Griffin’s abuse. In line with our terms of reference, we considered in detail the history of complaints and concerns raised about this nurse at Launceston General Hospital. The length of the case study about Mr Griffin reflects the volume of material we received and evidence we heard, much of which was already available to the hospital and other agencies and had been for some time. The amount of information about Mr Griffin’s offending points to numerous missed opportunities—by Launceston General Hospital, Tasmania Police and Child Safety Services—to intervene earlier.

We heard from many victim-survivors, former patients and current and former hospital staff, some of whom shared their anguish and frustration that their reports and concerns about Mr Griffin had been ignored. We are indebted to all the victim-survivors, former patients and current and former staff who shared information with us. Without the public participation of some of these witnesses, particularly victim-survivors Kylee Pearn and Tiffany Skeggs and whistleblower Will Gordon, we would not have been able to make the findings we have. These witnesses went to extraordinary lengths to draw attention to systemic failures to protect children and young people from Mr Griffin. We were humbled by their actions, their generous assistance to our Inquiry and their unwavering commitment to children’s safety.

We document the case study of Mr Griffin in Chapter 14.

Some of the witnesses who gave evidence to us were wary of doing so. The Tasmanian Government encouraged witnesses to provide information to our Commission of Inquiry. In particular, the Premier, the Honourable Jeremy Rockliff MP, stated that the Government sought to ‘reassure all Tasmanians that we absolutely encourage people to come forward’.4

In August 2022, the Tasmanian Government also recognised the contribution of victim-survivors and state servants who had provided information to our Commission of Inquiry. The Premier stated:

I want to once again thank victims and survivors for having the courage to share their experiences, along with State Servants who have come forward in an effort to make things better for children and young people in Tasmania. I want to again reiterate today that all State Servants have my full support to come forward and shine a light on these matters.5

The Commissions of Inquiry Act 1995 also reflects the importance of protecting those who provide information to a commission.

We note the statement of Kathrine Morgan-Wicks PSM, Secretary, Department of Health, in our hearings, who welcomed the courage of some current and former staff in giving evidence to our Commission of Inquiry:

To our employees, to Will Gordon, to Maria Unwin and Stewart Millar, to Annette Whitemore, and may I also include Amanda Duncan as an employee that has spoken out for her sister: thank you for your bravery in coming forward as whistleblowers and for your continued efforts to try to alert the department to serious misconduct by other Health employees.

I am sorry that it has taken a Commission of Inquiry for you to be believed or for your complaints and our lack of action to be publicly known.6

We consider the commitment of these individuals, who were vulnerable in their own reflections about their past actions (some of which were described with some regret), should be viewed within the context of their broader actions at the time and subsequently. We agree with the Premier and the Secretary that they should be commended for coming forward and sharing their experiences.

Taken together, the case studies show a fundamental failure of leadership at Launceston General Hospital to respond to potential risks to child safety over more than three decades, contributed to by the associated failures of Tasmania Police and Child Safety Services. The accounts in these case studies cannot be categorised as ‘one-off’ or ‘rare instances’ of inappropriate responses by the hospital to allegations of unprofessional behaviour.

We heard about the absence of effective protocols to protect children and young people at the hospital, the poor attitudes of managers to complainants and the inadequate responses of the hospital to disclosures.

These systemic failures at Launceston General Hospital have existed for decades and are likely endemic to the Tasmanian health system. Our recommendations—which we summarise below—are therefore relevant to all health services.

This volume comprises three chapters; Chapter 13—Background and context: Children in health services, Chapter 14—Case studies: Children in health services, and Chapter 15—The way forward: Children in health services.

In Chapter 13 we provide the context for our case studies. We outline Tasmania’s health system (particularly as it relates to child safety) and summarise previous reviews of the health system that identified some of the same problems we discovered through our Commission of Inquiry. As previously noted, Chapter 14 focuses on our case studies—those of Dr Tim and Mr Griffin. In these case studies we identify systemic and individual failings within Launceston General Hospital relevant to the hospital’s response to these allegations.

In holding individuals to account, we have tried to be fair and balanced, recognising that none of us are immune from imperfect responses and that we hold the benefit of knowledge that was not available to some at that time. We are also mindful that people operated in a broader context and that it was, in part, the hospital’s lack of leadership and protocols, as described in the case studies, that enabled the unsatisfactory response of some to concerns and complaints about misconduct.

We are also conscious that some people were subject to greater scrutiny than others because of their roles in responding to complaints about Dr Tim and Mr Griffin, or because these people were more prominent in the information we received. We acknowledge that we may have not identified the relevant conduct of others because we were not made aware of it or did not have enough evidence to substantiate it. In considering the actions of individuals, we carefully considered their relative roles and responsibilities, and whether we considered their conduct justified our particular focus.

In these case studies we identify individual and systemic failings. These inform our understanding of the broader problems that need to be addressed in health services to protect children and young people from sexual abuse in the future, and to ensure health services respond better when abuse does occur.

In Chapter 15 we make recommendations for reform.

We recommend that the Department of Health develops and publicly communicates a policy framework and implementation plan for reforms to improve responses to child sexual abuse in health services. This policy and plan should explain the purpose and need for the reforms; the role, responsibilities and interactions of bodies established by the Department of Health as part of the reforms; how the reforms will work together to provide a system-wide response to child sexual abuse in health services; how the reforms are being prioritised for implementation; who is responsible for their implementation; and the expected timeframes for implementation.

Of national significance, recognising the risks we have identified of child sexual abuse in health settings, we recommend that the National Principles for Child Safe Organisations should be a mandatory requirement for accrediting health services against the National Safety and Quality Health Service Standards under the Australian Health Service Safety and Quality Accreditation Scheme, and the Tasmanian Government should advocate for this reform at the national level.

