1. Introduction

Health services have a duty of care to patients, which extends to keeping them safe from sexual abuse while they are under care. The National Safety and Quality Health Service Standards require that health services protect the public from harm and provide quality health care to all patients. The National Principles for Child Safe Organisations, which have now been substantially adopted in the Child and Youth Safe Organisations Act 2023 (‘Child and Youth Safe Organisations Act’), set out the expectations of organisations to create cultures that foster child safety and wellbeing. The Children, Young Persons and Their Families Act 1997 (‘Children, Young Persons and Their Families Act’) and the Health Practitioner Regulation National Law Act 2009 (Qld) (‘National Law’) require that sexual misconduct by health practitioners be reported, including to the Australian Health Practitioner Regulation Agency (‘Ahpra’).1

There is limited research into the prevalence of sexual abuse in health services. However, we know from the available evidence that abusers who are also health workers will exploit their often unquestioned, intimate access to young patients, and that children and young people’s vulnerability to abuse is heightened when they are sick, injured or otherwise unwell.

This volume makes a much-needed contribution to the research on child sexual abuse in health services. We learned that abusers use tactical strategies to avoid detection when offending in health services. They leverage the trust and deference that many of us afford health workers, take advantage of the assumption that sexual abuse cannot happen undetected in a health service, and are effective at grooming vulnerable young patients, as well as their families and their colleagues. They can enhance their perceived trustworthiness by appearing to go ‘above and beyond’ in providing health care to young patients and supporting their family and carers.

A health service can provide an ideal environment for health workers to abuse young patients if it does not have systems, policies and protocols in place relevant to preventing, detecting and responding to child sexual abuse.

In Chapter 14, we examined Launceston General Hospital’s response to allegations of child sexual abuse. We identified systemic problems with leadership, culture, policies and processes at the hospital.

In this chapter, we discuss some of the work already underway to address these problems. In Section 2, we outline recent reviews and numerous new initiatives designed to improve children’s safety in health services and better support staff to identify signs of abuse. In Section 3, we discuss the foundations that can assist health services to protect children, reflected in the National Principles for Child Safe Organisations, including building a strong culture, strengthening leadership and accountability, empowering children and young people, and investment in clear policies and professional development. In Section 4, we discuss responses to complaints, concerns, and allegations of child sexual abuse. In Section 5, we discuss the importance of recognising the impact of Mr Griffin’s offending on Launceston General Hospital and restoring trust in that institution. In Section 6, we discuss the role of oversight bodies.

Throughout this chapter, we make recommendations to further enhance work already underway. Our recommendations are aimed at ensuring the Tasmanian health system is better placed to identify child sexual abuse and respond appropriately when it occurs in future.

In summary, we recommend:

• developing and communicating a policy framework and implementation plan to improve responses to child sexual abuse in health services
• that the Tasmanian Government advocates for the National Principles for Child Safe Organisations to become a mandatory requirement for accrediting health services nationally
• increasing the participation of children and young people in decisions affecting health care delivery, including through:
  • establishing a health services young people’s advisory group
  • increasing young people’s and their families’ and carers’ knowledge of patient rights
  • regularly monitoring children and young people’s sense of safety within health services
  • identifying actions that can be taken to make health services safe and inclusive for diverse groups of children and young people
• increasing the accountability of leaders and staff in protecting child safety and embedding safety through cultural improvement initiatives
• reviewing and consolidating departmental policies, procedures and protocols to address gaps in the safeguarding of children, including publishing child safety policies to promote accessibility and transparency within the community; in particular, improvements to, or developing, policies on key child safety matters, including mandatory reporting and voluntary reporting, professional conduct for staff and chaperones
• establishing minimum requirements for staff professional development on child safety
• improving responses to child safety concerns, including establishing a clear complaints management, escalation and investigation pathway and developing a critical incident response plan to respond to human-caused traumatic events
• restoring trust through Launceston General Hospital, the Department and Tasmania Police offering ongoing assistance to known and as yet unknown victim-survivors of child sexual abuse by Mr Griffin that related to the hospital
• reviewing the Health Complaints Act 1995 (‘Health Complaints Act’) to ensure the role of the Health Complaints Commissioner extends to addressing systemic issues within health services related to child safety.

1. Implementing recent reviews

In 2022, following the revelations about Mr Griffin’s offending, and throughout our Commission of Inquiry, the Department began addressing risks to child safety within health services. In particular, the Department initiated two reviews—the Independent Child Safe Governance Review of the Launceston General Hospital and Human Resources (‘Child Safe Governance Review’) and the Launceston General Hospital Community Recovery Initiative (‘Community Recovery Initiative’). Kathrine Morgan-Wicks PSM, Secretary, Department of Health, has accepted all the recommendations of these two reviews.2 The Department has also introduced reforms under its Child Safe Organisation Project, which primarily sought to implement the National Principles for Child Safe Organisations and the associated Child Safe Standards recommended by the National Royal Commission.3

In this section, we provide an overview of these reviews and reforms. The Department has also set up a Statewide Complaints Oversight Unit in the Office of the Secretary, and a statewide policy framework and incident reporting system. We discuss this in a later section on improving responses to child sexual abuse in health services.

We conclude that while the Department’s recently initiated reforms represent progress on improving child safety, it remains unclear exactly which reforms will be implemented and by whom. The community is entitled to know more about the Department’s reforms, how the reforms will work to provide a system-wide response to child sexual abuse in health services, how the reforms are being prioritised, and the expected timeframes for implementation. To this end, we recommend that the Department develops and communicates a policy framework and implementation plan.

1. Recent reviews and reforms

Following evidence presented to our Commission of Inquiry at hearings relevant to Launceston General Hospital, the Department announced the Child Safe Governance Review and the Community Recovery Initiative to respond to community concerns about the hospital.

1. Child Safe Governance Review

On 3 July 2022, the Honourable Jeremy Rockliff MP, Premier of Tasmania, together with Secretary Morgan-Wicks, announced the immediate establishment of the Child Safe Governance Review.4 The Premier said:

We knew the evidence before the Commission of Inquiry would be confronting and there would be serious lessons to learn. There is nothing more important than keeping children safe which is why we are listening and acting now to ensure past wrongs are not repeated.5

Two external and independent co-chairs were appointed to lead the Child Safe Governance Review—Adjunct Professors Karen Crawshaw PSM and Debora Picone AO.

The terms of reference for the Child Safe Governance Review were to consider a range of operational matters related to Launceston General Hospital, including assessing its organisational structure, the roles and responsibilities of leaders and managers, training and staff development, policies and procedures and the management of complaints.6 Some of the terms of reference went to issues beyond the focus of our Inquiry, particularly around clinical governance and patient safety more broadly.

A Lived Experience Expert Reference Group was established as part of the Child Safe Governance Review. Although the membership of this group was not made public, we know that it comprised victim-survivors.7 The report of the Child Safe Governance Review states that the Lived Experience Expert Reference Group was given the opportunity to inform the review and shape recommendations to the Secretary.8

The report of the Child Safe Governance Review contained 92 recommendations, including in relation to the role and skills of leadership, staff and human resources; governance structures; strengthening child safeguarding; and improved record keeping. We discuss specific recommendations, where relevant, in subsequent sections.

Secretary Morgan-Wicks confirmed to us that the Tasmanian Government had accepted all recommendations set out in the Child Safe Governance Review report.9 She also wrote to us following the public release of the report to provide an update on the progress of implementing the recommendations. She told us that:

• a Statewide Child Safety and Wellbeing Service had been established, with child safeguarding officers to be recruited and located onsite at all major hospitals in Tasmania, including at Launceston General Hospital
• a fact sheet for staff had been drafted and promoted to guide the reporting of child safety concerns
• the Chief Executive Hospitals North would assume responsibility for safeguarding children at Launceston General Hospital10
• the co-chairs would be appointed to monitor implementation of the review’s recommendations.11

Adjunct Professors Picone and Crawshaw advised us in July 2023 that many of their recommendations involved ‘major systemic changes in technology, business operations and culture’, some of which take months or years to fully implement and embed.12 However, they said that in overseeing the implementation of all the recommendations, they maintained a particular focus on those relating to child safety and that ‘significant progress’ had been made.13 Areas identified as most relevant for priority oversight included:

• strengthening complaints and incident management policies
• ensuring delivery of child safety training
• embedding accountabilities for child safety in all statements of duty
• appointing child safeguarding officers within each region
• supporting implementation of the Child Safe Organisation Framework
• ensuring leadership is proactively working to improve the culture of Launceston General Hospital.14

We provide some more detail on progress related to these matters in relevant sections.

Seven working groups were established, each chaired by a health executive role holder and focusing on different aspects of implementation—with progress to be reported back to the broader Health Executive, acting as the Steering Committee.15

Adjunct Professors Picone and Crawshaw described their process of independent monitoring as involving a wide range of sources—including documentary evidence (progress reports, draft policies, relevant data), as well as targeted meetings with departmental executives that often involved ‘probing questioning’ and requests for additional information and follow-up.16 The co-chairs advised us that they also met with a range of other stakeholders and role-holders, including victim-survivors involved in the development of recommendations, Launceston General Hospital’s Community and Consumer Engagement Council, employee and professional organisations, as well as focus groups with frontline staff.17 Where the co-chairs felt implementation was ‘sub-optimal’ or required additional support, they raised these concerns with Secretary Morgan-Wicks, who they described as having been ‘responsive and timely in addressing our concerns’.18

We were pleased to be advised that Adjunct Professors Picone and Crawshaw’s independent oversight role had been extended by Secretary Morgan-Wicks until the end of December 2023, and greatly encouraged by the overall positive assessment made by them of the Department’s (and Launceston General Hospital’s) progress in promoting the safety of children receiving health services.19

1. Community Recovery Initiative

Elizabeth Daly OAM and Malcolm White, two ‘experienced and known members of the northern region community’, were appointed to act as co-chairs of the Community Recovery Initiative, designed to improve community trust in Launceston General Hospital.20

The key objectives of the Community Recovery Initiative are to:

1. Learn from the community – for the Department to gain a deeper understanding of the northern community’s concerns, and have those concerns inform its efforts to improve the [Launceston General Hospital’s] systems, processes and culture to prevent child sexual abuse from happening again.
2. Restore community confidence – to rebuild the northern region community’s confidence in the [Launceston General Hospital] as a trusted public institution.
3. Build community capacity – through this process, aim where possible or appropriate to build ongoing capacity, strength and resilience within the northern region community.21

The co-chairs of the Community Recovery Initiative made eight recommendations directed at improving management, leadership and culture; improving communication with staff and the media; and increasing staff training.

Secretary Morgan-Wicks told us that she accepted the recommendations of the Community Recovery Initiative, which she believes are consistent with, and able to be implemented through, the recommendations of the Child Safe Governance Review.22 The co-chairs of the Community Recovery Initiative stated an intention to liaise with the Department to monitor progress of actions towards the implementation of their recommendations.23

1. Child Safe Organisation Project

Other Department-initiated reforms are relevant to our Commission of Inquiry. In particular, the Child Safe Organisation Project was set up primarily to implement the National Principles for Child Safe Organisations and associated Child Safe Standards, as recommended by the National Royal Commission and endorsed by the former Council of Australian Governments in February 2019.24

The objective of the Child Safe Organisation Project was to ensure the Department has a strong, common understanding of child safety and wellbeing, that children’s voices are heard, and that children and their families are involved in decisions affecting them.25

Key elements of the Child Safe Organisation Project were to develop a framework for child safety and wellbeing, set up an independent panel for child safety and wellbeing, and establish a new Child Safety and Wellbeing Service within the Department.

The Child Safe Organisation Project finished in December 2022. The Child Safety and Wellbeing Service now leads implementation of the Department’s work to improve child safety and wellbeing.26 We understand that child safeguarding officers located at Tasmania’s four public major hospitals are also supporting implementation of the Department’s Child Safety and Wellbeing Framework, including providing education on mandatory reporting and identifying grooming and professional boundary breaches.27 We have been advised that these roles have been successfully filled in each region.28

We note that Tasmanian health services will be subject to legislative requirements to embed the Child and Youth Safe Standards (which are based on the National Principles for Child Safe Organisations) and will also be subject to a Reportable Conduct Scheme to enable oversight of how investigations of reportable allegations (which includes child sexual abuse and sexual misconduct) are conducted.29 For further discussion on these schemes, refer to Chapter 18.

1. A policy framework and implementation plan

Although substantial reform work is underway across the Department, we consider this would be strengthened by clarifying:

• 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
• expected timeframes for implementation.

To this end, we recommend that the Department develops and communicates a policy framework and implementation plan for reforms to improve responses to child sexual abuse in health services, against which it will be accountable to the community. This plan should explain how reforms—including departmental reforms, those recommended by the Child Safe Governance Review, Community Recovery Initiative and our Commission of Inquiry—fit together to ensure the safety of children in health settings. Publishing the policy framework and implementation plan will provide a greater degree of transparency and accountability around the Department’s implementation of reforms.

In February 2023, Secretary Morgan-Wicks provided a written update on the Department’s reform work. She told us that an implementation plan had been prepared and included the recommendations of the Child Safe Governance Review and Community Recovery Initiative.30 She said the plan covers implementing the recommendations not only within Launceston General Hospital but also across the Department.31 She also told us that several of the recommendations have already been ‘completed’.32

We are pleased that the Department has started implementation planning in relation to the recommendations of the Child Safe Governance Review and Community Recovery Initiative. However, given the number and complexity of recommendations to be implemented (and, as we note above, the fact that some may take time to become fully embedded), we consider the Department and the community would benefit from a policy framework and implementation plan that outlines:

• the purpose and need for the reforms
• the role, responsibilities and interactions of bodies the Department has set up as part of the reforms
• how the reforms work together to provide a system-wide response to child sexual abuse in health services
• how the reforms are being prioritised for implementation and who is responsible for their implementation
• the expected timeframes for implementation.

We asked the co-chairs of the Child Safe Governance Review about the features they considered important in a monitoring and oversight function relating to health services. Adjunct Professors Picone and Crawshaw advised us that, in their view, the following skills and capabilities are needed:

• independence (actual and perceived)
• strong understanding of public sector management, health service administration and subject-specific knowledge relevant to recommendations
• good access to engage with individuals responsible for implementation and scope to offer objective guidance and advice
• sound reporting methodology, which includes monitoring of front-line staff experiences of the implementation of recommendations
• a long enough period of oversight to cover the reform agenda.33

We acknowledge that the policy framework and implementation plan may need to evolve over time because of changes in implementation dependencies and unexpected challenges, but we consider that, at the outset, the policy framework and implementation plan should contain the elements set out in the following recommendation.

Recommendation 15.1

The Department of Health should develop and communicate a policy framework and implementation plan for reforms to improve responses to child sexual abuse in health services. The policy and implementation plan should:

1. set out the purpose and need for the reforms
2. set out the role, responsibilities and interactions of bodies the Department has set up as part of the reforms
3. explain how reforms, including departmental reforms and those recommended by the Child Safe Governance Review, Community Recovery Initiative and this Commission of Inquiry, will work together to respond to child sexual abuse in health services
4. outline how the reforms are being prioritised for implementation and who is responsible for their implementation
5. set out the expected timeframes for implementation
6. be published on the Department’s website.

1. Creating strong foundations to protect children

In this section, we make recommendations aimed at creating child safe cultures across Tasmanian health services including:

• establishing the National Principles for Child Safe Organisations as a mandatory requirement for accrediting health services against the National Safety and Quality Health Service Standards
• creating a child safe culture in Tasmanian health services
• empowering children to influence how health care is delivered
• creating safe physical environments for children
• ensuring the development and implementation of key child safe policies that are publicly accessible and create a shared understanding of the rights of children and expectations of staff conduct
• improving professional development for staff about child sexual abuse and related matters such as grooming and professional boundaries.

1. Implementing the National Principles for Child Safe Organisations

Health services that prioritise child safety share key organisational characteristics. These characteristics are reflected in the expectations of the National Principles for Child Safe Organisations (‘National Principles’) and include good culture, competent leadership, the empowerment of children and young people, safe physical environments, appropriate policies and targeted professional development. Although these principles are reflected in Tasmania’s Child and Youth Safe Standards, we refer to the National Principles in this chapter because health services must be accredited nationally.

The Tasmanian Government and the Department should continue to work to implement the expectations of the National Principles in Tasmanian health services. The National Principles should also be a mandatory requirement for accrediting health services against the National Safety and Quality Health Service Standards.

1. National Safety and Quality Health Service Standards

The National Safety and Quality Health Service Standards (‘National Standards’) are the starting point for determining what is required for a hospital (or any health service) to be safe for patients. The National Standards are a consistent statement on the level of care consumers can expect from health services across Australia.34

The primary aims of the National Standards are to ‘protect the public from harm and to improve the quality of health service delivery’.35 All public and private hospitals, as well as other health services, are assessed for compliance with the National Standards as part of their accreditation under the Australian Health Service Safety and Quality Accreditation Scheme.36

While the National Standards make no express reference to child safety, the Standards most relevant to child safety are the Clinical Governance Standard and the Partnering with Consumers Standard.37 Aspects of these Standards are discussed throughout this section.

1. Launceston General Hospital’s accreditation against the National Standards

The last organisation-wide assessment of Launceston General Hospital against some of the National Standards occurred in 2022.38 As of July 2023, the Australian Commission on Safety and Quality in Health Care’s website indicates that the Launceston General Hospital is accredited, with an assessment against the National Standards ‘to be completed by 12/12/2022’.39

One of the co-chairs of the Child Safe Governance Review, Adjunct Professor Debora Picone, also gave evidence to us in her capacity as Chief Executive Officer, Australian Commission on Safety and Quality in Health Care. She told us that in June 2022, the Tasmanian Health Service North Region, which includes Launceston General Hospital, underwent assessment during the week of 4 April 2022.40 The assessment covered three of the eight Standards—the Partnering with Consumers Standard, the Preventing and Controlling Infection Standard and the Comprehensive Care Standard.41 Independent assessors were also specifically asked to review the hospital’s systems for incident reporting, complaints handling, risk management and open disclosure.42 The assessors found the systems in place at the hospital ‘were effective, were being used appropriately, and were being monitored’.43

1. Integrating the National Principles into the National Standards

While the National Standards apply to services provided to all patients, including children and young people, they do not specifically address issues of child safety.44 Adjunct Professor Picone told us that aspects of the National Principles are reflected in the National Standards, particularly in the Clinical Governance Standard and Partnering with Consumers Standard.45 Although it is not currently mandatory, there is an expectation that health services will implement systems to keep children safe and manage risks to children as part of complying with the National Standards.46

Adjunct Professor Picone told us that it would be possible, and indeed preferable, to embed the National Principles into the National Standards, making the National Principles mandatory for all accredited health services.47 She noted that the Australian Commission on Safety and Quality in Health Care has not previously had enough information about the failures of child safety systems in health services to warrant this.48

The Tasmanian Government has recently made efforts to implement the expectations of the National Principles, including within the Department (as evidenced in the new Child Safety and Wellbeing Framework referred to above and discussed below).49 The enactment of the Child and Youth Safe Organisations Act will also legislate that health services providing care to children and young people must adopt the National Principles in the form of the Child and Youth Safe Standards, and implement a Reportable Conduct Scheme.50

However, in our view, the expectations of the National Principles should be reflected explicitly within mandatory requirements for accreditation against the National Standards under the Australian Health Service Safety and Quality Accreditation Scheme. This will highlight the core importance of child safety to broader concepts of patient safety, provide another safeguard for children and young people, and allow implementation of the National Principles to be assessed at least once every three years by a body that is familiar with the operating environments of health services.

We anticipate the Australian Commission on Safety and Quality in Health Care will engage and share information with the Independent Regulator of the Child and Youth Safe Standards and Reportable Conduct Scheme in Tasmania, as well as with the Tasmanian Health Complaints Commissioner, Ahpra and the National Health Practitioner Boards (‘National Boards’), about the compliance of health services and health practitioners with the National Principles.

The need to ensure compliance with principles and standards of child safety extends beyond health services to health departments as system administrators for state-based public health systems and regulators of the private health sector.51 Secretary Morgan-Wicks told us that the Department had not previously identified child sexual abuse in public health services as a specific strategic risk; instead, risk assessments tended to form part of patient safety and clinical decision-making processes in individual health services.52 Secretary Morgan-Wicks identified areas in the Department that provide direct service delivery to children and young people, or that have access to the personal information of children and young people, as posing the greatest risk of child sexual abuse.53 These areas included Women’s and Children’s Services, and Child and Adolescent Mental Health Services.54

Secretary Morgan-Wicks acknowledged that it was a ‘critical oversight’ that there was not a broader focus on managing the risks of child sexual abuse in public health services and indicated that the occurrence of child sexual abuse had now been added to the Department’s Strategic Risk Register and approved by the Health Executive.55 Secretary Morgan-Wicks told us that the Department’s Child Safe Organisation Project was managing work to address this risk.56

The case studies discussed in Chapter 14 highlight the risk of child sexual abuse in health services and demonstrate that these services need to have systems in place to prevent such abuse occurring, and to respond appropriately when it does occur. The Tasmanian Government should advocate for the Australian Commission on Safety and Quality in Health Care to formally integrate the expectations of the National Principles into the National Standards.

Recommendation 15.2

1. The Tasmanian Government and Department of Health should continue to implement the National Principles for Child Safe Organisations across all health services.
2. The Tasmanian Government should advocate at a national level for compliance with the National Principles for Child Safe Organisations to 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.

1. Protecting children through a child safe culture

In this section, we recommend that the Department takes steps to embed a child safe culture in health services.

As noted in other chapters of our report, an organisation’s ‘culture’ refers to the assumptions, values, beliefs and norms that distinguish appropriate from inappropriate behaviours in an organisation, and how those assumptions, values, beliefs and norms translate into practice, including staff conduct.57

Professor Ben Mathews, Research Professor, School of Law, Queensland University of Technology, told us that in Australia and other countries such as the United States it has been found that institutions with strong leadership and a positive culture have higher prospects of early recognition, reporting and appropriate responses to child sexual abuse.58

In Chapter 13, we outlined previous reviews that had identified common themes related to a poor organisational culture across Tasmanian health services including:

• ineffective governance arrangements and a lack of clarity about roles and responsibilities among health service staff
• 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 poor behaviour, including misconduct by State Service employees in relation to conflicts of interest, underperformance and mistreatment of other staff
• failures to report misconduct due to fear of retribution
• instability because of changes in organisational and governance structures.

In the health context, the National Standards explicitly require that the governing body of a health service ‘provides leadership to develop a culture of safety and quality improvement, and satisfies itself that this culture exists within the organisation’.59 The Australian Commission on Safety and Quality in Health Care defines a safety culture as:

A commitment to safety that permeates all levels of an organisation, from the clinical workforce to executive management. Features commonly include acknowledgement of the high-risk, error-prone nature of an organisation’s activities; a blame-free environment in which individuals are able to report errors or near misses without fear of reprimand or punishment; an expectation of collaboration across all areas and levels of an organisation to seek solutions to vulnerabilities; and a willingness of the organisation to direct resources to deal with safety concerns.60

We consider that this requirement of leadership to support a safety culture should extend to ensuring safety and quality processes protect children and young people who are under a health service’s care. Given our findings, achieving this outcome will require cultural change, at least within Launceston General Hospital and possibly across the Department.

Professor Erwin Loh, Group Chief Medical Officer and Group General Manager, Clinical Governance, St Vincent’s Health Australia, told us: ‘Culture change management is probably the hardest thing to do in any organisation, no matter what the profession or industry’.61 As an expert in facilitating such change within health services, he offered the following reflections:

• Organisations need to have broad strategies for encouraging staff to speak up and not be afraid to ‘challenge the status quo’. Organisations cannot rely on single initiatives alone.62
• Senior leadership must model the desired behaviours. The leadership should welcome criticism and feedback from staff and patients, ensuring those who have spoken up feel appreciated, listened to and that their concerns have been acted on.63
• Middle management (such as nurse unit managers and heads of medical units) must also be engaged in creating a safety culture.64

1. Cultural improvement initiatives

Secretary Morgan-Wicks recognised that organisational change is ‘one of the most significant challenges’ facing the Department.65 She told us of several measures being implemented across the Department and at hospitals that are directed at improving organisational culture. These include:

• the Speaking up for Safety program being implemented at Royal Hobart Hospital, which is designed to build ‘a culture of safety and reliability’ in the hospital by encouraging all staff to speak up if they experience or observe concerning actions or behaviour66
• the One Health Cultural Improvement Program, which the Department began working on in January 2022.67

Professor Loh explained that the Speaking up for Safety program is based on the Vanderbilt Promoting Professional Accountability model (‘Vanderbilt model’) that is used widely in the United States and in some Australian hospitals.68

Professor Loh gave evidence of a similar program he is responsible for administering in St Vincent’s Health Australia, known as the Ethos Program. Like Speaking up for Safety, this is a peer-based early intervention program designed to recognise staff who demonstrate positive behaviours, remove barriers from speaking up about concerns that affect patient or staff safety, and allow for a quick, fair and transparent response ‘to all staff’, including those making a complaint and those with concerning behaviours.69

Under the Ethos Program, staff are trained on how to ‘speak up’ effectively and can use an online messaging system to submit feedback for recognition (to acknowledge positive behaviour) or reflection (to offer feedback for improvement).70 This feedback is delivered by a trained Ethos Messenger, who is generally a peer of the staff member, via an informal conversation.71 The program allows for anonymous reports; however, Professor Loh told us that, in his experience, most people using the program are happy to be identified.72 The Ethos Program supplements other practices at the hospital, including raising a concern directly with a colleague.73

Trained staff triage reports received through the Ethos messaging system across four levels, depending on the seriousness of the incident.74 Less serious behaviour would not necessarily be formally reported. While Speaking up for Safety and the Ethos Program have a similar intent, a key difference is that the Ethos Program includes an option for positive recognition, whereas Speaking up for Safety facilitates only feedback in response to negative interactions.75

We consider a staff reporting system that applies to all staff, volunteers, contractors and sub-contractors in a hospital is a valuable initiative for creating a culture that enables giving and receiving of feedback.

We note, however, that professional boundary breaches towards a child by a staff member, whether they are an employee, volunteer, contractor or sub-contractor, should always be formally reported, responded to and recorded in centralised records for future reference.

Secretary Morgan-Wicks told us that the Department’s One Health Cultural Improvement Program is based on a ‘cultural baseline’ of information drawn from staff interviews; an academic literature review relating to health care and organisational culture; departmental surveys and reviews; and data relating to workers compensation, State Service Code of Conduct investigations and workplace safety reports.76 In May 2022, Secretary Morgan-Wicks told us that work had begun under the program to:

• develop and embed departmental values that signal acceptable behaviours, and what to do if these are not upheld
• build leadership and management skills, including around communication and how to respond to complaints or grievances
• improve induction procedures for new employees to help them better understand values and desired behaviours
• improve complaints and disciplinary policies and processes.77

When Secretary Morgan-Wicks gave evidence at our hearings in September 2022 she advised that the Department was putting the finishing touches on the program.78

The Child Safe Governance Review made several recommendations to improve the culture at Launceston General Hospital.79 These included recommendations to:

• set up a specific advisory group at the hospital with diverse membership80
• improve communication with staff about progress against cultural improvement plans81
• clarify the expectations of executive and management through performance agreements82
• develop a culture improvement strategy83
• monitor staff feedback through annual surveys on patient safety culture.84

As noted above, the Tasmanian Government has accepted all the recommendations set out in the Child Safe Governance Review.85

In a written update provided to our Commission of Inquiry in February 2023, Secretary Morgan-Wicks stated that senior leadership at Hospitals North, which includes Launceston General Hospital, is implementing an accountability and culture framework called Excellence Together.86

1. Our observations

We welcome the focus of the Tasmanian Government and the Department on addressing organisational culture to address child safety concerns. We consider that these reforms should be guided by a set of principles, which we set out in the following recommendation. We also consider that progress reports to the Child Sexual Abuse Reform Implementation Monitor (Recommendation 22.1) should demonstrate how these principles have been translated into policy and practice.

Initiatives designed to support cultural change should be informed by a range of sources and be the subject of regular review and evaluation against pre-established criteria to ascertain whether they are achieving desired outcomes.

Recommendation 15.3

The Department of Health should ensure its cultural improvement program embeds a safety culture in health services by:

1. requiring clear organisational values be observed across all levels of health services, including in relation to staff conduct
2. establishing strong governance arrangements to address staff practices that place children at risk of abuse, and complementing established patient safety governance structures
3. ensuring all levels of management demonstrate a commitment to a safety culture, including by addressing poor staff conduct
4. clarifying roles and responsibilities among staff when there is a suspicion that child sexual abuse has occurred or that safety policies are not observed
5. ensuring there are processes that hold senior managers and executives accountable to respond appropriately to the conduct of their staff, including through performance agreements and role descriptions
6. establishing measures of a strong organisational culture that indicate an organisation
   1. welcomes concerns about staff and sees them as an opportunity to improve safety for staff and patients
   2. empowers staff to feel safe and supported to raise concerns about colleagues with their leaders and gives them confidence in the ability of leaders to respond to concerns and take disciplinary actions (including termination) where appropriate
   3. ensures staff are clear about the process for raising concerns, how these concerns will be addressed and what feedback they can expect to receive
7. providing progress reports to the Child Sexual Abuse Reform Implementation Monitor to demonstrate how these principles have been translated into policy and practice (Recommendation 22.1).

Recommendation 15.4

1. The Department of Health should consider integrating features of the St Vincent’s Health Australia’s Ethos Program into its cultural improvement program.
2. The Department of Health should ensure, in adopting its cultural improvement program, professional boundary breaches by staff towards a child are always formally reported, responded to and recorded in centralised records for future reference.

1. Embedding child safety as a priority for leadership

The National Principles state an expectation that ‘child safety and wellbeing is embedded in organisational leadership, governance and culture’.87 As Professor Mathews says:

To succeed in preventing child sexual abuse requires a genuine commitment by the institution or organisation to children’s rights to safety. If the leadership in an organisation does not possess this quality, it is near impossible to prevent instances of child sexual abuse.88

1. Problems of leadership and accountability

In Chapter 14, Case study 3, relating to James Griffin we make several findings about the failures of leadership in Launceston General Hospital. These included findings that:

• Launceston General Hospital leadership collectively failed to address a toxic culture in Ward 4K that enabled James Griffin’s offending to continue and prevented his conduct being reported.
• Leadership at Launceston General Hospital collectively failed to provide appropriate supervision and proactive oversight, which is a systemic problem.
• Leadership at Launceston General Hospital was dysfunctional, and this compromised its collective response to revelations about James Griffin.
• Launceston General Hospital did not have clear accountabilities for child safety.

Several senior executive staff at Launceston General Hospital told us that responsibility for child safety was not part of senior executive roles and that they were not subject to any performance measures, indicators or financial outcomes in relation to safeguarding children.89

1. The need for accountability

Dr Samantha Crompvoets, Director, Australian Human Rights Commission and sociologist with expertise in organisational culture, was frank in her evidence to our Commission of Inquiry about the limits of incremental organisational change in response to a crisis. She noted that there may be times, due to the nature and significance of particular events, when a ‘complete reset’ of the organisation will be required from the ground up.90 Dr Crompvoets said that leadership accountability is essential to achieving change within an organisation.91 She spoke about the importance of ‘tangible’ accountability, which requires a specific person to be responsible for a particular recommendation or action.92 Dr Crompvoets noted that accountability should not be a ‘tick and flick’ exercise, but built into a leader’s key performance indicators.93

Will Gordon, the Launceston General Hospital nurse who blew the whistle on the management of complaints about Mr Griffin, told us that nothing would change at the hospital ‘unless management at every hierarchical level ... changes’.94 Another staff member said that the hospital needed ‘to be flushed from the top down’ and that ‘[n]ew staff should be put in all senior positions’.95 The co-chairs of the Community Recovery Initiative described ‘strong feelings’ among those they consulted that senior leaders who gave evidence at our Commission of Inquiry ‘be seen to be made accountable and be seen to be removed and not allowed just “to retire”’.96 The co-chairs went on to say:

To not meet this criterion will, in our view, lead to the risk of an overall failure assessment of restorative trust actions from those we heard from and, more generally, for those whom [the Department] seeks to restore a trusting relationship.97

At our hearings, Secretary Morgan-Wicks also acknowledged that it was time Launceston General Hospital had a ‘complete reset’.98

1. Recent reforms

The Department has developed the Child Safety and Wellbeing Framework as part of its Child Safe Organisation Project. This framework, publicly released in September 2022, has the objective of establishing ‘a systemic approach to enhance the way the Department of Health works with vulnerable people, specifically children and young people’.99 It:

• ensures structures, systems and processes are in place to mandate and foster a child safe organisation and child safe culture100
• establishes the National Principles as key priorities to be embedded into the Department’s child safe approach101
• applies to the entire Department, as well as organisations funded by the Department102
• details the responsibility and requirements to be met by all people engaged by the Department in protecting the health, safety, welfare and wellbeing of children and young people.103

Secretary Morgan-Wicks told us that the framework is an important step in ensuring a Department-wide commitment to child safe practices and reporting of suspected child sexual abuse.104

The Tasmanian Government has also committed to clarifying expectations and improving accountability for child safety through Head of Agency performance agreements.105 Jenny Gale, Secretary, Department of Premier and Cabinet and Head of the State Service, told us on the final day of our hearings:

Every Head of Agency’s performance agreement with the Premier will commit them to identify and take action within their own department and across the service that will keep children safer. This commitment applies regardless of whether that agency engages directly in child-related work.106

We would expect such performance measures to also filter down into the responsibilities of other management teams in health services.

Adjunct Professors Picone and Crawshaw advised us in July 2023 that Secretary Morgan-Wicks had issued a directive to all staff under section 34 of the State Service Act 2000 (‘State Service Act’) in respect of their child safeguarding responsibilities as employees of the Department of Health, and is updating all statements of duties to include the following:

Champion a child-safe culture that upholds the National Principles for Child Safe Organisations. The Department is committed to the safety, well-being, and empowerment of all children and young people, and expects all employees to actively participate in and contribute to our rights-based approach to care, including meeting all mandatory reporting obligations.107

The Child Safe Governance Review also made several recommendations for ensuring accountability of leadership through improved governance, organisational structure, clearer roles and accountabilities, and professional development. Although many of these recommendations relate to Launceston General Hospital, they are relevant to other health services across Tasmania. Key recommendations of the Child Safe Governance Review include:

• ensuring collective and individual commitment to child safety through the Secretary, executive and clinical leadership of Launceston General Hospital implementing the Child Safety and Wellbeing Framework, signing a statement of commitment and undertaking an annual review of child safety and wellbeing status, confirmed by a publicly reported attestation statement108
• changes to the organisational structure and executive titles at Launceston General Hospital, including splitting the role of Chief Executive Hospitals North/North West and advertising for a new Chief Executive Hospitals North109
• more frequent meetings between various management and governance groups in Hospitals North, including at least a quarterly discussion on culture improvement initiatives and the implementation of the Child Safe Organisation Framework, which, under the Child and Youth Safe Organisations Act, comprises the Child and Youth Safe Standards and Reportable Conduct Scheme at Launceston General Hospital110
• various changes to role responsibilities and added performance measures relating to child safety, culture, workplace and patient safety for executives and senior managers, supported by annual performance reviews.111

On accepting the interim recommendations of the Child Safe Governance Review in September 2022, the Premier announced more changes to support leadership renewal at Launceston General Hospital and the Department, including changes to existing positions and the creation of new positions.112 The announcement stated that some key members of Launceston General Hospital’s executive team had either moved to another leadership role, were acting in their current role or were ‘on a period of extended leave’ before their impending retirement.113

1. Our observations

Health leaders need to be equipped and empowered to embed the expectations of the National Principles and related reforms in the day-to-day work and practice of staff working in health services. Various activities will aid their endeavours, including culture-improvement initiatives, refreshed policies and practices, and relevant professional development, for which we make recommendations elsewhere in this chapter.

Health leaders (and State Service staff) are subject to annual performance reviews. We consider that health leaders should have accountability measures for child safety in their performance agreements and that they should receive regular feedback on their performance against these measures.