We recommend that the Department of Health’s cultural improvement strategy ensures clear organisational values, has strong governance, and ensures accountability of senior managers and executives. We recommend the Department of Health establishes processes and forums to facilitate the participation of children and young people in decisions affecting the delivery of health services, including a health services advisory group. The advisory group should comprise young people of varying ages and backgrounds, but who share significant experience with health services. Through the advisory group young people should have a say in departmental strategies, policies, procedures and protocols that affect them.

We recommend that the Department of Health develops a professional conduct policy for staff who have contact with children and young people in health services. The policy should provide examples of behaviour that is inappropriate in clinical and non-clinical contexts, such as engaging with children through online social networks and having unnecessary contact with children outside the professional relationship. It should also reference existing professional and ethical obligations held by registered health practitioners.

The development and implementation of a clear complaints management, escalation and investigation process is critical. Noting the specialised context in which health workers operate, the Department of Health may choose to establish a standalone Health Services Child-Related Incident Management Directorate or to partner with the Child-Related Incident Management Directorate we recommend in Volume 6 (Recommendation 6.6).

The Department of Health, Launceston General Hospital and Tasmania Police must ensure ongoing assistance to known and as yet unknown victim-survivors of child sexual abuse by Mr Griffin. The Department of Health should also develop and implement a critical incident response plan to ensure that measures are in place to communicate with clarity and consistency, and to support the affected members of the community, in the event of a future critical incident, such as a serious breach to children’s safety within the public health system. The plan should identify who is responsible for leading the response to the critical incident, facilitate psychological first aid, support and critical incident debriefing and provide for a review of how the Department of Health responded to the critical incident.

Further, the Tasmanian Government should ensure a review of the Health Complaints Act 1995 is completed and considers the role of the Health Complaints Commissioner in relation to addressing systemic issues within health services related to child safety.

Although the case studies in Chapter 14 focus on conduct that occurred at Launceston General Hospital, the aim of our report and recommendations is to prompt and facilitate change across the broader Tasmanian Health Service, the Department and agencies that work alongside those services, such as Tasmania Police and Child Safety Services.

Although most health services are places of healing and safety for children, our Commission of Inquiry has identified the high cost of complacency about the risks of child sexual abuse in these settings. The issues at Launceston General Hospital can and doubtlessly do occur within other health services. Services beyond the immediate remit of our Inquiry are encouraged to reflect on their own understanding and decision making about child safety and to take steps to make their organisation safe for children and young people. We trust the evidence presented in this volume of our report provides compelling reasons to do so.

1. Introduction

In this chapter we summarise what is known about child sexual abuse in international and Australian health services, including through the Royal Commission into Institutional Responses to Child Sexual Abuse (‘National Royal Commission’) and our own research into children and young people’s perceptions of safety in government health institutions in Tasmania. We briefly describe the Tasmanian health system and the key regulatory bodies that play a role in overseeing health services and the people who work within them. We also summarise four key reviews that have examined aspects of the Tasmanian health system relevant to our Commission of Inquiry, including organisational culture, governance arrangements and the reporting and management of misconduct. We conclude the chapter by highlighting what we heard about the organisational culture at Launceston General Hospital, which as noted earlier is the primary focus of the remainder of this volume, including our case studies in Chapter 14.

1. Understanding the health context

Health services and health workers have a duty of care to patients, including children and young people, that extends to keeping them safe from harm while they are under their care.

Because people often assume health services are highly controlled, supervised and public environments, the risk of sexual abuse to children in these settings can be underestimated. People rightly expect that health workers will act in the best interests of patients and according to their professional obligations.

We reviewed a key report examining child sexual abuse in healthcare contexts published in the United Kingdom (discussed in Section 2.1.1), as well as research we commissioned into the experiences of Tasmanian children (discussed in Section 2.1.2), to learn more about the vulnerability of children and young people in health services. We also learned from the lived experience of victim-survivors and people working in these settings about the specific factors that can increase the risks of abuse to children in health services.

1. Research into child sexual abuse in health services

Unlike other government or government funded institutions of interest to our Commission of Inquiry, child sexual abuse within health services has not been the subject of significant research. There is limited data on the prevalence and incidence of child sexual abuse perpetrated within health services.7 Consequently, the extent and nature of child sexual abuse that occurs in these institutions is not well understood.

Although the National Royal Commission heard evidence from some people who had experienced child sexual abuse in health services, child sexual abuse in health institutions was not a specific focus of the National Royal Commission.8 Nonetheless, the National Royal Commission made the following general observations about child sexual abuse in health contexts:

Medical practitioners, health professionals and hospitals are responsible for improving and maintaining the health of their patients. Patients, who are in a vulnerable state of illness, place their trust in health care providers. Patients, and the parents of child patients, place such trust in medical practitioners that they permit those medical practitioners to view and touch intimate parts of the patient’s anatomy. Patients permit these acts because of the close nature of the health practitioner–patient relationship and because they believe that a health practitioner is acting in pursuit of a higher purpose of assisting the patient with his or her illness or injury and not out of personal sexual gratification.