The Australian Commission on Safety and Quality and Health Care’s User Guide for Acute and Community Health Service Organisations that Provide Care for Children (‘User Guide’) suggests mechanisms through which health services should adopt the Charter on the Rights of Children and Young People in Healthcare Services in Australia (discussed below), including:

• allocating responsibility for the implementation of the Charter to a senior individual or committee
• building the requirements of the Charter into the organisation’s safety and quality systems, and processes of care for children
• displaying the Charter in areas within the organisation frequented by children, such as paediatric units or play areas
• providing accessible copies of the Charter in formats that meet community needs, especially for those with limited capacity to read and comprehend complex written text
• providing education about the Charter to new members of the workforce responsible for providing care for children
• using the Charter as the basis for discussions between clinicians and children about care planning and treatment
• using play-based techniques when appropriate
• adding specific questions relating to the Charter to consumer experience surveys.114

We consider some of these mechanisms could be used to support a commitment to child safety across health services. We also recommend that the Department have appropriate processes in place to ensure leaders have the knowledge, skills, aptitude and core capability requirements to effectively manage people and to lead a child safe organisation.

Recommendation 15.5

The Department of Health should make health leadership accountable for embedding child safety as a priority, including by:

1. ensuring that all relevant health leaders have an obligation to act consistently with the National Principles for Child Safe Organisations (reflected in Tasmania’s Child and Youth Safe Standards) in their role descriptions and performance agreements, with compliance with this obligation to be reviewed annually
2. ensuring that the role descriptions and performance agreements of all staff providing services to children require them to protect child safety, with compliance with this obligation to be considered as part of annual performance reviews.

Recommendation 15.6

The Department of Health, to support health services become child safe organisations, should ensure:

1. child safety, including safety from abuse in health services, is overseen by the governance and leadership structures established through the cultural improvement program
2. child safety is built into the safety and quality systems of health services
3. staff responsible for providing care to children have the knowledge and skills to respond to child safety concerns in line with the expectations of a child safe organisation and relevant health service policies, including being equipped to identify and respond to indicators of child sexual abuse
4. staff act consistently with the National Principles for Child Safe Organisations (reflected in Tasmania’s Child and Youth Safe Standards) when performing their work, including in discussions between health practitioners, health workers and children about care planning and treatment.

1. Empowering children, families and carers

Children’s views about their health care are important and should inform health services’ policies and practices. In this section, we consider the barriers that children and their families and carers may face in identifying inappropriate behaviour by health workers and in raising concerns with health services, particularly in a hospital setting. We also consider how children can and should influence health services’ policies and practices more generally. We make recommendations that will help to:

• facilitate engagement with children about safe health care
• address concerns about children’s perceptions of safety in hospitals, including by creating a safe physical environment
• ensure consistent information is provided to children and their families and carers about patient rights, what they can expect of staff, and ways to provide feedback.

1. Empowering children and young people through meaningful engagement and participation

Principle 2 of the National Principles states, in part, an expectation that organisations ensure children and young people participate in decisions affecting them.115 In health services, this means that children and young people should have the opportunity to inform decisions about their individual health care, and be consulted about the development, implementation and evaluation of health services’ policies and strategies that are relevant to their care and safety.116

The Australian Commission on Safety and Quality in Health Care’s User Guide states that health services can involve children and young people (as well as their families) in the development, implementation and evaluation of relevant policies and strategies through a governance structure that, among other things:

• effectively engages children and their families and carers
• has representation from children and their families and carers
• includes mechanisms to maximise engagement with children
• includes the views of children and their families when planning new facilities or redesigning existing ones.117

The National Standards also require health services to ‘seek regular feedback from patients, carers and families about their experiences and outcomes of care’ and to ‘use this information to improve safety and quality systems’.118

At our hearings in September 2022, we asked Secretary Morgan-Wicks about how the voices and views of children were informing the Department’s work. She indicated that the Department had engaged the Commissioner for Children and Young People and Child Wise, a child safeguarding consulting organisation, to provide expert advice on the best ways to ensure children’s perspectives were reflected in the Child Safety and Wellbeing Framework and new policies and procedures.119 In November 2022, Secretary Morgan-Wicks wrote to our Commission of Inquiry to tell us that the Department had worked with the Commissioner for Children and Young People to consult with children on a new name for the paediatric ward (previously known as Ward 4K) at Launceston General Hospital.120 In a progress update provided to our Inquiry in February 2023, Secretary Morgan-Wicks wrote:

The consultation process with children to engage them initially on child safeguarding themes is progressing and will also include consultation on renaming the children’s wards across the State. The Department of Health will implement an ongoing engagement mechanism from the initial consultation process. Engagement with children will also feed into the development of child safe behaviours and further consideration of child-friendly complaint mechanisms.121

In June 2023, it was announced that paediatric wards across Tasmania’s major hospitals will soon be known as the ‘Wombat Ward’, based on consultative processes with young Tasmanians aged 8 to 18 years through workshops at the Royal Hobart Hospital, Launceston General Hospital and the North West Regional Hospital in April 2023.122 We were advised that these workshops also canvassed broader discussion of children’s experiences of health services, including what was working well and what could be improved.123

We welcome this engagement, but consulting children and young people on the renaming of a hospital ward is a small step. While we are encouraged by some broader discussions about children and young people’s experiences of health services, we would like to see the Department’s engagement with children and young people continue to expand as reforms are further planned and implemented.

In December 2022, the Child Safe Governance Review reported that children and young people who are treated at Launceston General Hospital do not have a pathway for reporting concerns about their safety, other than raising these concerns ‘in person’ with a staff member.124 The review made two recommendations relevant to this issue:

• the Department of Health [develops] an online form for children and young people to report concerns about their safety (in real time)125
• children and young people who are provided with health care within the Tasmanian Health Service be provided with the opportunity to complete a survey of their patient experience.126

Again, these steps are commendable. But we consider that the Department should go further to proactively empower children and young people to meaningfully participate in decision making on matters that affect them, including their safety. The Department could do this by setting up ways to engage with children and young people regularly and meaningfully.

The relationship between children and young people feeling heard and feeling safe was something identified through our commissioned research into safety in government run organisations.127 Associate Professor Tim Moore, Deputy Director, Institute of Child Protection Studies, Australian Catholic University, who was one of the researchers we commissioned, told us:

Children and young people want to play a part in their own protection and, in building alliances with adults to develop strategies to meet their safety needs, they can build confidence, awareness and an ability to turn to adults if they are being harmed ... ‘participatory’ strategies need to empower individual children and young people through child-friendly and proactive means as well as through collective activities such as youth advisory groups.128

Liana Buchanan, Principal Commissioner, Commission for Children and Young People (Victoria), similarly stated that:

Efforts to empower children in organisations are critical. An organisation can have perfect policies, processes and systems but if children do not feel that they will be listened to if they speak up, and that they will be believed and action taken, the policies and systems will be of little value.129

Victoria’s Commission for Children and Young People has developed a guide for organisations working with children and young people.130 The guide recognises that everyone benefits when children and young people’s participation is done well, outlining principles to support the meaningful participation of children and young people in decision making.131 The Commission for Children and Young People’s guide also includes specific advice for involving children and young people of different ages.132

The Office of the Advocate for Children and Young People in New South Wales has developed a comprehensive guide for setting up a children and young people’s advisory group.133 The purpose of such an advisory group is to facilitate the voices of children and young people on a range of issues relevant to service delivery.134 An advisory group is a way to gather feedback, test ideas and ensure policies and practices best reflect the unique needs of children and young people.135 Participation in an advisory group can build children and young people’s trust and confidence in an organisation, improve the experience of children and young people within that organisation, and enhance the knowledge of an organisation’s leaders about child safety.136

Establishing a dedicated health services young people’s advisory group in Tasmania will help facilitate the contribution of young people in creating safer health services and will complement measures the Department is already implementing.

The types of issues that the health services young people’s advisory group could contribute to, using developmentally appropriate methods, include:

• policies and practices that relate to providing health care to children and young people (for example, expected standards of staff behaviour, use of chaperones (or accompanying persons/observers) and processes for getting informed consent, or how to make a complaint)
• induction materials for staff in child-facing roles
• the design, interpretation and response to surveying children and young people cared for in Tasmanian health services recommended by the Child Safe Governance Review137
• initiatives to improve the experience of health care for groups with particular needs
  (for example, Aboriginal and other culturally diverse children, gender diverse young people and those with disability or mental illness, or those who identify as LGBTQIA+)
• analysing complaints data and advising on how to avoid future complaints
• implementing initiatives under the Child Safe Organisation Project
• built environment projects or upgrades to facilities that will affect younger patients
• contributing to recruitment processes for senior roles focused on child safety.

It is important that the health services young people’s advisory group is adequately funded and that the role and functions of the group, including the scope of its authority, are clear from the outset. Without this support and role clarity, participants may feel the group is tokenistic or hollow, creating understandable cynicism and distrust that only serve to damage an organisation.

It would be beneficial for senior leaders within the Department and its agencies, as well as statutory role holders—such as the Health Complaints Commissioner, Ahpra, the National Boards and the Commissioner for Children and Young People—to regularly engage with the health services young people’s advisory group. This engagement could include making themselves available for questions and discussion.

We acknowledge that setting up a health services young people’s advisory
group may mean that only a small number of children and young people are consulted. It is therefore important that the Department also pursues other strategies to engage children and young people of all ages. These strategies may include consultations, surveys, youth forums and events, staff communications and social media.138 One strategy, for example, could involve extending the role of hospital-based child safeguarding officers to include engaging and empowering children and young people through regular visits to hospital wards and providing information to them in appropriate formats. It is imperative that the Department identifies age-appropriate ways to engage with all children and young people on questions of patient safety.139 The health services young people’s advisory group would be well placed to advise on these strategies.

Recommendation 15.7

1. The Department of Health should establish a health services young people’s advisory group. The advisory group should:
   1. have a clear purpose and objectives
   2. be guided by clear terms of reference developed in consultation with children and young people
   3. comprise young people with significant lived experience of health services, including young people of different ages, from diverse backgrounds and with different care needs
   4. enable young people to contribute to decision making in a safe and meaningful way about issues that affect them
   5. allow young people to have a say in departmental strategies, policies, procedures and protocols that affect them
   6. be adequately funded and resourced.
2. Summaries of the health services young people’s advisory group meetings should be prepared and distributed to all senior executive teams in the Department.
3. The Department should report on the activities of the health services young people’s advisory group and on other engagement with children and young people through its annual report.
4. The Department should undertake other age-appropriate engagement with children to ensure as many children and young people as possible can take part in shaping health services.

1. Children and young people’s perception of safety in hospitals

Our commissioned research showed that children often feel unsafe and disempowered during hospital stays. Some reported feeling unsafe because they were given little information about their treatment or because medical staff dismissed their opinions.140 Associate Professor Moore said:

Children continue to report that they feel disrespected, their needs and wishes disregarded and their ability to influence change as limited. While we see children as having less value to adults and their views and needs as secondary to those of adults, children are vulnerable.141

Speaking of their experience receiving care at a hospital, one young person explained how not being believed affects how safe and well young people feel:

Socially, often, children aren’t believed when they say something. Their opinions aren’t valued as much because they’re children, because they’re young. A lack of life experience. I also think because I was unwell mentally, physically. But regardless, if I’m unwell, I should still be treated with compassionate decency. To treat somebody in that state in such [a] dehumanising and most humiliating way, it just makes you feel worse. It makes you not want to commit to getting better. I makes you feel like you’re hopeless.142

This young person went on to describe how raising concerns did not resolve their negative situation at the hospital and left them feeling their issues were not taken seriously. They said that for children to feel safe in institutions like hospitals it is essential that they are believed and listened to.143

Some people, including children and young people, are not aware of their rights when receiving health care.144 Angelique Knight, a former Ward 4K patient, told us: ‘You are so vulnerable while you are in hospital because you are completely reliant on someone else doing everything for you’.145 She said: ‘Patients should be told about how they can make complaints. There could be signs up on the wall or a pamphlet could be placed in your hospital pack’.146 This sense of disempowerment can also extend to parents and carers of child patients. For example, Angela (a pseudonym) described the challenge she faced when she raised concerns about vaginal cream being used for her young daughter, who has cerebral palsy and needs support to communicate.147 Angela said she raised her concerns but felt staff dismissed them and that she was unaware of any action being taken.148

It can be difficult for children, families and carers to identify improper conduct when receiving health care or medical treatment. Some witnesses only came to understand the behaviour of Mr Griffin as inappropriate once they were adults. For example, Kirsty Neilly, another former Ward 4K patient, reflected on an incident where Mr Griffin had carried her from the ward shower back to her room, wrapped only in a towel: ‘I now think that Jim carrying me from the shower like that is weird. I shouldn’t have been so casual about it’.149

To further complicate matters, children and young people and their families and carers can sometimes understandably perceive inappropriate and unprofessional behaviours as the actions of dedicated and caring health workers. Kim (a pseudonym) told us that when she attended Launceston General Hospital with her daughter Paula (a pseudonym), Mr Griffin was a familiar face at a time she was feeling scared.150 She described perceiving Mr Griffin’s interest in her daughter and his ‘touchy-feely’ nature as him being friendly and caring.151

Sonja Leonard, former Nurse Unit Manager, Ward 4K, Launceston General Hospital, commented that children and parents often reacted positively to Mr Griffin’s boundary breaches, such as hugging child patients, and that staff witnessing the behaviour ‘did not respond negatively’.152

1. Rights when receiving health care

Health services have a critical role to play in promoting patients’ rights, expected standards of staff behaviour and complaints pathways.

The National Standards Partnering with Consumers Standard requires that ‘leaders
of a health service organisation develop, implement and maintain systems to partner with consumers’ in relation to ‘the planning design, delivery, measurement and evaluation of care’.153

Under the National Standards, health services must adopt a charter of rights that is consistent with the Australian Charter of Healthcare Rights and ensure this local charter is accessible to patients, carers, families and other consumers.154 The Australian Charter of Healthcare Rights describes what patients, families and carers should expect when receiving health care. It says that an individual has the right to:

• provide feedback or make a complaint without it affecting the way they are treated
• have concerns addressed in a transparent and timely way
• share their experience and take part in improving the quality of care and health services.155

The Charter on the Rights of Children and Young People in Healthcare Services in Australia also sets out 11 rights that ‘aim to ensure that children and young people receive health care that is both appropriate and acceptable to them and to their families’.156

These include the rights of children and young people to:

• express their views, and to be heard and taken seriously
• participate in decision making and, as appropriate to their capabilities,
  to make decisions about their care
• be kept safe from all forms of harm.157

Secretary Morgan-Wicks told us that the information given to patients, including children and young people, varies across Tasmanian public health services.158 Information is sometimes provided through the following publications:

• Australian Charter of Health Care Rights, including the consumer booklet Understanding My Healthcare Rights (published by the Australian Commission on Safety and Quality in Health Care)
• Young People’s Healthcare Rights (published by Children’s Healthcare Australasia)
• The Rights of Every Child in Healthcare (also published by Children’s Healthcare Australasia).159

Secretary Morgan-Wicks also told us that the practices of different health services relevant to informing patients about their rights will align as part of the Department’s ongoing reform work.160

In our view, the Department should ensure all health services provide consistent information to young patients and their families and carers about rights, safety and care.
This information should be delivered in accessible and age-appropriate language and formats. Health workers should also receive professional development on these issues. Again, child safeguarding officers in Tasmania’s four major public hospitals could help provide such information to health consumers and staff.

Recommendation 15.8

1. The Department of Health should ensure consistent information is provided to patients, including suitable age-appropriate resources for children and young people and their families and carers, across its health services. These resources should include information on:
   1. requirements and expectations of a child safe organisation
   2. patient rights when receiving health care, including the rights of children and young people
   3. expected standards of behaviour for health service staff
   4. processes for raising concerns and making complaints internally and externally
   5. roles of health regulatory bodies in receiving complaints.
2. This information should be provided in formats that meet community needs, especially for those with less capacity to comprehend complex written text.

1. Creating a safe physical environment

The National Principles state an expectation that an organisation’s physical environment must promote the safety and wellbeing of children and young people while minimising the opportunity for them to be harmed.161 The National Standards require health services to maximise safety and quality of care for patients through the design of the health service’s environment and by ensuring buildings, equipment, utilities, devices and other infrastructure are fit for purpose.162

In this section, we discuss physical factors that can affect the safety of children and young people in health services. We also summarise what we heard about recent efforts to improve the physical environment of Launceston General Hospital.

We make recommendations to ensure children and young people’s sense of safety is monitored to inform improvements in the physical environment of health services, and that these safety considerations extend to the needs of children and young people with diverse needs and backgrounds (for example, those who are Aboriginal, come from culturally diverse backgrounds, have disability or mental illness or identify as LGBTQIA+).

1. Physical factors affecting the safety of children and young people

In our commissioned research into children’s perceptions of safety, several young people said that they did not feel safe in hospitals because of their physical characteristics. These young people described:

• hospitals as ‘creepy’ and ‘sterile’163
• their hospital room as dark and not having a window—‘I didn’t feel like I could flourish in an area like that’164
• feeling uncomfortable ‘being in a room with strangers’165
• hospitals not being welcoming spaces for Aboriginal children and young people.166

Catherine Turnbull, Chief Child Protection Officer, SA Health, Department for Health and Wellbeing, told us about a range of physical factors that make children and young people vulnerable to abuse and harm in hospital settings. These include children and young people being kept in individual rooms that are not closely monitored by staff or CCTV, and health workers examining children and young people without a chaperone present (such as a parent, carer or other staff member).167

Others who shared their experiences made observations about the physical environment of Launceston General Hospital at the time of their admission and how they felt unsafe, isolated, out of view of others, or that staff could easily be alone with patients.168

This evidence illustrates why health services should not assume that the ‘busyness’ of a hospital ward, emergency department or other health service negates the risk of abuse of children and young people.

1. Efforts to improve physical safety at Launceston General Hospital

One of the Department’s new Child Safety and Wellbeing Principles in its Child Safety and Wellbeing Framework focuses on providing safe health care environments (including physical and online environments), and ensuring health services that contract third-party providers have ‘procurement policies that ensure the safety of children and young people’.169

Launceston General Hospital’s paediatric ward has recently undergone an extensive redevelopment as part of broader upgrades to the hospital’s Women’s and Children’s Services precinct.170 This redevelopment was completed in November 2022.

Secretary Morgan-Wicks described the redevelopment as adding a 34-bed children’s ward and a paediatric outpatient clinic incorporating allied health.171 Secretary Morgan-Wicks also described that the new ward offers more single rooms with bathrooms, is divided into two age-appropriate pods for younger patients and adolescents, and meets Australian building standards.172 Other features include a playroom, playground and outdoor courtyards.173

Secretary Morgan-Wicks said the redevelopment has resulted in ‘improved observation of patients by staff’ and provided ‘room for an adult support person to stay with a child patient throughout the admission, promoting safety, advocacy and comfort for everyone’.174 She said that in addition to providing ‘a brand new, contemporary and safer layout’, the redevelopment has also ‘helped to trigger significant staff conversations in relation to brand new models of safer care in their new environment’.175 Commissioner Benjamin visited the redeveloped paediatric ward on 14 March 2023.

We welcome these improvements and view them as a good start, but not an end point, for improving child safety.

The Department should seek feedback on how to ensure health spaces designed for children feel safe and welcoming. The Child Safe Governance Review recommended that children and young people be provided with the opportunity to complete a survey on their patient experience.176 This survey should include questions about children and young people’s perception of safety, including physical safety, in the hospital. Responses should inform ongoing monitoring, evaluation and improvements to the hospital’s physical environment. Data obtained from this and other surveys such as the Patient Safety Culture Survey, Child Safe Organisation Survey and People Matter Survey may also inform improvements. We would like the Department to work to ensure the physical environments of all its health services are safe for children and young people. Again, the child safeguarding officers at each of Tasmania’s four major public hospitals could play a role in this work.

We understand that the Department has embedded Aboriginal health liaison officers at its major hospitals. We have not, however, seen evidence of any work to ensure the paediatric ward, Launceston General Hospital or other Tasmanian health services are culturally safe spaces for Aboriginal children and young people.177 In our view, the Department should actively consider actions in this regard.

The Department should work with relevant stakeholders to consider diverse and varied needs and backgrounds of children and young people using health services, including those who are Aboriginal, come from culturally diverse backgrounds, have disability or mental illness or identify as LGBTQIA+.

Recommendation 15.9

The Department of Health should require its health services to undertake regular and ongoing monitoring of children and young people’s sense of safety in health services to inform continuous improvements to child safety, including in the safety of the physical environment.

Recommendation 15.10

The Department of Health should work with relevant stakeholders to consider the needs and backgrounds of children and young people using health services, including Aboriginal children, children from culturally diverse backgrounds, children with disability, children with mental illness and children who identify as LGBTQIA+. The Department should consult with Aboriginal communities on how it can provide culturally safe spaces for Aboriginal children across its health services.

1. Policies, procedures and protocols on child safety

Policies, procedures and protocols play a key role in supporting health services to reduce the risk of child sexual abuse and to appropriately respond to concerns when they arise. As our case studies in Chapter 14 show, informally assessing or responding to concerns about staff conduct with children and young people does not keep them safe. Well-drafted, targeted and up-to-date policies, procedures and protocols on child safety enable child safety to be embedded in practice and for any concerns to be quickly raised by staff and appropriately addressed by the health service.

In this section, we recommend a review and consolidation of the Department’s existing policies to identify gaps in safeguarding children. Once consolidated and revised, these policies should be regularly reviewed so they reflect best practice and provide accurate, up-to-date information to staff, who rely on them to effectively perform their roles and fulfil their responsibilities. We also identify key policies in relation to child safety—such as those that explain external reporting obligations, professional conduct and chaperoning—that need revising or drafting and should be prioritised in the review of policies and procedures.

1. The importance of child safety policies

The National Principles recognise the importance of policies to safeguard children.178
The Australian Commission on Safety and Quality in Health Care’s User Guide provides that ‘policies, procedures and protocols should include processes for identifying children at risk of harm from health care’.179 The User Guide suggests several strategies to protect children’s safety and privacy, including minimising non-essential exposure of children to people not authorised to provide their care, detailing requirements for mandatory reporting and balancing the promotion of children’s rights to use electronic devices with the risks posed by these devices.180

1. Current policies and procedures

The Department has ‘numerous’ policies, procedures and protocols in place to reduce the risk of child sexual abuse.181 These include those relating to pre-employment, clinical practice, behavioural standards, identifying child sexual abuse, consumer complaints, complaints and incident handling, external reporting, targeted supports, and records and information management.182

These policies, procedures and protocols are available to staff through the Department’s Strategic Document Management System, which is accessible via the intranet.183 Changes to key policies, procedures and protocols are communicated to staff through a communications platform called ‘Reach’, as well as through email, updated hardcopies and at staff meetings.184

Secretary Morgan-Wicks told us that staff are made aware of the location of policies, procedures and protocols when they start in their role. She said it was her expectation that managers would draw key policies, procedures and protocols to the attention of staff and encourage them to familiarise themselves with those that are relevant to their role.185 Secretary Morgan-Wicks also stated that volunteers are expected to comply with departmental policies, procedures and protocols.186

We received some evidence that the technology used to access policies needed improvement. For example, Sue McBeath, Nursing and Midwifery Director, Women’s, Adolescent and Children’s Services, Tasmanian Health Service South, told us the intranet site used by staff relies on outdated technology, which contributes to ‘confusion and delays’ in accessing relevant information.187

Our examination of departmental policies, procedures and protocols revealed that many were past their review date or only applicable to particular regions, areas or services. Further, many focused primarily on the risk of familial abuse of children and young people, rather than the risk of child sexual abuse being perpetrated by a health worker. There did not appear to be any policies, procedures or protocols developed specifically in response to the National Royal Commission’s recommendations.188

Launceston General Hospital used several overarching policies and information guides covering the care of children and young people including:

• A Manual for Working with Vulnerable Children and Their Families189
• Child Safety Practice Framework190
• Reporting Concerns About the Safety and Wellbeing of Children and Young People191
• Charter on the Rights of Children and Young People in Healthcare Services in Australia.192

Again, most of these resources focused on the risk of familial abuse of children and young people rather than the risk of child sexual abuse in health settings. The Child Safe Governance Review also noted that Launceston General Hospital had been inconsistent in implementing and following statewide policies and frameworks.193

Ms Turnbull told us that SA Health has developed several policies, guidelines and directives that specifically address the safeguarding of children and young people in the health system, including the Child Safe Environments (Child Protection) Policy Directive and the Responding to Suspected or Alleged Offences Against a Child or Young Person Occurring at a SA Health Facility or Service Policy Guideline which are available online.194

In contrast with the Tasmanian Department’s policies, procedures and protocols discussed above, SA Health’s policies are clearly targeted at preventing and responding to child safety concerns in a health service context.

1. Efforts to improve child safety policies

Secretary Morgan-Wicks told us that one of the Department’s recent initiatives has been to review and align its policies, procedures and protocols.195 She described this process as ‘time-consuming’ and requiring ‘significant change management to align disparate regional practices into a consistent and statewide protocol that is accepted by all health professional and support staff groups’.196 She also said that the COVID-19 pandemic had slowed progression of this initiative.197

One of the Department’s Child Safety and Wellbeing Principles in its Child Safety and Wellbeing Framework is ‘[a]ccessible and inclusive child safety and wellbeing policies’.198 The framework foreshadows the development of several policies, protocols and guidelines relating to child safety, including:

• a child safety and wellbeing policy
• a protocol for interacting safely with children and young people
• a policy for safeguarding children and young people
• a protocol for safeguarding children and young people.199

The Child Safety and Wellbeing Framework is accompanied by practice guidance titled Recognising the Signs of Harm to Children and Young People and practice guidance titled Disclosures of Harm to Children and Young People.200

1. Our observations

We agree that child safeguarding policies should apply to health services statewide.

We also agree that the Department’s review of policies should include specific policies for safeguarding children in health services. We discuss specific policies below.

The Department should ensure it complies with the requirements set out in Action 1.7 of the National Standards when conducting its review of policies, including to:

• set out, review and maintain the currency and effectiveness of policies, procedures and protocols
• monitor and take action to improve adherence to policies, procedures and protocols
• review compliance with legislation, regulation and jurisdictional requirements.201

It is also our view that children and young people be involved in the development and testing of existing and new policies that affect them, through the health services young people’s advisory group we recommend above and other empowerment and engagement strategies (refer to Recommendation 15.7).

We consider that the Department should make its child safety policies and guidelines publicly available on its website, so they are easily accessible to staff, patients, families and consumers. This will promote transparency, consistency and accountability in approaches to child safety across the Department and its services. It will also assist children, young people and their parents and carers to understand how to raise a concern, and what process to expect in response. We also consider there is a potential role for child safeguarding officers in ensuring children and young people and their families and carers are aware of these policies, what they say and where to find them.

Recommendation 15.11

1. The Department of Health should review and consolidate its policies, procedures and protocols. This review should prioritise identifying gaps in relation to safeguarding children and should inform the development and implementation of consistent statewide policies, procedures and protocols on child safety.
2. The Department’s safeguarding policies should include implementing the National Principles for Child Safe Organisations and other recommended policy changes (namely, policies on reporting obligations, professional conduct and providing a chaperone (Recommendations 15.12, 15.13 and 15.14)).
3. The Department should undertake regular scheduled reviews of its policies, procedures and protocols for child safety to ensure they continue to reflect best practice and organisational changes.
4. The Department should publish its policies, procedures and protocols for child safety on its website to promote transparency and ensure accessibility to staff, patients and their families.

1. Mandatory and other reporting policies

Doctors, nurses, midwives and departmental employees and volunteers are all prescribed mandatory reporters under the Children, Young Persons and Their Families Act.202 Mandatory reporters must report to Child Safety Services when ‘in carrying out official duties or in the course of [their] work’ they believe, or suspect ‘on reasonable grounds’ or know that ‘a child has been or is being abused’.203

Employers and staff who are registered in a health profession under the National Law are also obliged to make mandatory notifications to Ahpra and the National Boards in circumstances including when they form a ‘reasonable belief’ that a health practitioner has engaged in sexual misconduct in connection with the practice of a health profession.204

In Chapter 14, we find that Launceston General Hospital had no clear system, procedures or process in place to report complaints about Mr Griffin to external agencies, such as Tasmania Police, Child Safety Services, the Registrar of the Registration to Work with Vulnerable People Scheme or Ahpra. Consequently, ward staff, nurse unit managers, senior management and members of the executive were not aware of their distinct roles and responsibilities for reporting. Many staff members were also not aware that they could independently make reports to external agencies on a mandatory or voluntary basis.

The Tasmanian Health Service Protocol – Complaint or Concern about Health Professional Conduct (‘Complaints Protocol’), which came into effect in November 2020 and applies to all Tasmanian Health Service staff, sets out how staff should report complaints or concerns about colleagues.205

The Child Safe Governance Review recommended that the Complaints Protocol focus on practical guidance for staff in managing and responding to risks of child sexual abuse.206 The Complaints Protocol states:

In the case of reporting an offence complaint, this should be undertaken through the relevant Executive/Medico-Legal Advisor (South) through Human Resources. Mandatory reporting of a registered health professional, as represented by the organisation, must be sanctioned formally (in writing) and in accordance with line delegations.207

We have two concerns about this approach.

First, although it is reasonable—for the purpose of keeping management informed of concerns or to avoid multiple staff making a report about the same incident—that an organisation has a process in place for reporting child safety concerns through senior personnel, a staff member cannot be precluded from making a mandatory report themselves, and this should be made explicit in the Complaints Protocol. Put another way, there should be no suggestion in the Complaints Protocol that a staff member’s reporting of a health worker must be authorised according to line delegations. Under the Children, Young Persons and Their Families Act, it is a defence to a charge of failing to make a mandatory report if a person can prove that they ‘honestly and reasonably believed’ another person had already made a report.208 It is not a defence that they did not make the report because they were not given approval to do so by their manager or an executive at their organisation.

Second, a protocol that relies on senior personnel to make a mandatory report must be supported by a transparent reporting process against which senior personnel will be held accountable. It also requires that health service executive members be aware of their reporting obligations and requirements.

We heard evidence that some health service executive members at Launceston General Hospital were not aware of the Strong Families, Safe Kids Advice and Referral Line—the first point of contact for reporting child safety and wellbeing concerns, including making mandatory reports under the Children, Young Persons and Their Families Act.209

In our view, the Complaints Protocol should provide more guidance on external reporting obligations, including about voluntary pathways for reporting and support for staff.

Adjunct Professors Picone and Crawshaw advised us that, as of July 2023, a draft complaints management framework had been developed by the Department and has been subject to some initial consultation. This initial feedback is being incorporated before a broader round of consultation, which will involve consumer engagement.210

Recommendation 15.12

1. The Department of Health should ensure there are up-to-date policies on mandatory and voluntary reporting obligations, including for concerns about staff conduct, and that these are effectively communicated to staff. These policies must not require that reporting be formally authorised.
2. The Department’s review of the Tasmanian Health Service Protocol – Complaint or Concern about Health Professional Conduct and associated documents should include:
   1. a description of external reporting requirements in relation to child safety, including voluntary reporting pathways, and reporting to Tasmania Police, Child Safety Services, the Registrar of the Registration to Work with Vulnerable People Scheme, the Independent Regulator under the Child and Youth Safe Organisations Act 2023 and the Australian Health Practitioner Regulation Agency
   2. guidance on when it is appropriate to acquit mandatory reporting obligations by reporting concerns to a superior (for example, to avoid multiple notifications). This should make clear that a person is always entitled to make a notification to an external agency if they wish to do so
   3. a list of internal contacts for staff who have questions about child safety concerns and their reporting obligations.

1. Developing and implementing a professional conduct policy

The National Royal Commission identified an increased risk of institutional child sexual abuse when expectations of conduct between children and staff are not clear or consistently enforced.211 This clarity and consistency can be achieved by implementing a professional conduct policy for staff (including employees, volunteers, contractors and sub-contractors). The Australian Commission on Safety and Quality in Health Care’s User Guide states that creating a ‘code of conduct that establishes clear expectations for appropriate behaviour with children’ is one strategy for building a child safe culture in health services.212

The National Royal Commission recommended that a code of conduct contain clear descriptions of acceptable and unacceptable behaviour towards children, articulate the process to be followed in response to breaches of the code, be signed and acknowledged by all staff, and be broadly publicised, including to children and their families.213

Neither the Department nor Launceston General Hospital appear to have had a professional conduct policy beyond the State Service Code of Conduct in place during the period under examination by our Commission of Inquiry.

We recommend that the Department develops and implements a professional conduct policy for staff including employees, volunteers, contractors and sub-contractors who have contact with children and young people. The policy should reflect the content recommended by the National Royal Commission and include information about what constitutes a boundary violation or grooming behaviour. The policy should give examples of behaviours that are inappropriate in clinical and a non-clinical contexts, such as being overly or unnecessarily familiar with children, making inappropriate comments to children, engaging with children through online social networks, and having inappropriate and unnecessary contact with children outside the professional relationship. The policy should also address the challenges of maintaining these expectations of staff when they live in small communities, and outline realistic ways in which these expectations can be met. The policy should also state that a breach of the professional conduct policy may amount to a breach of the State Service Code of Conduct and result in disciplinary action (refer to our discussion and recommendations in Chapter 20).

Given the diversity of staff working in the Department and across its services, the professional conduct policy may need to differentiate between general expectations relevant to all staff and expectations that are specific to particular staff—for example, clinical staff, some of whom will be registered health practitioners under the National Law. The latter are subject to other professional codes and guidelines developed by their respective National Boards.

Recommendation 15.13

1. The Department of Health, in developing a professional conduct policy (Recommendation 20.2), should ensure:
   1. there is a separate professional conduct policy for staff who have contact with children and young people in health services
   2. the professional conduct policy for health services, in addition to the matters set out in Recommendation 20.2
      1. specifies expectations outlined in other relevant Department of Health policies and procedures
      2. refers to other professional obligations of registered health practitioners, including those developed by the Australian Health Practitioner Regulation Agency and the National Boards
      3. reflects the specific risks that arise in health services, particularly the sometimes intimate and invasive nature of health services, and the significant trust and power afforded by patients and the broader community to those providing health services
   3. the professional conduct policy for health services spells out expected standards of behaviour for volunteers, contractors and sub-contractors
   4. the Department uses appropriate mechanisms to ensure compliance by volunteers, contractors and sub-contractors with the professional conduct policy for health services.
2. The professional conduct policy for health services should be reinforced through professional development requirements (Recommendation 15.15).

1. The importance of chaperone policies

Chaperone (or Accompanying persons/Observer) policies are designed to ensure children and young people have another person (be that a parent, guardian or another health practitioner) present when any intimate examinations are undertaken on them (for example, an unclothed examination).

Adjunct Professor Picone of the Australian Commission on Safety and Quality in Health Care emphasised the importance of chaperone policies in health services:

Now, as far as clinical practice is concerned it is essential if you’re doing intimate procedures, particularly on children, and also in my view older cognitively impaired people or people that may have an intellectual or some other disability, you must have two people there: that’s the end of it.214

The Tasmanian Health Service Statewide Chaperone Protocol for Intimate Examinations (‘Chaperone Protocol’) (effective from September 2016) states that all patients ‘must be offered the presence of a chaperone during any intimate examination and/or treatment’, with ‘consideration for higher risk patients’, who include ‘children and adolescents—in addition to the parents’.215

The Chaperone Protocol provides guidance on documenting the request for, and use of a chaperone, obtaining consent from the patient to the examination and the presence of a chaperone, the role of the chaperone, and sexual misconduct by a health practitioner in connection with their profession.216

We find in Chapter 14, Case study 2, relating to Dr Tim (a pseudonym) that Launceston General Hospital should have formalised, implemented and enforced a chaperone policy as soon as practicable after Zoe Duncan’s May 2001 disclosure, and not waited until June 2002 to do so.217 We heard evidence to suggest that staff at Launceston General Hospital are still not aware of the Chaperone Protocol.218

The Child Safe Governance Review observed that, apart from the Chaperone Protocol, there were no other policies, procedures or guidelines in the Department or Tasmanian Health Service covering the accompanying of children and young people (or other vulnerable people) when accessing health services.219

The Child Safe Governance Review recommended that the Chaperone Protocol be broadened to include all examinations (not just intimate examinations) of vulnerable or at-risk patients, including children and young people, and that the information pack the hospital provides to patients on admission be updated to include the offer of the presence of an extra staff member during examinations or episodes of care where no family member or carer can be present.220

In our view, children and young people, and other vulnerable patients, should be offered a chaperone for all examinations and treatments. The risk for abuse is not confined to examinations or treatments of an intimate nature.