Children often follow instructions from health care providers without question and the private one-on-one nature of therapy places children in a vulnerable position.9

This observation extends beyond medical practitioners—it applies to all health workers within the health system, some of whom will use their position to abuse or manipulate children and young people.10

1. Truth Project thematic report into child sexual abuse in healthcare contexts

In 2020, as part of the Independent Inquiry into Child Sexual Abuse in the United Kingdom, the Truth Project published a thematic report that included findings about the experiences of victim-survivors of child sexual abuse in healthcare contexts.11 The report described the research into health workers as sexual abusers of children as ‘dated and sparse’.12 The report also stated that it is difficult to estimate the prevalence of health workers breaching sexual boundaries, particularly in relation to children, because most child sexual abuse is hidden.13

The Truth Project report considered power dynamics that exist between health workers and patients, including the power dynamics between children and the health workers upon whom they rely to treat them.14 The report described health services (particularly mental health facilities) as ‘strong institutions’; that is, the power imbalance between patients and staff, coupled with the depersonalisation of patients that can occur in such institutions, creates an environment that enables abuse to occur.15 This can be exacerbated when there is a workplace culture that prevents people from speaking up about wrongdoing.16 We found similar problems through our Inquiry.

Key qualitative findings from the Truth Project report included:

• The vulnerability of patients in health settings was heightened because of patients being alone and without chaperones, and due to the ‘unique nature of the position of trust and authority’ held by health practitioners.17
• Although there were examples of children, their parents and staff being manipulated by abusers, overall, there was little evidence of grooming from health workers, which was attributed to the fact that such workers often did not need ‘special’ explanations to perpetrate their abuse.18
• Abusers were most commonly men with routine access to children, with many abusing children under the guise of medical procedures or examinations, sometimes involving medication.19
• Many (but not all) abused children had experienced abuse and neglect at the hands of family members and had experienced other difficulties (for example, bullying) that contributed to their health problems and made them particularly vulnerable to abuse within health services.20
• Only a quarter of the children who were abused felt they could disclose their abuse. Those who did disclose were often not believed, particularly if they were experiencing mental health problems at the time of their treatment. There were also limited processes or pathways for young people to disclose sexual abuse, particularly if they were inpatients.21
• For victim-survivors, abuse in a health setting sometimes contributed to a lifelong fear and mistrust of health workers.22

1. Commission of Inquiry’s research into children and young people’s perceptions of safety in government health institutions in Tasmania

As part of our Commission of Inquiry, we commissioned research that explored children and young people’s perceptions of safety in government organisations in Tasmania, including hospitals.23 This research enabled us to learn directly from the views and experiences of children and young people.

As part of this research, children and young people described two factors that contributed to making a health institution or hospital feel safe. The first was the presence of an adult who was ‘friendly and kind’, who ‘showed interest’ and who asked children and young people what they needed.24 The second was the protective role parents or carers play in a child or young person’s home life and engagement with institutions. For example, one young person reported feeling a lot more at ease in hospital knowing that his parents were there to make sure he was getting the care he needed, as well as to help him raise concerns and to advocate on his behalf.25 Other children and young people who had spent time in hospital held a similar view:

When there were issues, my mother had to go to the front counter, the main hub desk of the paediatric unit, and voice her frustration on behalf of not only my parents, but also me.26

Another participant in the research said:

It does help to have someone to talk to. They said parents could sleep on a couch in the room. If I needed something I would ask my mum to ask them because I was too scared to talk to nurses. I was a real timid little kid. I just felt really little and [I would] just get Mum to do it.27

Several young people who had experienced a stay in hospital reported not feeling safe due to the physical characteristics of the hospital environment. They talked about how hospitals could feel ‘creepy’ and ‘sterile’. One young person described the hospital environment in the following way:

My room was dark. I didn’t have access to a window. It felt like solitary confinement. It was quite horrible: that situation, I didn’t feel safe. I didn’t feel like I could flourish in an area like that. I didn’t feel like I could get better in an area like that. It really wasn’t useful until I was moved into a room where there were three windows and where I had different nurses, where I felt like, ‘okay, I’m starting to get better. I can do this. I can get out of here’.28

Another young person talked about how having their own space in hospital was important:

I’ve had a few surgeries and sometimes I am in a room by myself, sometimes I am in a room with someone else and that doesn’t feel comfortable being in a room with someone you don’t know. It’s being in a room with strangers.29

One young person discussed the experience of being Aboriginal and having contact with a health institution. This person said the hospital made no attempts to acknowledge their culture or to support them to stay connected to their culture while they were in hospital:

I didn’t really feel represented or supported in terms of my cultural identity. I wasn’t even asked if this was something I wanted, or if this was something that I valued about myself. It wasn’t until I had been mentioning parts of my culture to nurses that that was a topic of conversation.

[Question (from researcher): So, you would’ve been able to tell if it was culturally safe for you. In what way? How would it have been culturally safe for you?]

If I had an Aboriginal youth worker come over. I didn’t feel support in that aspect. And also, even whether there was access to national indigenous TV on the television, whether there was an Aboriginal mural in the hospital or things like that.30

These views from children and young people show how hospitals can feel unsafe and unwelcoming for many and how difficult it can be to raise concerns with staff, particularly if a young person does not have protective family or carers to advocate for them. The views referenced above reinforced for us the importance of hearing directly from children and young people about what is needed to facilitate and enhance their safety.31 We discuss empowering children and young people in health services in Chapter 15.

1. Evidence of the risk factors for child sexual abuse in hospitals

Catherine Turnbull, Chief Child Protection Officer, SA Health, Department for Health and Wellbeing, told us that children and young people can be at risk of abuse or neglect perpetrated by adult patients, visitors, health workers or other children and young people in hospital settings.32 She identified several risk factors that can make children and young people more vulnerable to abuse and neglect in hospital settings. These risk factors include:

• children and young people recovering in rooms that are not closely monitored by staff and/or closed-circuit television33
• placing children and young people in group rooms without enough regard for their suitability to be placed together34
• inpatient services that have a mix of child and adult patients35
• health workers treating children and young people without other people present (such as a parent/carer or other staff member)36
• failure to offer a chaperone where treatment is provided by a staff member of a different gender37
• the length and regularity of children and young people’s attendance at hospital, and the degree of familiarity between children and young people and their treating health workers38
• feelings of disempowerment and dependency that arise in children and young people who have been hospitalised for long periods (or who have been hospitalised repeatedly), which can affect their ability to disclose concerns.39

Kathryn Fordyce, Chief Executive Officer, Laurel House, also described the vulnerability of young people in health services, stating that, ‘[u]nfortunately, there are social norms that mean we condition children, especially those with disabilities and health conditions, to be compliant and submissive’.40 She described that trying to empower children to speak up when they are harmed is:

… even more complicated for a child with a disability or a health condition who has been poked and prodded their whole life, and had their personal space invaded many times for legitimate medical or care reasons. All too often adults ignore a child’s attempt to maintain their bodily autonomy, and then those same adults are surprised when children are abused and do not report it.41

1. Tasmania’s health system

The Tasmanian Government provides a range of healthcare and health support services to the community. These services are delivered through major hospitals, district hospitals and community health services across three service areas—North, North West and South.42

The four major government hospitals that service the Tasmanian community are Launceston General Hospital, Mersey Community Hospital, North West Regional Hospital and Royal Hobart Hospital. Launceston General Hospital, North West Regional Hospital and Royal Hobart Hospital each have a paediatric unit and offer outpatient services to children and young people.43 The smaller Mersey Community Hospital provides emergency paediatric services. District hospitals and community health services also provide healthcare and support services to children and young people.

1. Department of Health

The Department of Health is the system-wide administrator of the public health system and its attendant organisations in Tasmania. The Department is one of the largest public sector agencies in Tasmania, employing around 15,500 people who work across approximately 330 sites statewide.44 The Department’s workforce includes medical practitioners and specialists, allied health professionals, dental practitioners, paramedics, nurses and midwives, facilities officers, administration and support staff and contracted locum and agency staff.45 A large base of volunteers also contribute their time and efforts across health services.46

The Department of Health has undergone several ‘machinery of government’ changes since the late 1990s.47 These have resulted in substantial modifications to the Department’s organisational structure and governance arrangements.48 The recent Independent Child Safe Governance Review of the Launceston General Hospital and Human Resources (discussed in Chapter 15) found that this restructuring has contributed to ‘some confusion around management roles, responsibilities and accountabilities’ and a level of ‘restructuring “fatigue”’.49

As noted, Secretary Morgan-Wicks leads the Department of Health. Secretary Morgan-Wicks started in the role on 2 September 2019.50 The Secretary has a range of duties including planning health services and overseeing the performance of executive and senior staff.51 The Secretary is also responsible for the performance of the Tasmanian Health Service and the Health Executive.52

A note on language

Unless otherwise stated, further references to ‘the Department’ in this volume are to the Tasmanian government department responsible for ‘hospitals, ambulances, community health, and related areas such as primary healthcare’.53 During the period under examination by our Commission of Inquiry (that is, responses to reports of child sexual abuse since 1 January 2000) this Department has been called the Department of Health and Human Services and the Department of Health.

1. Tasmanian Health Service

In line with the Tasmanian Health Service Act 2018, the Tasmanian Health Service is a statutory entity responsible for delivering health services to the community. Its functions are:

• to manage the operations of health services, including at public hospitals
• service planning
• budget management
• ensuring the Minister for Health’s policies are implemented.54

1. Health Executive

The purpose of the Health Executive is to ‘lead the strategic direction and provide oversight of the Department’s key responsibilities’.55 It includes the Secretary as well as a range of other senior roles, including the chief executives of Tasmania’s hospitals, the Chief People Officer, the Chief Medical Officer and the Chief Nurse and Midwife.56

The functions of the Health Executive are to:

• administer and manage the Tasmanian Health Service
• perform and exercise the functions and powers of the Tasmanian Health Service
• ensure the services the Tasmanian Health Service provides are delivered in line with Tasmanian Health Service standards and within budget
• manage and monitor, and report to the Secretary on, the administration and financial performance of the Tasmanian Health Service
• monitor and report to the Secretary on the outcomes, for people, of providing health services to those people
• set up appropriate management and administrative structures for the Tasmanian Health Service
• perform any other functions specified by the Secretary.57

Various subcommittees and local health service managers across the State support the Health Executive.58

Some of the members of the Health Executive also serve on the Tasmanian Health Service Executive, which is responsible to the Secretary for administering and managing the Tasmanian Health Service.59

1. Oversight of the Tasmanian health system

As in other states and territories, external agencies oversee aspects of Tasmania’s health system. These agencies are:

• the Office of the Health Complaints Commissioner Tasmania, which responds to systemic complaints about Tasmanian health services
• the Australian Health Practitioner Regulation Agency (‘Ahpra’) and the National Health Practitioner Boards, which respond to notifications about registered health practitioners, including those in Tasmania
• the Australian Commission on Safety and Quality in Health Care (‘Safety and Quality Commission’), which accredits Tasmanian health service organisations against the National Safety and Quality Health Service Standards.

A core function of these oversight bodies is ensuring the safety of patients, including children and young people, who receive healthcare or health support services.

We briefly outline below the role of these bodies in overseeing aspects of Tasmania’s health system.