Recommendation 15.14

The Department of Health’s chaperone (or Accompanying Person/Observer) policy should be updated to require the presence of an extra staff member during examinations or episodes of care where no family member or carer can be present.

1. Professional development for health service staff

Many people (including employees, volunteers and contractors) who work with children and young people in health services are in a unique position to identify and respond to child safety concerns because they develop a rapport with children and young people as part of the care relationship. However, to run a child safe health service, staff must know how to recognise the indicators of child sexual abuse, respond to disclosures and comply with relevant reporting requirements. As Professor Mathews from the Queensland University of Technology School of Law told us:

Education and training are the cornerstone of any effort by an institution to embed the capacity and skills to properly recognise child sexual abuse.221

Policies, procedures and protocols relating to child safety must be supported by comprehensive induction and ongoing professional development programs that equip staff to see the practices and behaviours of others through a child safety lens.222 The National Principles (Principle 7) state the expectation that staff and volunteers are ‘equipped with the knowledge, skills and awareness to keep children and young people safe through ongoing education and training’.223

This section summarises what we heard about professional development relevant to child safety in the Department and Launceston General Hospital, and how it should be improved. We recommend that the Department identifies minimum requirements for professional development on child safety for different levels of staff, including leadership.

1. Professional development at Launceston General Hospital

We observed a lack of awareness about the risks to child safety at Launceston General Hospital. This lack of awareness was apparent among paediatric ward staff, middle management, human resources staff and executives. Staff at the hospital did not have specific training on, or an understanding of, grooming behaviours and professional boundary breaches. They didn’t know where to go with concerns or how to fulfil reporting requirements.

At our hearings, Eric Daniels, former Chief Executive, Hospitals North/North West, acknowledged a ‘significant failure’ to provide professional development to all staff (from frontline staff through to senior management), particularly for identifying grooming behaviours.224 Mr Daniels told us that additional training has since been developed in relation to child safety.225

Secretary Morgan-Wicks told us that while there are mandatory training requirements for departmental staff, they are not specific to identifying, reporting or responding to child sexual abuse, or to trauma-informed practice.226 Secretary Morgan-Wicks advised that staff training needs are assessed by managers and officials at the local level, and that the focus on child safety depends on the type of service provided.227

Michael Sherring, Clinical Nurse Educator, Women’s and Children’s Services, Department of Health provided the details of mandatory and voluntary training sessions organised for staff in Women’s and Children’s Services at Launceston General Hospital, including Ward 4K staff, during the period examined by our Commission of Inquiry. These sessions covered topics such as Child Safety Services, vulnerable children, the effects of child abuse, the child safety liaison officer role and trauma-informed care.228

Mr Sherring advised that orientation packs for new staff (including support and administrative staff) have always included information about child safety, mandatory reporting and professional boundaries.229 However, we saw no evidence of any training or resources provided to staff specifically covering the risk of child sexual abuse perpetrated by a staff member at the hospital. Also of note is that the findings of the National Royal Commission did not prompt the hospital to provide any training to its staff on child sexual abuse in institutional settings.230

Other evidence confirmed that limited professional development on recognising and responding to child sexual abuse was provided to the staff, management and executive at Launceston General Hospital before the revelations of Mr Griffin’s offending in 2019.231

We accept Mr Sherring’s evidence that he arranged training for staff on professional boundaries, but we consider that training could be strengthened. Emily Shepherd, Branch Secretary, Australian Nursing and Midwifery Federation (Tasmanian Branch), met with Ward 4K members on 24 October 2019 after Mr Griffin’s death.232 In her statement to us, she wrote that ‘members reported minimal, if any, education and training on mandatory reporting obligations or grooming behaviours’.233

Ms Shepherd said that it was clear to her that ‘there was confusion, lack of clarity, and there was a myriad of different reporting systems’.234 Ms Shepherd also observed that, beyond raising concerns with their nurse unit manager or nursing director, Ward 4K members were not clear on the processes for escalating their concerns.235

We recommend that the Department ensures there are up-to-date policies on mandatory and voluntary reporting obligations, including for concerns about staff conduct (refer to Recommendation 15.12).

However, policies alone are not enough—staff must also receive regular professional development that reinforces their reporting obligations and provides the opportunity to clarify these obligations.

1. Professional development for human resources staff

Human resources staff in health services have a central role in responding to complaints and concerns about staff and, by extension, in managing risks connected to child sexual abuse. They are often the first port of call for a staff member or manager who is unsure about how to respond to concerns or complaints about the behaviour of a colleague.

We were extremely concerned about the clear lack of understanding among human resources staff at Launceston General Hospital about child safety issues, including risks of child sexual abuse, grooming and professional boundary breaches perpetrated by staff members. Mathew Harvey, former Human Resources Consultant, Department of Health told us that, to the best of his knowledge, prior to the allegations concerning Mr Griffin becoming more broadly known in 2019, neither he nor anyone else in the human resources department had received any professional development in relation to identifying child sexual abuse or grooming behaviours.236 This lack of training was confirmed by other human resources staff.237

It is our view that human resources staff must have sufficient knowledge to recognise potential risks to child safety and to provide advice and direction to staff on how to respond to and navigate these risks, as well as associated concerns such as staff animosity and disagreements that may arise when a complaint is made.

Knowledge relevant to child safety and abuse is particularly important when managers and staff have a close working, or even personal, relationship with the staff member against whom a complaint is made. This relationship, in the absence of a trained response to child safety risks, can compromise objectivity and create difficult dynamics in a workplace. To ensure accurate advice and appropriate referrals, it is critical that human resources staff understand child sexual abuse risks, know their reporting and notification requirements, and are familiar with all relevant hospital policies, procedures and protocols related to child safety.

1. Recent professional development on child safety

Secretary Morgan-Wicks acknowledged an absence of department-wide training in child safety.238 However, we understand that since revelations about Mr Griffin’s offending in 2019, some steps have been taken to improve professional development opportunities for staff on child safety matters. For example, following feedback from a staff member, Launceston General Hospital arranged education sessions for Ward 4K staff on abuser profiles, tactics and strategies with respect to grooming behaviour. An external organisation delivered this training in February and March 2020.239 As far as we are aware, this was one-off training provided only to Ward 4K staff.

Secretary Morgan-Wicks told us that in May 2022, mandatory child safety training had also been developed as part of the Department’s Child Safe Organisation Project.240 We understand from the Child Safe Governance Review that this training is being delivered across the Department and Tasmanian Health Service.241 Secretary Morgan-Wicks reported that key areas of focus for the training include the National Principles, indicators of abuse and grooming behaviours, mandatory reporting, and trauma-informed approaches to receiving reports or complaints about child safety.242

In a written update provided to our Commission of Inquiry in February 2023, Secretary Morgan-Wicks told us that the Australian Childhood Foundation’s ‘Foundations of Safeguarding Children and Young People’ course was made available to departmental staff in November 2022.243 Secretary Morgan-Wicks also reported that ‘short online sessions’ on mandatory reporting, professional boundaries, grooming and lodging child safeguarding concerns in the Safety Reporting and Learning System had been developed and would be available ‘over coming months’.244

The Child Safe Governance Review made numerous recommendations for staff professional development across Launceston General Hospital and the Department.
Key recommendations included that:

• a capability review be conducted for any necessary training and upskilling of statewide human resources staff245
• a full-time child safety liaison officer role and a dedicated child safe unit be established to support reporting and training in child safety at Launceston General Hospital and to provide expert advice to staff246
• the content and frequency of mandatory training for all Launceston General Hospital staff be reviewed as soon as possible to streamline, and ensure an optimum environment for, implementing mandatory child safety training.247

The Child Safe Governance Review’s recommendations are consistent with a more general recommendation made by the co-chairs of the Community Recovery Initiative that all staff ‘undergo training in their responsibility to prevent and report incidents of child sexual abuse and more generally in the principles and pillars of the Launceston General Hospital safety culture’.248 The co-chairs of the Child Safe Governance Review advised us that, as of July 2023, more than 15,500 staff have undertaken mandatory child safety training.249 We were told the Department is mindful that undertaking such training may be difficult for staff with their own personal experiences of abuse, which has contributed to the development of a confidential Safety Plan tool. This tool can be used by affected staff with their line manager to ensure they receive sufficient support to undertake their work duties safely.250

1. Improving professional development on child safety

The ability of staff to view the clinical practice of their colleagues through a child safety lens is a key part of ensuring child sexual abuse and inappropriate behaviours, including grooming and professional boundary violations, are identified and acted on early.

Many management and executive staff who made statements to our Commission of Inquiry said that professional development on child safety was a way to improve the health system’s response to allegations of child sexual abuse and would help restore community confidence in Launceston General Hospital.251 We consider that substantial professional development is required across all levels of staff at Launceston General Hospital and the Department on a range of matters concerning child safety.

Professional development in relation to children and young people should be designed for all health workers, not just those who are specially trained to deliver health care to children.252 It should also extend to a health service’s executive and human resources personnel so they can understand the risks of abuse to children and young people, identify staff training needs to address these risks, and ensure managers are well supported to respond to and manage complaints about staff conduct.

However, over-reliance on professional development to address child safety concerns must be avoided. An ability to identify and respond effectively to child abuse must also be coupled with a preparedness to act.

The executive and senior managers who appeared at our hearings were well into long careers in the health sector. While employers have a responsibility to provide professional development opportunities to staff on a broad range of matters, including child safety, individuals also have a responsibility to be attuned to the types of risks that may arise within their workplace. This extends to applying good judgment and common sense to situations and to escalating concerns up the chain or to external agencies (as the case may be). This is particularly important in paediatric wards where frontline staff would more routinely be confronted with disclosures or evidence of child abuse that has taken place elsewhere, including the family home.

In our view, the work already underway by the Department and the implementation of the Child Safe Governance Review’s recommendations are appropriate to address concerns about the lack of professional development on child safety and must be given time to succeed. We consider that child safeguarding officers at Tasmania’s major public hospitals are well placed to help plan and deliver training to staff on child safety issues in health services.

We consider the professional development requirements for staff in relation to child safety should be subject to public reporting. This would be one way to assure the community that a particular standard of knowledge and capability has been reached across the workforce. Periodic evaluations also enable assessment of whether existing professional development requirements and opportunities continue to align with best practice and, importantly, whether the desired uplift in workforce capability has been achieved and maintained over time.

1. Enhancing leadership skills

Above we discuss the importance of leadership in establishing a child safe culture. Professor Loh, from St Vincent’s Health Australia, described the importance of management training for health practitioners moving from clinical practice into senior executive roles. For doctors, this may be training through the Royal Australasian College of Medical Administrators, and for nurses and other health practitioners, training through the Australasian College of Health Service Management.253 In evidence during our hearings, Adjunct Professor Picone indicated that either an undergraduate or postgraduate degree in management was required, at a minimum.254 Ms Turnbull, from SA Health, agreed, adding that those making the transition to management should also receive ongoing mentoring and supervision.255

Ms McBeath, who at one point held the role of Director of Nursing at Launceston General Hospital, told our Inquiry about the challenges some nursing staff face when transitioning from a clinical to a managerial or leadership role:

I believe that one of the many challenges for particularly Nurse Unit Managers is the broadness of their responsibility and the lack of support and preparation for them as they transition from a clinical to a managerial and leadership role. Investment in leadership development and manager support would provide much needed opportunities which may assist managers in identifying and responding appropriately to complex issues such as the issues under review in this investigation.256

The Child Safe Governance Review considered the professional development needs of leaders, including managers. It noted that a key component of the Department’s One Health Cultural Improvement Program is ‘consistent and effective leadership and management development and training across the Department and Tasmanian Health Service’.257 The Child Safe Governance Review noted that the Department was participating in a range of leadership and management development activities and developing two more management and leadership programs for staff, one with the University of Tasmania.258

The Child Safe Governance Review recommended that leadership and management training be prioritised for frontline and middle managers at Launceston General Hospital, and that the Department’s leadership and management training ‘retain a multi-disciplinary focus rather than a siloed approach involving different professional cohorts’.259

In a written update provided to our Commission of Inquiry in February 2023, Secretary Morgan-Wicks identified two professional development programs the Department is delivering: the Aspire Leadership Program and the Elevate Management Program.260 She told us that the Aspire Leadership Program is a specialised program designed to ‘identify and support our senior leaders’ and was piloted with 18 participants from different health services and professional areas between August and December 2022.261 A second cohort of 20 participants began the program in February 2023.262 Secretary Morgan-Wicks stated that the Elevate Management Program is designed to develop management skills in staff across areas such as governance, risk, problem solving, communication, people management and project delivery and execution.263

In July 2023, we were advised by Adjunct Professors Picone and Crawshaw that the One Health Culture Elevate Management Development Program had commenced, which is specifically designed for the Department and is:

… designed to upskill managers in the non-clinical aspects of their roles and focuses on development in the areas of planning, delegating, financial and people management, governance, performance management, communication and human resources.264

While we welcome the Department’s recent efforts at improving the professional development of those in leadership roles, organisations such as Launceston General Hospital and the Department must have leaders and managers who are committed to prioritising children’s and staff safety and wellbeing over the long term. In the context of our findings in Chapter 14, Case study 3, relating to James Griffin, leaders must have the capacity to effect organisational change, the curiosity to ask questions to understand problems, and an aptitude for developing and implementing reforms. Managers must also be supported to confidently perform their roles and responsibilities through appropriate professional development and ongoing supervision and mentoring. Because their roles and responsibilities include managing and responding to complaints about staff conduct and any associated conflict in an open and transparent way, their training must focus on helping them to discharge these responsibilities well. Ideally, staff applying for senior leadership and management roles in the Department and at Launceston General Hospital should have leadership and management qualifications or training at the time of appointment. At a minimum, the organisation should support them to undertake this training and obtain these qualifications when new to the role.
New and emerging leaders, such as those being promoted from clinical practice into people management roles, should be provided with professional development to help them navigate this transition.

Professor Mathews commented on the need for external governance to be in place to ensure institutions and their leaders have a genuine commitment to child safety. Such governance may include requirements for leaders to hold certain qualifications or undertake professional development related to child sexual abuse, and for leaders to prove its workforce meets a standard of education.265

1. Our observations

In addition to the Department’s recent professional development initiatives, we consider that the Department should monitor the effectiveness of these initiatives. Outcomes-based measures of effectiveness could include consumer and staff feedback on the knowledge and skills of staff and leadership, including through consumer and staff surveys.

Recommendation 15.15

1. The Department of Health should identify minimum requirements for professional development on child safety for different levels of staff, including staff, volunteers and contractors, as well as leadership. Professional development should cover, at a minimum:
   1. understanding child sexual abuse (including grooming and boundary breaches)
   2. the requirements and expectations of a child safe organisation
   3. mandatory and voluntary reporting obligations, including the role and function of Tasmania Police, Child Safety Services, the Registrar of the Registration to Work with Vulnerable People Scheme, the Independent Regulator under the Child and Youth Safe Organisations Act 2023 and the Australian Health Practitioner Regulation Agency
   4. relevant child safeguarding policies and procedures.
2. The Department should have appropriate processes in place to ensure leaders have the knowledge, skills, aptitude and core capability requirements to effectively manage people and to lead a child safe organisation.
3. The Department should develop outcomes-based measures of the effectiveness of child safety professional development initiatives for all categories of staff, volunteers, and contractors, including management, leadership, human resources, and professional and non-professional staff.
4. These outcomes-based measures should be reviewed annually and the results used to inform further professional development initiatives and leadership selection.

1. Improving responses to child sexual abuse

The National Principles aim to prevent the likelihood of child sexual abuse occurring in institutions. However, the National Principles require that organisations have robust systems in place to respond to child safety concerns where they arise. Principle 6 states that processes to respond to complaints and concerns should be ‘child focused’.266 Robust complaints management and investigations systems are also requirements of the National Standards.267

The National Royal Commission noted that responses to complaints of child sexual abuse encompass a range of actions that institutions should take. These actions include:

• identifying complaints—child or adult survivors who report possible child sexual abuse should be taken seriously
• assessing risk—potential safety issues for victims and other parties should be identified and action taken to ensure their safety (including for the subject of the complaint where necessary)
• reporting—all relevant bodies and institutions should be informed of the complaint, including, for example, the police, the Registrar of the Registration to Work with Vulnerable People Scheme, the Strong Families, Safe Kids Advice and Referral Line and any relevant professional oversight body
• communicating and providing support—institutions may need to communicate with all affected parties and must assess the need for, and be able to provide, support for those involved, including complainants, parents, employees and other affected children
• investigating—this process should begin after a complaint is received and risk assessment completed; some actions, such as ensuring the integrity of a location as soon as possible after a complaint is received, can be crucial to an investigation
• maintaining records—institutions should maintain relevant records, including of investigation processes
• completing a root cause analysis—where required, institutions should review the circumstances of the complaint to identify possible systemic factors that may have contributed to the incident
• monitoring and reviewing—institutions must have policies and procedures to help continually improve the ‘protection of children for whom the institution has responsibility’.268

The case studies in Chapter 14 show that Launceston General Hospital and the Department more broadly did not have a robust complaints management framework in place for responding to child safeguarding concerns. In Case study 3, we make findings that:

• Launceston General Hospital failed to manage the risks posed by James Griffin.
• Launceston General Hospital did not have a robust system for managing complaints involving child safety.
• Launceston General Hospital failed to consider the cumulative effect of complaints about James Griffin.
• Launceston General Hospital had no clear system, procedures or process
  in place to report complaints about James Griffin to external agencies.
• The response of Launceston General Hospital to complaints about James Griffin suggested it was ultimately not concerned about his conduct.

The case studies in Chapter 14 have also exposed a disciplinary system that is not tailored to addressing high-risk, sensitive complaints involving children’s safety. In the health service context, we saw a highly conservative approach to initiating disciplinary proceedings.

In Chapter 6, we recommend that a Child-Related Incident Management Directorate be established. This directorate would support agencies to meet the requirements outlined by the National Royal Commission in relation to child safety concerns and complaints about staff conduct. The Directorate would also receive, assess, investigate, coordinate and oversee responses to allegations of child sexual abuse against staff. The Directorate’s management of such misconduct matters, including procedures for an investigation and the recommendations made at the end of an investigation, would be controlled by the State Service’s disciplinary system. We discuss the failings of the State Service disciplinary system extensively in Chapter 20.

In this section, we make recommendations to improve the Department’s complaints and disciplinary processes in line with the directorate we recommend in Chapter 6.

1. Complaints

This section considers the systems and processes required to effectively respond to complaints in a health service and outlines the reforms currently underway to strengthen the complaints and disciplinary processes at Launceston General Hospital and across the Department. We discuss the specific problems we identified at Launceston General Hospital, so the Department and the hospital can focus on addressing these problems when implementing reforms. We recommend a series of principles to shape reforms to complaints processes.

1. Best practice approaches to complaints about child sexual abuse

It is important to use a consistent and transparent process in responding to all complaints about health workers. Complaints that may initially seem minor or trivial can hold vital information or reveal more concerning behaviour on further investigation. Complaints about professional boundary breaches, for example, often point to more serious misconduct.269

Complaints can also be an important sign that something is not working as intended in the health system and that clearer policies, changed practices or improved staff training and development are necessary. Professor Loh told us that research into doctors consistently shows that the more complaints that are made about a doctor, the more likely their patients will experience adverse clinical events and outcomes.270

In the context of child sexual abuse, complaints that a health worker is overly familiar with young patients, has made inappropriate comments in the presence of young patients or has contact with young patients outside the clinical setting, may indicate grooming, which is a serious precursor of other forms of child sexual abuse. We consider that the Department should adopt the widest possible interpretation of what defines a child safety complaint, and therefore what may or may not constitute child sexual abuse. Kathryn Fordyce, Chief Executive Officer, Laurel House, told us:

Low reporting thresholds are important in protecting children from child sexual abuse. If minor issues are identified, corrected and dealt with constantly and consistently, this deters perpetrators of child sexual abuse from committing child sexual abuse because they are aware that the system will be able to identify them … If we reaffirm that reporting is for the purpose of protecting children from child sexual abuse rather than prosecuting offenders, the process will be more effective.271

Adjunct Professor Picone told us that an effective complaints management system is underpinned by health services encouraging all staff to bring concerns to management at the earliest opportunity.272 She said that health services should record all incidents, including ‘near-misses or complaints’, which can act as a public health tool in providing ‘intelligence’ to inform system improvements.273

Adjunct Professor Picone also made clear that child sexual abuse complaints should be treated as ‘extremely serious’ and require a ‘thorough’ response from senior management.274 She laid out the following best practice approach to child sexual abuse complaints:

• the matter is immediately escalated to the appropriate senior manager
• the senior manager immediately reports the matter to the police
• the senior manager takes an immediate administrative decision regarding the duties of the alleged offender, including whether they are to be suspended
• the senior manager initiates an open disclosure process with the victim and their family.275

Adjunct Professor Picone emphasised that it is not the role of senior management to determine whether an alleged abuser has engaged in child sexual abuse; rather, part of their role is to notify the police of the allegation as soon as possible.276 We would add that a senior manager must act on the basis that the allegation is true, ensure the risks to child safety as a result of the allegation are addressed and gather organisational information on any previous conduct of concern relating to child safety or professional boundary breaches that might relevant to an investigation and/or assessment of child safety risks. They will also need to ensure all mandatory external reporting requirements are met and appropriate records made.277

1. Current complaints processes

Secretary Morgan-Wicks described the following key features of the Department’s complaints system:

• Complaints about child sexual abuse in health settings can come through several channels including online enquiries, consumer feedback, public interest disclosures, referrals to human resources staff, reports made on the Department’s Safety Reporting and Learning System, notifications of suspensions of registration to work with vulnerable people or other mandatory accreditation, self-disclosures, unions and media reports.278
• On admission, health services give patients, families and carers information about how to raise concerns or to make complaints.279
• Supports provided to parties involved in complaints about child sexual abuse are managed on a case-by-case basis, with consideration given to who the most appropriate person is to make contact with a complainant and the way to make contact (in person, by phone, by email or by letter).280 Other supports offered to affected parties may include the Employee Assistance Program or referrals to external support services and providing a contact person at the Department.281

Secretary Morgan-Wicks conceded that the Department’s complaints process departed from best practice in the following ways:

• The various avenues for receiving complaints mean that the approach to ‘recording, reviewing, investigating and reporting is varied and uncoordinated’.282
• There is no consistent governance and oversight of complaints. The person responsible for the complaint depends on how the complaint is received.283
• Complaints can be referred to the area that is the subject of the complaint, creating potential conflicts of interest and concerns about confidentiality.284
• There is no ‘regular, structured analysis, reporting and monitoring of complaints data’ due to the disparate ways complaints are managed. This means information on ‘trends and systemic issues’ is not available to the governance committee to inform decision making.285

The evidence we received about how poorly Launceston General Hospital responded to complaints about health practitioners reinforces our view that all complaints about staff conduct towards children should be independently managed through a dedicated unit, such as a Health Services Child-Related Incident Management Directorate. Before outlining the desirable features of such a unit, we describe some reforms in relation to child safety complaints recently announced by the Department.

1. Efforts towards ensuring a stronger, safer child safety complaints system

In her statement of 22 June 2022, Secretary Morgan-Wicks advised us that she was establishing a complaints management oversight unit (‘Statewide Complaints Oversight Unit’) in the Office of the Secretary.286 She said the unit will be responsible for recording and tracking the progress of complaints in a document management system, assessing complaints against previous complaints, and allocating the complaint to an appropriate business unit for action after identifying any potential conflicts of interest.287 She said the unit will be supported by internal trauma-informed investigators to assist with employee misconduct matters.288

As noted above, in November 2020 a Complaints Protocol was introduced across the Tasmanian Health Service. The Complaints Protocol distinguishes between complaints that are ‘minor’ and able to be ‘immediately resolved’, and those considered ‘serious’.289

Under the Complaints Protocol, complaints from consumers are considered more serious where they give rise to a possible legal claim, are a ‘public relations risk’, may require an external peer review or a root cause analysis investigation, or are subject to open disclosure.290 In such instances, the relevant executive must be notified—in the case of Launceston General Hospital, this is the Executive Director of Medical Services.291 Complaints about staff conduct are also considered serious if they give rise to potentially significant misconduct under the State Service Act.292 The responsibility for deciding whether a matter is minor or serious sits with the relevant manager.293 We are concerned that the focus of the Complaints Protocol is managing reputational risk and public perception, rather than the harm or risk of harm to patients. We recommend below that the Department’s complaints policy prioritises risks of harm to children.

We understand that the Child Safety and Wellbeing Service has been established to receive and triage at least some child safety complaints. The new Child Safety and Wellbeing Service sits with the Deputy Secretary, Community, Mental Health and Wellbeing.294 The Child Safe Governance Review reported that the Child Safety and Wellbeing Service would receive and triage all concerns and complaints about child safety and make determinations about referrals to other entities (including the Statewide Complaints Oversight Unit, Ahpra and the National Boards), departmental human resources, child safeguarding officers in hospitals, the Strong Families, Safe Kids Advice and Referral Line or the police.295 We are uncertain about the proposed relationship between the Child Safety and Wellbeing Service and the Statewide Complaints Oversight Unit.

The Child Safe Governance Review also made a broad range of recommendations for managing complaints, the most relevant of which can be summarised as follows:

• The Statewide Complaints Oversight Unit should develop clear and consistent forms, policies and practices for complaints, and the Tasmanian Health Service should review its complaints management framework.296
• The Department’s Safety Reporting and Learning System should be the single point for recording complaints and concerns.297
• There should be increased monitoring, auditing and public reporting of incidents logged in the Safety Reporting and Learning System.298
• The Complaints Protocol (described above) should be reframed to include a focus on providing practical guidance in responding to concerns about staff, and a concise document summarising patient safety reporting obligations based on the different categories of staff should be developed.299

The Secretary has accepted these recommendations.

Secretary Morgan-Wicks gave evidence that she is establishing an independent statewide Child Safety and Wellbeing Panel. The purpose of the panel will be to oversee the monitoring and investigation of child safeguarding concerns in the Department.
The Child Safety and Wellbeing Panel will comprise experts in child safeguarding and health systems.300 Its specific functions will include:

• reviewing and assessing all serious child safeguarding events referred by the Secretary (including completing a root cause analysis)
• conducting research and providing advice or evaluations on evidence-based approaches to safeguarding
• advising on improvements based on lessons from serious safeguarding incidents.301

The Department has since appointed several individuals to serve on the Child Safety and Wellbeing Panel, including two consumer representatives.302

1. Principles to guide the implementation of reforms

Our evidence pointed to specific weaknesses and shortcomings in complaints handling in the Tasmanian health system. From this we have developed principles that we consider should drive reforms to the Department’s complaints management system. This is in addition to the need we identify above that the complaints process should have clear escalation processes, internal and external reporting requirements within specific timeframes, and address immediate risks to children’s safety. These principles are that:

• Complaints processes should be well understood, trusted and accessible to staff, patients and others.
• There should be appropriate scrutiny and oversight of how complaints about child safety are escalated to senior staff, managed and recorded.
• Complaints about child safety should be recorded comprehensively and stored securely in incident management (Safety Reporting and Learning System) and human resources systems.
• Complaints about unprofessional conduct and boundary violations with child patients should be recognised as a patient safety issue and treated as serious.
• Complaints data should support decision making and inform system improvements.
• There should be appropriate communication and supports provided to those making complaints or affected by the alleged conduct, including through open disclosure processes.

Except for appropriate communication and supports (which we discuss below), we discuss each of these principles, and the evidence that gave rise to them, in turn.

1. Complaints processes should be well understood, trusted and accessible

Our case studies in Chapter 14 reveal shortcomings in Launceston General Hospital’s complaints management processes. Chapter 14, Case study 3, relating to James Griffin most clearly illustrates the lack of clarity and inconsistency in managing complaints, which were received, recorded and responded to in a variety of ways and with no clear process. This was, in large part, because of:

• a failure to recognise boundary violations towards child patients as a potential child safety concern
• the absence of clear, organisation-wide directives on how child safety concerns should be managed
• the significant discretion given to staff in responding to complaints of this nature.

We heard that line managers were often the first port of call for any child safety complaints, with the occasional involvement of the human resources team.303 Ms Shepherd, from the Australian Nursing and Midwifery Federation, told us that the Tasmanian health system is hierarchical and therefore staff are likely to report any concerns to a manager or senior staff member.304 Secretary Morgan-Wicks made a similar observation, noting a tendency for health workers to report suspected misconduct by another health worker to a direct line manager such as a nurse unit manager.305

The absence of a transparent and user-friendly complaints process also meant that patients were not supported and empowered to report concerns. Chapter 14, Case study 3, relating to James Griffin outlined that attempts made by Ward 4K patients to raise concerns about Mr Griffin’s conduct were often dismissed or downplayed by senior and frontline staff. We also heard that patients were not aware they could report a concern to external agencies.

It is vital that any complaints framework is clear, simple to use, consistently applied, accessible and transparent.

1. Internal and external scrutiny and oversight

The absence of a transparent and consistent complaints framework at Launceston General Hospital meant that line managers, some of whom were relatively junior in the overall hospital hierarchy, carried significant responsibilities for assessing and resolving serious complaints. Most of the complaints made about Mr Griffin were reported to his nurse unit manager at the time, who sometimes (but not always) sought advice and assistance from human resources staff. We heard that the human resources team may or may not be notified, depending on the nature of the complaint and how it was made.

Very few complaints filtered up to senior nursing management. This reflects the significant power and responsibility placed on local managers to designate a matter as ‘minor’ and manage it informally. Perverse incentives may motivate managers to resolve complaints informally; for example, they may be worried about how such complaints reflect on their own performance. The lack of formality in responding to complaints creates many problems.

As we saw across our case studies, an informal approach to complaints management contributed to failures or delays in notifying or involving external agencies such as the Registrar of the Registration to Work with Vulnerable People Scheme, Child Safety Services, Tasmania Police and professional regulators. The involvement of these agencies would likely have made the risks posed by particular staff more apparent and empowered agencies to take protective measures. External oversight by these agencies would have also facilitated some scrutiny of the hospital’s response.

Line managers should not be unilaterally responsible for determining complaints connected to child safety. Information about ‘minor’ complaints, as defined in the Complaints Protocol, should also not be held exclusively by line managers in file notes or diary entries. There should be one system for capturing all complaints, no matter how minor.

1. Recording and storing information about complaints

The purpose of the Safety Reporting and Learning System is to record reports of all safety concerns in clinical settings, including any complaints of child sexual abuse.306

Nursing staff and managers who gave evidence to our Commission of Inquiry seemed to believe that the Safety Reporting and Learning System was primarily for recording clinical events (for example, medication errors), rather than concerns about staff conduct towards a patient.307

Human resources staff also gave evidence to our Inquiry that the Safety Reporting and Learning System was not designed to capture child safety concerns, which were instead addressed through local managers.308 Mr Harvey noted that human resources staff never see most reports in this system.309

Adjunct Professor Picone told us that although systems such as the Safety Reporting and Learning System are more frequently used to record clinical incidents, they should also be used to record non-clinical incidents—for example, complaints about abuse or suspected abuse.310

At our hearings, Adjunct Professor Picone confirmed that she had examined the Department’s Safety Reporting and Learning System and that, while records can be altered, and frequently are altered from what is first recorded, there is a clear record of such alterations, and the original entry is not destroyed.311 Adjunct Professor Picone described the system as ‘probably the best in the country’ in this regard.312

Ms Turnbull, from SA Health, told us there is often confusion about what is a human
resources issue and what is a clinical issue, and that it is important that staff understand that a complaint about child safety must be recorded in a hospital’s incident management system and its human resources system.313 Ms Turnbull indicated that in South Australia, which uses the same incident management system as Tasmania (but called the Safety Learning System), there is a specific notification section that deals with child sexual abuse complaints.314

We understand that a new Child Safety Module has been specifically developed to ‘facilitate the reporting of child safety incidents and issues’ in Tasmania’s Safety Reporting and Learning System. This new model is supported by training and ‘how to’ guides for staff.315 Complaints made under this module are sent directly to the Child Safety and Wellbeing Service to be risk assessed and referred for follow-up and ongoing management with appropriate respect for confidentiality.316 Individuals who made the relevant report are advised of the actions taken, and outcomes of the safeguarding concern.317 Adjunct Professors Picone and Crawshaw advised us in July 2023 that while the module was relatively new, reporting to date has been stronger in the Northern region of Tasmania compared to other areas, and that the Child Safety and Wellbeing Service would continue to promote awareness and reporting across the State.318 A new complaints reporting dashboard has also been created, which is consistent across all three Tasmanian regions.319

We consider that in addition to recording concerns or complaints about child safety in the Safety Reporting and Learning System, complaints involving staff should also be recorded in a health service’s human resources system to ensure they are accessible to those who require such information to inform decision making about staff management, including disciplinary action.

1. Recognising complaints about child sexual abuse as a patient safety issue

Launceston General Hospital’s Quality and Patient Safety Unit is dedicated to managing and resolving complaints.320 Despite the central role that the Quality and Patient Safety Unit apparently holds in managing complaints, we received little evidence that those making or responding to complaints about child safety concerns dealt directly with this unit.

Dr Peter Renshaw, former Executive Director of Medical Services, Launceston General Hospital, described the Quality and Patient Safety Unit (and its various iterations over the years) as being the area that records ‘complaints or grievances made by either staff, patients or family members of patients at the LGH’.321 He described the unit allocating complaints and clinical incidents to a senior clinician or manager in the affected area, who would oversee an investigation and determine the appropriate response.322 He said that the Quality and Patient Safety Unit was responsible for ensuring that a response to the complaint was provided within 28 days and ‘evaluated the quality of the complaint responses through audit of complainant experience’.323

A former nurse within the Quality and Patient Safety Unit at Launceston General Hospital told us that the service coordinates patient safety programs, quality improvement, and risk and incident management.324 The nurse said that the Quality and Patient Safety Unit is not directly tasked with investigations into staff performance or other human resources matters but that these issues are sometimes uncovered in the unit’s reviews of patient safety events, and are then referred to the relevant manager or director, or to the human resources department.325

The nurse told us that the Quality and Patient Safety Unit held safety event meetings attended by relevant staff from the unit and by the Executive Director of Medical Services (who, until recently, was Dr Renshaw).326 The purpose of these meetings was to review serious incidents and discuss investigation processes and improvement opportunities.327 Following the public release of The Nurse podcast, the matter of Mr Griffin was apparently discussed at a serious safety event meeting.328 The Quality and Patient Safety Unit also sought advice from Dr Renshaw on how to respond when queries from concerned families related to Mr Griffin were raised with the hospital.329

Other than this meeting, the Quality and Patient Safety Unit does not appear to have been involved in any of the complaints about Mr Griffin. Again, this suggests that child safety governance arrangements at the hospital have primarily focused on clinical risks, with risks to child safety posed by staff boundary breaches considered a matter for the human resources team. It is important that organisational and governance arrangements in health services recognise that the risk a staff member poses to the safety of children is a serious patient safety issue and not simply a staffing problem to be managed locally.

1. Complaints data should support decision making and inform system improvements

One of the main problems we noted across all our case studies was that complaints about child sexual abuse or boundary breaches tended to be considered as isolated incidents and did not prompt reviews of child safeguarding systems more broadly. Rarely were complaints routinely escalated to the Secretary to contemplate disciplinary action. This represents many missed opportunities to learn from mistakes and to work to prevent future misconduct.