1. Office of the Health Complaints Commissioner Tasmania

The Office of the Health Complaints Commissioner Tasmania was established in 1997 under the Health Complaints Act 1995. The Health Complaints Commissioner (at the time of writing) is Richard Connock, who was appointed to the role in July 2014.60

The functions of the Health Complaints Commissioner include to receive, assess and resolve complaints and to enquire into and report on matters relating to health services, at their discretion or as directed by the Minister for Health.61

The Health Complaints Commissioner performs their functions independently, impartially and in the public interest.62 The Commissioner is not subject to the direction of any person about the way their functions are performed.63

1. Australian Health Practitioner Regulation Agency and National Health Practitioner Boards

In 2008, Australian states and territories agreed to develop a National Registration and Accreditation Scheme for health practitioners. This scheme replaced individual practitioner regulation in each jurisdiction.64 The Health Practitioner Regulation National Law Act 2009 (‘National Law’) began in all states and territories in 2010. Tasmania adopted the National Law through the Health Practitioner Regulation National Law (Tasmania) Act 2010.65 The National Law established Ahpra and 15 National Health Practitioner Boards (‘National Boards’) for 16 health professions.66 The National Law applies to all health practitioners who are registered in any one of these 16 health professions.67

Ahpra is the national organisation responsible for administering the National Registration and Accreditation Scheme.68 Ahpra has a range of functions, but it primarily provides administrative support to the National Boards in performing their functions under the National Law.69 Ahpra also establishes procedures for receiving and assessing applications for registration and notifications about registered health practitioners and maintains the national register of registered health practitioners.70 This register, which can be searched on Ahpra’s website, contains information about registered health practitioners, including information about current restrictions that apply to their registration.71 An Agency Management Committee oversees Ahpra’s work.72

The National Boards for the 16 health professions have a range of functions including:

• determining requirements for registration within the health professions
• approving accredited programs of study for registration in the health professions
• registering suitably qualified people in the health professions
• working with Ahpra to ensure the national register of health practitioners is up to date
• developing standards, codes and guidelines for the health professions
• overseeing notifications about people who are or were registered in the health professions
• overseeing the management of health practitioners registered in the health professions
• referring matters about people who were or are registered in the health professions to a relevant tribunal.73

In Tasmania, the relevant tribunal is the Tasmanian Civil and Administrative Tribunal.74

1. Australian Commission on Safety and Quality in Health Care

The Safety and Quality Commission was established by the former Council of Australian Governments in 2006 and is jointly funded by the Commonwealth and states and territories.75 It started as an independent statutory authority on 1 July 2011.76 The objectives of the Safety and Quality Commission are to ‘contribute to better health outcomes and experiences for all patients and consumers and improve value and sustainability in the health system by leading and coordinating national improvements in the safety and quality of health care’.77

The Safety and Quality Commission has a range of functions in relation to healthcare safety and quality, which are set out in the National Health Reform Act 2011 (Cth).78 As part of its role, the Safety and Quality Commission develops the National Safety and Quality Health Service Standards (‘National Standards’).79 The National Standards ‘provide a nationally consistent statement on the level of care that consumers can expect to receive from health service organisations’.80

There are eight National Standards, including a Clinical Governance Standard, a Partnering with Consumers Standard and a Communicating for Safety Standard.81 The primary aims of the National Standards are to protect the public from harm and to improve the quality of health service delivery.82 We consider how the National Standards should relate to child safety (including the National Principles for Child Safe Organisations) in Chapter 15.

1. Previous reviews examining the Tasmanian health system

Over the past two decades the Tasmanian health system has been the subject of several reviews and investigations. These reviews and investigations have considered issues of performance, efficiency, organisational culture and misconduct committed by State Service employees. Although none of the reviews have specifically examined child sexual abuse in health services, many have identified some of the same problems that we found through our Commission of Inquiry as exacerbating the risks of child sexual abuse.

These problems include:

• ineffective governance arrangements and a lack of clarity about roles and responsibilities among staff in health services
• an absence of scrutiny over staff conduct and decision making and a lack of accountability for senior managers and executives
• organisational cultures characterised by poor leadership and toxic behaviour, including misconduct by State Service employees in relation to conflicts of interest, underperformance and mistreatment of staff
• failures to report misconduct due to fear of retribution
• instability because of changes in organisational and governance structures.

These reviews are relevant to our Inquiry because the available research into the risks of child sexual abuse in health services shows that workplaces with dysfunctional cultures—particularly those that allow poor conduct to go unaddressed—contribute to, or at least hinder, the identification of child sexual abuse.83 These reviews also show that problems with governance, culture and misconduct within the Tasmanian health system are longstanding.

1. Report of an Investigation into Ward 1E and Mental Health Services in Northern Tasmania (March 2005)

In March 2004, the then Minister for Health and Human Services directed the then Health Complaints Commissioner to investigate Ward 1E at Launceston General Hospital and its associated Oldaker and Spencer clinics. At the time of the investigation, Ward 1E and its associated clinics were managed by Mental Health Services as part of the Community, Population and Rural Health Division of the Department of Health and Human Services and was not managed through the Launceston General Hospital.84

The investigation was prompted by several complaints to the Health Complaints Commissioner and Nursing Board of Tasmania about the treatment of patients in these units.85 The complaints raised serious concerns about the standard of care and treatment provided to patients and alleged sexual misconduct by two nurses and a ward attendant against highly vulnerable adult patients.86

The Health Complaints Commissioner was tasked with examining the incidents and the Department’s response to these complaints.87 The Health Complaints Commissioner was also tasked with making recommendations for improvement, including in relation to complaints management, governance and risk management, performance oversight and the protection of patients.88

Two investigations addressed the terms of reference—one into the specific complaints about the behaviour of individual staff (which included sensitive information about patients) and the other into the broader systemic issues highlighted in the complaints.89 We summarise the findings of the latter investigation below, noting that many of the problems identified are similar to those we heard about nearly 20 years later through our Commission of Inquiry.