As previous reviews have revealed, there is a defensive culture within the Tasmanian Health Service. Richard Connock, Health Complaints Commissioner, described how he had ‘encountered a somewhat protective and adversarial attitude’ within the Tasmanian Health Service in responding to complaints, and had ‘routinely encouraged the [Tasmanian Health Service] to be more open with complainants’.330

Mr Connock told us that complaints can take an extremely long time to arrive at
his office and often seemed to be ‘waylaid in the “legal department” for long periods’.331 We agree with Mr Connock that the Department could do more to recognise the value of complaints across the organisation and, in doing so, apply principles promoting open disclosure by admitting mistakes and identifying opportunities to implement improvements.332

While the Department has started work to improve its complaints management processes for child safety concerns, there is not a clearly defined and publicised pathway for escalating, managing and investigating complaints across the Department and within its health services. The governance and review arrangements underpinning such complaints processes are also unclear. We acknowledge that this work is underway, but we consider that the Department must ultimately clarify the complaints pathway along with the roles and responsibilities of the various bodies involved in responses to child safety concerns. We consider that this information could be conveyed through an information diagram showing the complaint escalation, management and investigation pathways for child safety issues in the Department and associated governance and review arrangements. The diagram should be included in the complaints escalation, management and investigation policy that we recommend below, and be made available to health service users and the public.

Recommendation 15.16

1. The Department of Health should have a specific policy on responding to complaints and concerns about staff conduct. The policy should establish a complaints escalation, management and investigation process that is informed by the following principles:
   1. Complaints processes should be well-understood, trusted and accessible to staff, patients and others.
   2. Complaints processes should have clear escalation processes, internal and external reporting requirements within specific timeframes, and address immediate risks to children’s safety.
   3. There should be appropriate scrutiny and oversight of how complaints about child safety are escalated to senior staff, managed and recorded.
   4. Complaints about child safety should be recorded comprehensively and stored securely in incident management (such as the Safety Reporting and Learning System) and human resources systems.
   5. Complaints about unprofessional conduct and boundary breaches with child patients should be recognised as indicating a patient safety issue and treated as serious.
   6. Complaints data should support decision making and inform system improvements.
   7. There should be appropriate communication and supports provided to those making complaints or affected by the alleged conduct, including through open disclosure processes (Recommendation 15.18).
2. The policy should include a diagram showing the complaints escalation, management and investigation pathways for child safety concerns and associated governance and review arrangements. It should also outline the roles and responsibilities of the various bodies involved in responding to child safety concerns.
3. This policy and diagram should be available to health service users and the public.

1. Staff disciplinary processes

Despite being one of the largest public sector agencies, the number of preliminary assessments and Employment Direction No. 5—Breach of Code of Conduct investigations conducted by the Department of Health between 2000 and February 2023 were the lowest across all three child-facing agencies we examined.333 We describe the data we received from the Department relating to disciplinary processes taken against its staff in greater detail in Appendix H.

In this section, we discuss disciplinary processes and make recommendations for a reformed disciplinary process for child safety concerns and staff behaviour towards children, managed by a Health Services Child-Related Incident Management Directorate. This is consistent with recommendations we make for a new Child-Related Incident Management Directorate in Chapter 6.

1. Receiving complaints and concerns about child safety and staff conduct

Irrespective of where a complaint or concern about child safety is raised, it should be reported to a central body, which should be staffed by people with child safeguarding expertise who can assess and triage complaints and concerns. We consider this function should be rolled into the Health Services Child-Related Incident Management Directorate we recommend below. We have been told the intention is for the Child Safety and Wellbeing Service to ‘work closely’ with the Statewide Complaints Oversight Unit.334

1. Incident Management Directorate

In Chapter 6 on our recommendations for the way forward for children in schools, we describe the findings of the 2014 South Australian Report of the Independent Education Inquiry led by the Honourable Bruce Debelle AO KC (and often referred to as ‘the Debelle Report’). The South Australian Government commissioned this Inquiry in response to the handling of an incident of child sexual abuse at a local school.335 While this report was prepared with education settings in mind, it provides useful guidance to all organisations on how to respond effectively to complaints and incidents of child sexual abuse, including health services.

As part of implementing the Debelle Report, investigations into child sexual abuse in South Australian schools are now managed by a specialised Incident Management Directorate.336 The South Australian Education Department has published guidelines that outline in some detail the steps to take after receiving a complaint of sexual misconduct against a staff member.337 There is also a clear procedure for public disclosure processes when a staff member has been charged with child sexual abuse offences.

The Department should draw on insight from the Debelle Report when establishing the Health Services Child-Related Incident Management Directorate and associated policies on mandatory and voluntary reporting obligations, open disclosure processes and a critical incident response plan (refer to Recommendations 15.12, 15.18 and 15.19).

We recognise that there may be features of the health service environment that call for a tailored approach in responding to and investigating complaints. An understanding of the health care context (and sometimes specialised clinical knowledge) may be required to consider and investigate complaints of child sexual abuse effectively, particularly where conduct occurs under the guise of a medical procedure or nursing care. For this reason, we do not specifically recommend that complaints about grooming, child sexual abuse and other related harms to children in health services be considered by the Child-Related Incident Management Directorate that we recommend be set up in Chapter 6. Rather, we consider the Tasmanian Government should consider the most appropriate model for managing complaints of this nature against health workers. This could occur by the Tasmanian Government electing to partner with the Child-Related Incident Management Directorate and ensuring the Directorate has access to specialist skills and knowledge relating to complaints in a health services context when required. Alternatively, the Tasmanian Government may decide a separate Health Services Child-Related Incident Management Directorate is needed. If this is the case, it should be structured and operate consistently with the approach we recommend for the Child-Related Incident Management Directorate, including having three arms of responsibility—for incident report management (including complaints and case management), investigations, and misconduct and disciplinary advice respectively. We briefly summarise these functions below, but further detail can be found in Chapter 6.

We recommend an incident report management arm, which would assess and triage the complaint or concern and determine how it should be managed, including whether a formal investigation is necessary. Any conflicts of interest that may arise in this process should be promptly identified, documented and dealt with. This arm of the Directorate should also:

• ensure compliance with the policy on responding to concerns and complaints about child safety issues and staff conduct
• ensure staff have made appropriate notifications to agencies including Ahpra and the National Boards, Tasmania Police, Child Safety Services and the Registrar of the Registration to Work with Vulnerable People Scheme and the Independent Regulator of the Reportable Conduct Scheme, and act as liaison for these agencies regarding the complaint (such liaison must include seeking confirmation with agencies about whether and when the Department can initiate an investigation without compromising parallel criminal or regulatory investigations)
• ensure other agencies involved in a complaint about staff behaviour towards children (such as the new Commission for Children and Young People, the Health Complaints Commissioner or the Integrity Commission) receive any information they need to acquit their functions
• provide support and guidance, including through fit-for-purpose case management, to the relevant health service about: how any potential risks to patients can be managed while a complaint or concern is investigated; what information should be provided to different audiences (staff, patients and their families and the community) and when; ensuring affected children and young people (and their families and carers) are updated on the status of any complaint, receive appropriate support and can continue to safely receive the health care they need
• ensure all records about the complaint (and the staff member) are comprehensive, accurate and stored in incident management (such as the Safety Reporting and Learning System) and human resources systems.

Rather than human resources staff, the investigations arm of the Directorate should conduct or oversee investigations where sexual misconduct and professional boundary breaches related to children are alleged. Although the human resources team will not have a role in managing and investigating such matters, as noted above, we consider that human resources staff should be familiar with child safety policies so they can ensure any child safety concerns are appropriately responded to and referred when they arise.

Investigations of complaints should be undertaken by independent investigators who are trained and skilled in child development, child sexual abuse and trauma-related behaviours, and in interviewing vulnerable witnesses. Wherever possible, investigators should have knowledge and experience of the health services context.

Investigations should include the following processes:

• Complainants, their families and key witnesses should be invited to provide evidence or information if they choose to do so. If a decision is made to not contact a complainant or key witness, this should be explained and justified to the decision-maker (Head of Agency).
• Investigators should have access to the specialised and independent clinical knowledge or expert opinion required if a staff member argues that the behaviour subject to a complaint was legitimate clinical care.
• Once started, investigations should be undertaken promptly, and a clear and evidence-based report provided to legally trained adjudicators, who should then make recommendations to the relevant decision-maker (Head of Agency).

We consider some form of investigation should occur even if a staff member leaves the State Service. This investigation would need to determine the full extent of any possible open disclosure or mandatory reporting obligations and identify any necessary system improvements.

The misconduct and disciplinary advice arm should comprise staff who are trained to weigh evidence and assess compliance with procedural fairness requirements. Where a breach of the professional conduct policy, the State Service Code of Conduct or another associated departmental policy is found, this should be outlined in an investigation report provided to the Head of Agency, alongside any advice and recommendations.

Recommendation 15.17

1. The Department of Health should establish a separate Health Services Child-Related Incident Management Directorate or partner with the Child-Related Incident Management Directorate (Recommendation 6.6) to respond to allegations of child sexual abuse and related conduct by staff, breaches of the State Service Code of Conduct and professional conduct policies, and reportable conduct (as defined by the Child and Youth Safe Organisations Act 2023) in health services.
2. If the Department partners with the Child-Related Incident Management Directorate, it should ensure the directorate has access to specialised advice to inform investigations against health services staff, particularly where allegations have arisen in the context of provision of health care.
3. If the Department establishes a new Health Services Child-Related Incident Management Directorate, it should mirror the functions and manner of operation reflected in the Child-Related Incident Management Directorate, including having three distinct roles and skill sets covering incident response management, investigations, and misconduct and disciplinary advice.

1. Communicating with and supporting victim-survivors

A key element of an organisation’s response to child sexual abuse is communicating with and supporting victim-survivors, their families and carers, and others affected by the abuse.

1. An effective open disclosure process

Under the National Standards, health services must implement a framework of open disclosure with patients, family members and carers in relation to critical incidents that occur in their health service and result in harm to a patient.338

An open disclosure process involves an honest discussion with a patient or carer ‘about an incident that resulted in harm to the patient while receiving health care’.339

Adjunct Professor Picone told us that the key elements of an open disclosure process are:

1. an apology or expression of regret, which should include the words ‘I am sorry’ or ‘we are sorry’
2. a factual explanation of what happened
3. an opportunity for the patient, their family and carers to relay their experience
4. a discussion of the potential consequences of the adverse event
5. an explanation of the steps being taken to manage the event and prevent recurrence.340

Adjunct Professor Picone also told us that the principles of open disclosure can be applied at the broader community level. In such circumstances, the principles are:

1. being open and honest about the fact that an incident has occurred
2. admitting fault for the error or set of circumstances as appropriate
3. making a very genuine apology to the affected persons and community
4. identifying what has been learnt from the error
5. advising the community about what is being done or will be done to address the problem
6. demonstrating to the community that the organisation is following through with its promises.341

We discuss how open disclosure can be applied at the community level in more detail below (refer to Section 5).

Adjunct Professor Picone said a health service cannot promise an incident will never happen again, but the community needs to see that it is working to resolve issues and is taking steps to prevent recurrence.342

The Debelle Report discussed the concept of ‘responsible disclosure’ for schools managing child sexual abuse allegations. It described responsible disclosure as providing factual information, at an appropriate time, to the various people who have been or may be affected by an event.343 It notes that providing information after a critical incident or other crisis helps parents (in particular) to maintain their confidence in the institution. Such confidence can be ‘greatly undermined’ if important information is instead learned through the media.344

There was little evidence that the response of Launceston General Hospital to victim-survivors or potential victim-survivors of Mr Griffin’s abuse followed best practice. Conversely, there was much evidence that the hospital attempted to manage the revelations of Mr Griffin’s offending by restricting communication and the information provided to victim-survivors, former patients, and their families and carers.

Many of the elements of open disclosure (listed above) were missing from Launceston General Hospital’s response to the community in 2019, 2020 and thereafter. It was only at our hearings that Mr Daniels, former Chief Executive of Hospitals North/North West, showed some empathy and understanding for the scale of suffering that had occurred at the hospital.345

Secretary Morgan-Wicks issued a public apology to victim-survivors, validating a widespread feeling that the Department and Launceston General Hospital had not reckoned with the scale of suffering:

I am personally horrified by the lack of empathy, humanity and often a lack of trauma-informed approach by the Department and the Tasmanian Health Service to such devastating accounts of abuse from the victim-survivors who have shown immense courage to come forward.346

We consider that supports such as counselling should always be offered to patients and their families and carers as part of the open disclosure process.347 People looking for support should be personally assisted to access this support rather than just provided with information about how to seek support themselves (that is, they should be provided with a warm referral to a service).

Recommendation 15.18

The Department of Health should ensure open disclosure processes for patients who experience child sexual abuse in health services and their families and carers that:

1. create a safe, trauma-informed pathway for victim-survivors, or others affected by an event, to receive clear and personalised information in response to their questions or concerns
2. facilitate appropriate notifications including to Tasmania Police, Child Safety Services, the Registrar of the Registration to Work with Vulnerable People Scheme, the Independent Regulator under the Child and Youth Safe Organisations Act 2023 and the Australian Health Practitioner Regulation Agency
3. make appropriate supports available to affected people, including victim-survivors, their immediate family and carers, where abuse is connected to the Department’s health services, including warm referrals, with the person’s consent, to trained and experienced child sexual abuse counsellors.

1. Developing and implementing a critical incident response plan

Child sexual abuse in an institution can trigger a trauma event felt by many.348
The implications of this are discussed in Section 5. The sexual abuse of a child in a health service, particularly by a staff member who has worked in the service for a long time, can also be described as a critical incident for the purposes of workplace policies, procedures and protocols.

It is not uncommon for institutions to be unprepared and unsure about what to do when a critical incident occurs in the workplace.349 Dr Kate Brady, Research Fellow, Community Resilience, Melbourne School of Population and Global Health, University of Melbourne, told us that those tasked with managing recovery following a critical incident may not be trained in crisis management and often do not have the skill set required to respond appropriately.350 Dr Peter Rob Gordon OAM, a clinical psychologist specialising in trauma, emergencies and disasters, explained that a disturbing, tense and threatening event will place a person in a state of ‘high arousal’.351 When those responding to a critical incident enter a ‘high arousal state’ it can limit their ability to look at what has occurred systematically and morally, resulting in poor decision making.352 He said that those tasked with responding may focus on strategies to limit liability, such as forbidding or inhibiting communication outside the institution, and not acknowledging what has happened or not apologising to those involved.353

The behaviours described by Dr Gordon were apparent in Launceston General Hospital’s response to revelations about Mr Griffin. It is our view that the sheer scale of events connected to Mr Griffin overwhelmed the hospital’s executive and management. We heard that managers did not feel equipped or supported to respond to these events. While some senior staff, such as Dr Renshaw, had previously confronted matters of child sexual abuse in their careers (for example, in response to Dr Tim), for most staff it was the first time they had to respond to such a crisis. Helen Bryan, former Executive Director of Nursing, Tasmanian Health Service North, told us that, while she did not agree that there was a lack of urgency from senior management in response to this critical incident, ‘this was an incident or allegations that none of us had ever had to manage, experience, and we were navigating through an area that we were not familiar with’.354 Sonja Leonard, former Nurse Unit Manager, Ward 4K, Launceston General Hospital similarly reflected that ‘we were all in very uncharted waters and didn’t have any knowledge, or experience, or training in how to deal with this’.355

In response to a question from Counsel Assisting our Inquiry about whether management could have done more to ensure greater transparency in the hospital’s response, Janette Tonks, former Nursing and Midwifery Director, Women’s and Children’s Services, Launceston General Hospital said the following:

Yes … but I also need to acknowledge that we were navigating an issue that— that most of us had never travelled before. We also had been traumatised and significantly affected by the events that had occurred. I think that everything we did was in good faith, we did what we thought at the time was in the best interest of the staff, as well as maintaining the police request about their investigation.

It was extremely difficult to know what was the right thing and what was the wrong thing; there isn’t actually a rule book around how you navigate through this particular type of issue.356

We heard expert evidence that poor responses to critical incidents can be averted by developing a clear and considered critical incident response plan that leaders can refer to in unprecedented or unanticipated situations. Dr Gordon told us that while health services may have policies, procedures and protocols in place to guide responses to critical incidents such as natural disasters, they are less likely to have explicit policies designed to promote recovery following human-caused traumatic events (that is, intentional acts at the hands of humans such as deliberate negligence or criminal offending) including child sexual abuse by a member of staff.357 However, he indicated that policies that respond to these types of events can be developed.

In Chapter 14, Case study 3, relating to James Griffin, we find the lack of a coordinated and transparent response by Launceston General Hospital increased feelings of mistrust among hospital staff. Neither the Department nor Launceston General Hospital appear to have had a critical incident response plan in place at the time that Mr Griffin’s offending became widely known. However, Mr Daniels indicated that the hospital had started work on critical incident stress management processes for staff and the community in response to the Hillcrest School tragedy, which occurred in December 2021.358 Mr Daniels indicated that critical incident stress management processes could also apply in circumstances such as those involving Mr Griffin.359

In February 2023, Secretary Morgan-Wicks told us that a department-wide ‘Critical Incident Response Protocol’ would be developed as part of the One Health Culture Strategy 2022–2027.360 She said that the Critical Incident Response Protocol ‘will align with the [Department’s] overarching Health and Wellbeing program to provide guidance on what support is available, how it is arranged and monitored’.361

In our view, the Critical Incident Response Protocol should go further, acknowledging that it is currently under development.362 Dr Brady told us that a critical incident response plan should draw on Australia’s nationally endorsed principles for disaster recovery, which promote community care through psychological first aid.363 The principles were developed by the Social Recovery Reference Group Australia and are available on the Australian Institute for Disaster Resilience’s website.364 They are: understanding the context; recognising the complexity; use community-led approaches; coordinate all approaches; communicate effectively; and recognise and build capacity.365

Dr Brady also highlighted the importance of good communication after collective trauma events, which typically requires regularly communicating with those affected about what is known, what is not known, what is being done and what people can do to help.366

Dr Gordon told us it is crucial that those responding to critical incidents seek assistance from people who are external to the institution and its associated organisations to support clear thinking and to form appropriate responses.367

Those responsible for responding to critical incidents in health services should have clear policies, procedures and protocols to support their decision making. These policies, procedures and protocols should outline the key steps to take in communicating with and supporting those affected by the incident.368 We consider that other Tasmanian Government departments should also review whether they have appropriate policies, procedures and protocols in place.