1. Investigation into systemic issues

The Health Complaints Commissioner’s investigation explored how reported incidents were managed, whether the individual performance of staff members was monitored, whether standards set by regulatory bodies were complied with, and whether systemic problems were identified and addressed.90

The report found that Ward 1E and its associated clinics did not, in many respects, provide an appropriate model of care for mental health patients nor foster an environment consistent with best practice.91 The report also described serious sexual misconduct by staff at the facilities.92

The Health Complaints Commissioner made 26 recommendations, all aimed at improving the standard of care at the facilities.93 These recommendations related to nursing practice, governance and incident reporting within a safety and quality framework, and the importance of spelling out appropriate professional conduct and accountability.94

Key recommendations included:

1. Ethical and appropriate workplace conduct

That Area Management, HR [Human Resources] and non-nursing personnel receive education and training in relation to the State Service Code of Conduct and its operation, with particular reference to the sort of conduct that could constitute a breach of its terms.

2. Appropriate professional conduct

That guidelines, educational units and protocols be developed and implemented in relation to professional boundaries for MHS [Mental Health Service] health professionals, and operate in conjunction with a governance and professional mentorship model.

3. Training — incident reporting, complaints and grievances

That all ward staff and area management officers receive education and training in relation to the procedures for the reporting of incidents, concerns and complaints and their investigation and resolution; with particular reference to the need to have regard to any clinical and clinical risk management issues raised by incidents, concerns or complaints.

4. Clinical supervision and mentorship

4.1 That if feasible, clinical supervision be delivered by both internal and external supervisors.

4.2 That the model of care formulated clearly articulate[s] the governance arrangements for the service. These governance arrangements need to incorporate both the unit specific governance and the broader hospital or health service governance arrangements. Clear lines of accountability and minimal duplication should be established.

4.3 Clinical leadership should be reflected in the governance arrangements and the role of clinical leaders determined by the model of care implemented.

4.4 Any amendments to clinical leadership should be implemented as an interim measure until a model of care is agreed.

4.5 That a Ward Management committee be part of the governance model.

…

20. Complaints

20.1 Implementation of policy and procedures for a continuum that addresses information notification of complaints through to sentinel events. The policy should cover resources required, governance arrangements, legislative requirements, staff development, timeframes and quality improvement cycles.

20.2 Any complaints [about] sentinel events and associated investigations or responses should be recorded on a database to allow trend analysis to occur and corrective action implemented.

20.3 That the skills base of managers and HR staff in relation to complaint handling be strengthened through the provision of additional training, with a focus on the importance of timeliness in responding to these types of matters.95

The Health Complaints Commissioner concluded that systemic failures can create a workplace culture that is conducive to misconduct or unprofessional conduct. This in turn has the potential to have an adverse effect on clinical practice and professional workplace relationships.96

1. Implementation

In April 2005, the then Minister for Health and Human Services established a taskforce to oversee implementation of the 26 recommendations.97 The taskforce submitted a final report to the Minister in November 2006, which stated that 22 of the 26 recommendations had been implemented.98 The report noted that the four outstanding recommendations were to be implemented over the following year by senior mental health service staff on Ward 1E as part of the broader Mental Health Services Strategic Plan 2006–2011.99

In June 2007, following more allegations about staff behaviour on Ward 1E, an external reviewer was engaged to undertake an audit. The purpose of the audit was to assess whether the Health Complaints Commissioner’s 26 recommendations had, in fact, been implemented.100 The external reviewer found that the recommendations had been implemented and that actions beyond the recommendations were taken.101 However, the external reviewer identified that a persistent negative culture within the service and failures to adequately change this culture were having an ongoing adverse impact on practice.102

The external reviewer made a further 38 recommendations with respect to leadership, clinical governance, practice development, human resources management, partnership development, mental health promotion and information management.103 The Department of Health and Human Services undertook a range of actions in response to the external reviewer’s report.104

In December 2008, the external reviewer was invited to evaluate the progress the Department had made in implementing the 38 recommendations.105 A final report, which was not publicly released, noted significant progress. However, the external reviewer also made another seven recommendations, some of which were addressed as part of a workforce review of Mental Health Services in 2009.106

1. Parallels between the 2005 investigation and evidence before our Commission of Inquiry

At our hearings, Mr Connock, current Health Complaints Commissioner, told us it was ‘concerning’ that very similar issues to those identified in the investigation of Ward 1E had emerged before our Inquiry.107 He said there were ‘very strong parallels’ between the circumstances giving rise to the investigation into Ward 1E and the evidence that had emerged at our hearings, particularly about the nature of the misconduct, inadequate record keeping of complaints, poor communications about what had occurred, and inadequate support for those affected.108

1. Report to the Australian Government and Tasmanian Government Health Ministers, Commission on Delivery of Health Services in Tasmania (April 2014)

In September 2012, the Australian and Tasmanian governments set up the Commission on Delivery of Health Services in Tasmania (‘Delivery of Health Services Commission’). The purpose of the Delivery of Health Services Commission was ‘to investigate health service delivery in Tasmania, identify inefficiencies, and make recommendations on opportunities for lasting improvements in quality, efficacy, and system sustainability’.109

The Delivery of Health Services Commission’s report documented far-reaching problems and called for a ‘fundamental reform and redesign’ of the Tasmanian health system.110 The report noted that the health system had been the subject of several previous reviews, including Tasmania’s Health Plan 2007 and The Tasmanian Hospital System: Reforms for the 21st Century (2004), and that many of the issues identified in these previous reviews had not been rectified.111

The report also documented deficiencies in the clarity of roles and responsibilities between the Department of Health and Human Services (as it was then) and the former Tasmanian Health Organisations, finding that these deficiencies had negatively affected performance management, clinical governance, safety and quality, service planning, integration, engagement with the community and leadership and culture.112

Comments in the report on the culture of the health system were particularly concerning. The report described a ‘deeply engrained culture of resistance to change, evidenced by the system’s inertia in the face of several reviews recommending reform’.113 The culture, as described, was characterised by varying degrees of denial about the problems within the health system and cynicism about the ability to implement initiatives designed to improve efficiency and sustainability.114 The report stated that decisions made by some health practitioners or administrators appeared to be based on political convenience and self-interest rather than what was in the best interests of patients.115

Further, the report expressed serious concerns about the conduct of some staff within the health system:

We have observed a lack of respect amongst key stakeholders, competition and a lack of cooperation, and resistance to routine performance measures. While there are capable and committed individuals within the health system, there are administrators and clinicians in leadership positions who behave in an unduly territorial manner. Personal animosities appear to override professional considerations and what should be universally accepted codes of conduct.116

We are particularly concerned about the reference to territorial disputes because such disputes can lead to problems being concealed to protect the reputation of a division or staff contingent.

The Delivery of Health Services Commission further noted in its report that the lack of leadership and accountability mechanisms within the Tasmanian Health Organisations had created ‘a culture where behaviour that falls far outside acceptable professional conduct’ was tolerated without consequence and was therefore allowed to thrive.117 The Delivery of Health Services Commission also found that the Tasmanian Health Organisation model, whereby staff misconduct was the responsibility of local governing councils, shielded misconduct and the response to it from broader scrutiny by the then Department of Health and Human Services.118

The report concluded that ‘poor leadership and bad behaviour [was] at the heart of Tasmania’s inability to achieve both effective governance and sustainable change in its health system’.119 The report stated that cultural problems needed to be addressed before any system reform or clinical redesign could be effectively undertaken.120

The Delivery of Health Services Commission made six recommendations, focusing on:

• governance arrangements, including positive leadership and collaboration
• requiring leadership roles to be performed according to a code of conduct
• making cultural change and leadership a top priority
• delivering whole of system leadership training to managers within the health system
• requiring leaders within the Tasmanian Health Organisations to take part in performance management
• implementing a change management process informed through staff consultation.121

The website that housed the Delivery of Health Services Commission’s report has been decommissioned. The extent to which the Tasmanian Government accepted the Delivery of Health Services Commission’s recommendations is unclear because no formal response to the recommendations is publicly available.

Subsequent reforms to the health system appear to have at least partially responded to the Delivery of Health Services Commission’s report and prior reports. However, we note that the culture of leaving unprofessional conduct unaddressed and unscrutinised was evident in all our case studies, in particular our case study of Mr Griffin, which we discuss in Chapter 14.

1. An Investigation into Allegations of Nepotism and Conflict of Interest by Senior Health Managers (2014)

The Integrity Commission investigated senior health managers in 2014 following a complaint from a member of the public. The complaint alleged that two senior officers at the North West Area Health Service (as it was then) had used their positions to employ family members and associates.122

The Board of the Integrity Commission found that the two officers had not disclosed significant conflicts of interest and had failed to comply with the applicable policies for employment.123 Significant gaps were also found in record keeping relevant to the recruitment of these roles.124

A key issue the Board of the Integrity Commission considered was how the organisational culture at North West Area Health Service had influenced attitudes and responses to inappropriate behaviour. The Board commented that:

A good workplace culture which promotes the values, code of conduct and principles of the State Service can improve morale, boost productivity, and improve an organisation’s reputation with the community, suppliers and its own employees. Equally, an organisation whose leaders consistently breach the principles, code of conduct and applicable policies, and who demonstrate inappropriate and improper conduct, risks producing a workplace culture that fails to implement or even understand the principles.125

The Integrity Commission observed that the improper conduct had been instigated by senior officers, who should have known that such conduct was improper and contributed to an unhealthy culture that discouraged staff from raising concerns.126 The Integrity Commission noted it was significant that a member of the public had to complain about the conduct before any action was taken.127

The Integrity Commission’s report, which had 11 recommendations to prevent future misconduct, was referred to the then Premier and Auditor-General for action. Broadly, these recommendations were about keeping health service staff accountable for their recruitment practices.128

The Integrity Commission also noted that as part of a 2013 investigation into allegations of misconduct in recruitment within the Department of Health and Human Services, it had recommended to the Department of Premier and Cabinet that a mandated process of declaration of knowledge or association be established in State Service selection processes.129

In a media release issued in response to the 2014 Integrity Commission report, the Premier stated that the Government had acted on the recommendations.130 In 2020, the Integrity Commission again inquired into the misconduct of public officers in the Tasmanian Health Service, North West Region.131 The report noted that management can dictate culture. It highlighted that a similar culture existed in 2020 to that which it had identified in its 2014 report, noting that employees failed to report conduct even though they had significant concerns about the integrity of management’s actions.132

1. Performance of Tasmania’s Four Major Hospitals in the Delivery of Emergency Department Services (May 2019)

In 2019, the Tasmanian Auditor-General reported on the findings of an assessment of the efficacy of emergency departments in Tasmania’s four major hospitals, from the perspective of patients.133 These four hospitals were the Launceston General Hospital, Mersey Community Hospital, North West Regional Hospital and Royal Hobart Hospital.134

In his report, the Auditor-General concluded that the Tasmanian hospital system was not working effectively to meet the growing demand for emergency department care, inpatient beds and performance obligations in relation to emergency department access and patient flow, as required by the Tasmanian Health Service Plan.135 This failure was found to be due to capacity constraints and longstanding cultural and process weaknesses within the hospitals, which impeded effective discharge planning, bed management and coordination between emergency departments and inpatient areas.136 The Auditor-General made 10 recommendations.

Although most of the Auditor-General’s report concerned service delivery within emergency departments, it also referenced the culture within the Tasmanian Health Service. The report acknowledged that:

Successive reviews by the Tasmanian and Australian governments over the last decade have highlighted dysfunctional silos, behaviours, process barriers and resistance to change from some clinicians and administrators within hospitals as major drivers of inefficiencies.137

The Auditor-General further observed, while conducting the assessment, that hospital staff had described longstanding cultural and governance challenges as factors contributing to poor coordination between emergency departments and inpatient wards. These challenges included:

• the ongoing presence of dysfunctional operational ‘silos’
• the lack of effective whole of hospital leadership and action to drive change
• the effects of disruptive governance role ‘churn’ at the senior executive level
• perceived inadequate planning, governance and resourcing to implement past reforms
• lack of accountability among staff.138

Reference was again made to the findings of the Delivery of Health Services Commission in its 2014 report.139

To address the cultural issues raised, the Auditor-General recommended that:

[The] Tasmanian Health Service and [the Department of Health and Human Services] urgently implement a culture improvement program and initiatives with clearly defined goals, accountabilities and timeframes to:

• eliminate the longstanding dysfunctional silos, attitudes and behaviours within the health system preventing sustained improvements to hospital admission, bed management and discharge practices
• ensure that all Tasmanian Health Service departments and staff work collaboratively to prioritise the interests of patients by diligently supporting initiatives that seek to optimise patient flow.140

A media release from the then Minister for Health indicated that the Tasmanian Government had noted the recommendations and was considering opportunities for reform.141

1. Poor culture at Launceston General Hospital

Just as previous reviews have identified a dysfunctional culture across some of Tasmania’s health services, we heard from several current and former staff members about a longstanding dysfunctional culture at Launceston General Hospital. Staff members told us of their concerns about entrenched cultural problems at the hospital, including practices of favouritism in recruitment and the manipulation of recruitment processes, and deliberate attempts to suppress or conceal complaints of misconduct.142 A sample of the evidence we heard in relation to the dysfunctional culture at Launceston General Hospital is summarised below.

One former staff member, who worked at Launceston General Hospital in the late 1990s, described the hospital’s culture during their time of employment as ‘grotesque’ and ‘distorted’.143 They said the culture was:

Grotesque in that it prioritised reputations and institutional interests over staff and patient safety. Distorted in that it punished those who sought to protect staff, patients and children. I believe that patients are not safe if staff don’t feel safe.144

Maria Unwin told us of learning about an incident of alleged abuse from her colleagues when she started working at Launceston General Hospital in the 1990s. She said that, in the period she worked in Ward 4K, the response of hospital management to this incident left a clear message for staff:

I was always shocked that even when someone was caught in the act of child sexual abuse they would only be moved on and that would be covered up.145

Ms Unwin also stated that those who spoke up about issues at Launceston General Hospital were considered by management to be ‘trouble-makers’.146

Another nurse who had worked at Launceston General Hospital since the early 1990s told us she believed Ward 4K had a ‘culture of fear and insecurity’ that ‘allowed staff concerns about Jim Griffin’s behaviour to be ignored’.147

A current employee of the hospital told us she thought there was a ‘distinct cultural lack of regard for clinical governance’, resistance to change and narrow-mindedness.148 This employee also noted what she understood to be a resistance from management to receiving and acting on feedback, and that management had promoted ‘a culture of dismissing complaints’.149

At our consultation in Launceston, several former and current staff members independently raised concerns about the culture at Launceston General Hospital. These concerns included:

• a poor complaints process that lacked transparency
• management minimising staff concerns when reporting those concerns to senior management or the executive
• preferential treatment for some staff, including disclosing the identity of staff members who had complained about them
• victimising complainants
• managers not responding to complaints causing people to stop raising concerns
• a hierarchical, chauvinistic culture that normalised sexualised bullying of staff
• some staff members bullying, ostracising and intimidating colleagues so they would not make complaints against them
• staff being so fearful of management that they had physical traumatic reactions when management was nearby
• the hospital silencing dissent by ‘weaponising the legal system’ such that people were scared to speak up for fear that a defamation or breach of confidentiality action, or reprimands for failing to personally make a mandatory report, would be the consequence
• staff feeling as though they could not report poor conduct because they owed their jobs to those people exhibiting the conduct, or the allies of those people
• staff not making complaints due to fear of reprisal
• management being motivated by a desire to protect the reputation of the institution over the needs of children
• rumours that destroying incriminating records was a regular practice within the hospital.150

While we have not established that each of these concerns are true, when considered as a whole they paint a picture of a culture that discourages complaints and fails to respond to complaints when they are made and may allow poor conduct to go unaddressed. Such a culture increases the risk of child sexual abuse occurring or being ignored.

The cultural issues described above give context to what we heard about the ways in which Launceston General Hospital, its executive and senior managers responded to complaints about, and the alleged conduct of, staff at the hospital such as Dr Tim and Mr Griffin. We make a range of findings about the collective leadership of Launceston General Hospital in its response to Mr Griffin’s abuses within that case study.

In the next chapter—Chapter 14—we present our case studies.