Recommendation 15.19

The Department of Health should develop and implement a critical incident response plan for human-caused traumatic events where numerous staff and patients are affected, including serious child-related incidents. The response plan should:

1. identify who is responsible for leading the response to a critical incident and set out the applicable reporting arrangements
2. identify the steps to responding to a human-caused traumatic event (including incidents relating to child safety)
3. provide for external assistance from experts with training and expertise in crisis management
4. be based on best practice responses to traumatic events
5. provide for early communication of information about the event
6. provide psychological first aid to affected people
7. provide extra support from skilled psychologists on an ‘as needed’ basis to affected people
8. provide for information about other support services that can assist affected people
9. facilitate communication and support among affected people as a means of social support
10. provide for critical incident debriefing run by a neutral and trained expert where appropriate
11. provide for a review of the Department’s response to the critical incident
12. provide for an evaluation of any actions to be implemented as part of the Department’s response to the critical incident
13. provide for any lessons from a review or an evaluation of the Department’s response to the critical incident, to be shared with the Secretaries Board to further inform responses to critical incidents across the whole of government.

1. Restoring trust

The Launceston community has been profoundly affected by child sexual abuse at Launceston General Hospital and how that abuse was managed. These impacts are manifest in submissions, witness testimony, sessions with a Commissioner and consultations.

There has been a significant and long-term loss of trust in health workers among some in the Launceston community, with some parents avoiding taking their children to Launceston General Hospital and some victim-survivors refusing health care because they feel unsafe in health services. Where victim-survivors have sought health care at Launceston General Hospital, many described the feelings associated with their past experiences of abuse being reactivated, which hospital staff were often not well equipped to mitigate. This is a significant public health concern.

A lack of consistent and transparent information from a health service about what is being done in the wake of child sexual abuse revelations can serve to create an information vacuum. In the case of Mr Griffin, insufficient communication by Launceston General Hospital—with victim-survivors, their families and carers, former patients, staff and the broader community—led to various theories and rumours, some of which were well founded and others that we have not been able to substantiate. More generally, the hospital’s approach invited suspicion that it was, above all,
trying to protect its reputation.

As already noted, Dr Brady told us that child sexual abuse (particularly on this scale) can become a collective trauma event requiring a response that promotes community care and the restoration of trust using principles of disaster recovery.369 While it is always best to adopt this approach as quickly as possible after an event, experts assured us that it is never too late to start responding in ways that help a community to heal and regain trust.

Shortly after our first week of hearings relevant to Launceston General Hospital in June 2022, the Department took steps to address some of the issues that emerged from these hearings. These steps included conducting the Child Safe Governance Review and the Community Recovery Initiative. On 8 November 2022, the Tasmanian Parliament apologised to all victim-survivors of child sexual abuse in Tasmanian Government institutions, including those connected with Launceston General Hospital.370 These responses reflect a start, rather than an acquittal, of what is required to
re-establish trust and goodwill in the Northern Tasmanian community.

The public release of our final report, which includes a range of information that has not yet been made public, may have a further unsettling effect on the community and will require a thoughtful and nuanced response from the hospital and the Department.
There is a long road ahead.

In this section, we provide a summary of the evidence we heard from victim-survivors, their families and hospital staff about the loss of trust they have experienced following Launceston General Hospital’s response to child sexual abuse, particularly the response to the 2019 revelations about Mr Griffin’s offending.

We then consider the response of the hospital and the Department to this loss of trust and some of the Department’s efforts towards restoring community trust in Launceston General Hospital and public health services more generally.

We recommend that Launceston General Hospital and Tasmania Police assist victim-survivors of child sexual abuse at the hospital on an ongoing basis.

1. The loss of trust

This section describes some of what we heard from victim-survivors, their families and supporters about the effects on them of alleged abuse at Launceston General Hospital, including how these events have impacted their overall trust in health services. We also describe some of what we heard about the psychological toll on staff at Launceston General Hospital following the hospital’s manifestly deficient approach to responding to disclosures of abuse.

1. Victim-survivors’ loss of trust in the health system and particularly Launceston General Hospital

Several witnesses described to us the trust that they placed in health workers to care for their children. For example, Kim (a pseudonym), whose daughter Paula (a pseudonym), was nursed by Mr Griffin at Launceston General Hospital, told us: ‘We trusted the doctors and nurses, we trusted our children to LGH when they were at their most vulnerable’.371

Those whose trust has been undermined described an ongoing wariness and, at times, fear about seeking health care, particularly for their children.372

Several victim-survivors who experienced Mr Griffin’s abuse also told us that their abuse had made them reluctant to seek health care for themselves or their children. One person who had experienced abuse by Mr Griffin said: ‘I still feel uncomfortable going to LGH and hospitals in general because of what happened’.373 Another victim-survivor said: ‘Ever since the abuse, I have avoided hospitals and where I have required admission, I have discharged myself shortly after admission. I feel panic when I go near hospitals’.374 Keelie McMahon, who also experienced abuse by Mr Griffin outside of the hospital, said: ‘I shouldn’t be putting my children’s health on the line purely because I can’t step foot in that hospital’.375

Michelle Nicholson, a community health social worker, suggested that the reluctance to access health services, as described by some of the witnesses to our Inquiry, is widespread. She told us that it was not uncommon for her clients to avoid seeking health care due to their past experiences.376

The effects of breaches of trust by health workers can also extend to other care arrangements. One family that participated in Launceston General Hospital’s open disclosure process after their child (who has a disability) was identified in photographs found in Mr Griffin’s possession, said:

The long-term impact this has had on our family is significant. Our trust in others to care for [our child] is now very limited. We cannot bring ourselves to arrange overnight respite in supported accommodation facilities, even though we have been advised by other parents that the care is very good.377

We heard that mistrust in Launceston General Hospital has also resulted in people seeking care outside the region. Angela (a pseudonym) told us that she prefers to travel to Hobart to seek health care for her daughter (who has cerebral palsy) after receiving no response from Launceston General Hospital to a complaint she made about the care her daughter was receiving from nurses on Ward 4K, including Mr Griffin.378 Angelique Knight, a former Ward 4K patient, told us that she, too, attends another hospital whenever possible. She said ‘sometimes because of the complexities of my condition they send me to LGH. I dread going there every time’.379

Another victim-survivor who experienced abuse by Mr Griffin described going to significant lengths to avoid Tasmanian health services when her children need care.
She said: ‘When my children have had medical issues and a choice has existed around their treatment, I have made the decision to take them out of the state for treatment’.380

We heard from several witnesses that they avoid Launceston General Hospital because being there triggers the trauma of their abuse or otherwise makes them feel unsafe.381

One victim-survivor of Mr Griffin stated: ‘My son was in hospital recently. I wanted to stay with him but felt unsafe being by myself. Hospital staff did not let my partner stay with me. This response failed to cater to my needs associated with the trauma of the abuse’.382

The Child Safe Governance Review reported that ‘[s]ome survivors perceived staff interactions with them, albeit well intentioned, as making them feel treated as “victims” in a notorious case of serial child abuse rather than as members of the community attending for health care’.383

While acknowledging these experiences and the importance of providing trauma-informed care to victim-survivors, Ms Nicholson advocated for individual hospital staff to not be left navigating responses to intergenerational trauma caused by sexual abuse. She said:

… by and large the vast majority of health workers are doing the best they can in difficult and challenging understaffed circumstances where they are not provided with the necessary trauma informed care training … While on the surface it may look like people are failing to do their duty of care to survivors of historical trauma and children, I believe it is mainly not individuals but a flawed system that is the problem.384

The report of the Child Safe Governance Review, reflecting the views of the Lived Experience Expert Reference Group, states that any patient may have experienced prior trauma and therefore all patients should enjoy a level of care and sensitivity based on that assumption. We recommend in Chapter 19 that the Tasmanian Government should develop a whole of government approach to professional development in responding to trauma within government and government funded agencies that provide services to children, as well as statutory bodies that have contact with child sexual abuse victim-survivors (refer to Recommendation 19.2).

1. Loss of trust among Launceston General Hospital staff

Former and current Launceston General Hospital staff spoke to us about how the mismanagement of allegations of child sexual abuse at the hospital had affected them.

Maria Unwin, a former Ward 4K nurse, recalled that when she joined Launceston General Hospital in 1993, a colleague told her that a nurse had been caught in the act of sexually abusing a child on the ward during night shift. Ms Unwin stated:

It was clear that when I started at the hospital some staff were still traumatised by this incident and how it had been handled. When it was discussed you could sense a level of fear from the people who were talking about it … When I heard the allegations I was shocked and felt sick. 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 it would be covered up. I would never have expected this to be happening at the hospital in the 1990s.385

Kylee Pearn, a former hospital employee, told us that when Mr Griffin was allowed to remain on Ward 4K after she disclosed to human resources staff, in 2011 or 2012, that he had sexually abused her as a child, she ‘couldn’t cope’.386 She left her social work role at the hospital and moved to a new role in a school.387

Annette Whitemore, a former Ward 4K nurse told us that the hospital’s response to allegations against Mr Griffin contributed to her resigning from Ward 4K.388

We also heard that some staff were reluctant to seek health care from Launceston General Hospital because of the hospital’s failure to effectively respond to allegations of sexual abuse against young patients.389

1. Launceston General Hospital’s response to loss of trust

As outlined in Chapter 14, Case study 3, Launceston General Hospital offered open disclosure to some patients who were identified in photographs found in Mr Griffin’s possession. The one family that took part in the open disclosure process expressed concerns about how this process was conducted, in particular:

• hearing about Mr Griffin’s offending through a voice message left on their phone while they were at work
• whether they were told the truth that previous concerns raised with the hospital about Mr Griffin were not of a sexual nature
• not being offered counselling or follow-up support from Tasmania Police or the hospital.

The absence of clear communication from the hospital about the photographs found in Mr Griffin’s possession has also left some former patients, and their families, wondering if the patients may have been in the cache of images seized by Tasmania Police.

As discussed in Chapter 14, Case study 3, after hearing details of Mr Griffin’s offending on The Nurse podcast, Ms Knight recalled asking the hospital whether any of the photos found were of her and whether she could see them.390 The hospital told her that only one patient had been identified from the photos.391 Ms Knight said that the hospital ‘did not explain the process that led to this identification or explain why I couldn’t see [the photos] myself’.392 She went on to explain:

I don’t know if James Griffin did take photos of me and that bothers me. He had plenty of opportunity. I showered in front of him. I was naked in his presence. If there were photos of me on his phone I would have been able to identify myself. I was really annoyed by all of this and it felt like [the hospital] was just brushing me off again. I felt like I was nothing and just a number …393

As becomes clear in Chapter 14, Case study 3, beyond the existence of the photographs, the hospital’s executive was denying, internally and externally, that there was any connection between Mr Griffin’s offending and hospital patients. This denial continued until our hearings when the extent of complaints against Mr Griffin and the experiences of former patients became more broadly known.394

Dr Renshaw, who was involved in the response to revelations about Mr Griffin,
told us that he had turned his mind to communicating more broadly with potential victims, however:

I considered the logistics of doing a mail-out to the families of every paediatric patient of the LGH over the previous 15 or so years were well beyond the resources available within the LGH. It was also a factor that there were periods when Griffin was not working at the LGH. I did consider approaching patients and their families who had been inpatients for longer than a specified period of time (for example, over a week or over a month) as being more likely to have been victims of Griffin. However, there was also the potential with such a blanket approach to cause unnecessary distress and anxiety to families whose children had no contact at all with Griffin during their hospital stay.395

As set out in Chapter 14, Case study 3, we also heard that some victim-survivors who contacted the hospital were given generic lists of phone numbers for psychological support.396 While such resources can be useful, simply providing contact details for support services is not an appropriate response from an institution that has a duty to protect patients from harm.

We invited the leadership of Launceston General Hospital to reflect on what could be done to restore the trust of victim-survivors and staff of the hospital. Unfortunately, the responses we received suggested that restoring trust had not been the subject of any deep thought or reflection. Where suggestions were made, they tended to be superficial.397

It was clear to us that the hospital’s leadership lacked a meaningful understanding of the impact that Mr Griffin’s offending has had on victim-survivors, staff and the broader community, and that the leadership has failed to grasp the extent of the work required to restore trust. The hospital’s leadership provided no evidence to suggest any insight that acknowledging the extent of Mr Griffin’s offending, and providing information about how such offending continued for many years, are essential to restoring trust. We hope that our Commission of Inquiry and final report will provide some of these answers.

We accept that, due to poor records, failed memories, the absence of any witnesses and the reality that the full extent of Mr Griffin’s abuse is unlikely to ever be known, Launceston General Hospital will not be able to answer every question and reassure every individual. However, the hospital has an obligation to do what it can to provide some clarity and closure to those who remain distressed or concerned about the implications of Mr Griffin’s offending.

Launceston General Hospital’s response to victim-survivors, their families and carers, staff and the broader community must not be a bureaucratic exercise. The hospital must consider the needs of known and as yet unknown victim-survivors and, as we recommend above (refer to Recommendation 15.18), make appropriate supports available to affected people including victim-survivors and their immediate family and carers, including warm referrals to trained and experienced child sexual abuse counsellors.

We consider that Launceston General Hospital and Tasmania Police have an ongoing obligation to help identify victim-survivors of Mr Griffin when requests emerge, or, if this is not feasible, to clearly explain why. We are aware that other jurisdictions are using advances in technology to identify victim-survivors in child sexual exploitation material.398

We also consider that any communications with the broader community following an incident, such as the potential sexual abuse of patients by a staff member at a hospital, should be informed by the principles of open disclosure applied at the community level, which we have outlined earlier (refer to Section 4.3).

Recommendation 15.20

1. The Department of Health, Launceston General Hospital and Tasmania Police should make clear that they will continue to assist, on an ongoing basis, known and as yet unknown victim-survivors of child sexual abuse by James Griffin related to the hospital and should nominate a contact person for people who have enquiries.
2. Assistance should include:
   1. outlining what is known about Mr Griffin’s offending at the hospital
   2. taking steps to ascertain whether a person is or may be a victim-survivor of Mr Griffin’s offending or clearly explaining why this cannot be done.
3. The Department and Launceston General Hospital’s communications with known and as yet unknown victim-survivors of Mr Griffin and their families and carers and the broader community should be informed by the principles of open disclosure.
4. Launceston General Hospital should ensure victim-survivors and their families and carers who do not receive individual open disclosure (Recommendation 15.18) still receive a warm referral to trained child sexual abuse counsellors if desired.

1. The work of oversight agencies

In Chapter 13, we provided a brief overview of key agencies that oversee aspects of Tasmania’s health system, including health practitioners and health services. These agencies include Ahpra, the National Boards and the Health Complaints Commissioner. A core role of these agencies is ensuring the safety of children and young people who receive health care.

In this section, we discuss the role of each agency and make observations about how these agencies might be made more effective in helping to protect the safety of children. In relation to Ahpra and the National Boards, we highlight a general lack of community awareness of their roles and functions. We consider that the recommendations we make above will address concerns about ensuring consistent information is provided to patients, including age-appropriate resources for children and young people and their families and carers (Recommendation 15.8), ensuring there are up-to-date policies on mandatory and voluntary reporting obligations, including for concerns about staff conduct (Recommendation 15.12), developing of a professional conduct policy for staff who have contact with children and young people in health services (Recommendation 15.13) and strengthening professional development around child safety for different levels of staff (Recommendation 15.15).

In relation to the Health Complaints Commissioner, we highlight problems in its ability to fully perform its role and functions, and identify possible areas of improvement. We do not make recommendations about these improvements because we consider the new Commission for Children and Young People that we recommend be established (refer to Chapter 18) will be the peak oversight body responding to concerns about children and young people. We do, however, recommend a review of the Health Complaints Act to consider some of the problems we discuss.

1. Ahpra and the National Boards

Ahpra is the agency that administers the National Registration and Accreditation Scheme for health practitioners in Australia. It also provides administrative support to 15 National Boards, which carry out a range of functions for overseeing health practitioners registered across 16 health professions under the National Law.

1. Codes of conduct

Staff who are registered under one of the health professions recognised by the National Law must follow codes of conduct established by their respective National Board. These codes offer guidance on the expected standards of conduct for registered health practitioners that apply to health practitioners when they are delivering care and to their behaviour outside the workplace.399 These codes require that health practitioners maintain professional boundaries with patients.400

Codes and guidelines that have been approved by the National Boards are admissible in disciplinary proceedings under the National Law. They can be used as evidence of what constitutes appropriate professional conduct or practice for a particular health profession.401

1. Notifications to Ahpra and the National Boards

The National Law provides for notifications to be made to Ahpra and the National Boards where the health, conduct or performance of a registered health practitioner poses a risk to the public.402

Registered health practitioners and their employers are mandated under the National Law to report a registered health practitioner if they form a reasonable belief that the practitioner has engaged in ‘notifiable conduct’.403 Notifiable conduct includes ‘engaging in sexual misconduct in connection with the practice of a health profession’.404 Examples of sexual misconduct include sexual activity with a current patient, making sexual remarks, touching patients in a sexual way, touching a patient in an intimate area without clinical indication and engaging in sexual behaviour in front of a patient.405

A health practitioner who forms a reasonable belief that another health practitioner has engaged in notifiable conduct and does not make a mandatory notification may be subject to regulatory action.406

In addition to mandatory notifications, any entity or person, including patients or members of the public, can make a voluntary notification about a health practitioner.407 Voluntary notifications can be made to Ahpra and the National Boards on several grounds, including that the practitioner is or may not be a suitable person to hold registration in a health profession because they are not, for example, a fit and proper person to be registered in the profession.408 A notification may also be about concerns that a practitioner’s conduct is unprofessional, unlawful or below acceptable standards.409

1. Managing notifications involving sexual misconduct

Ahpra refers notifications about health practitioners to the National Boards.410
The National Boards are empowered to take a range of steps in response to a notification, including:

• taking immediate action to stop a health practitioner from practising
• launching an investigation
• imposing registration conditions
• directing the practitioner to attend a health or performance assessment.411

Where there is enough evidence for a National Board to form a reasonable belief that child sexual abuse has occurred, the National Board will refer the matter to a responsible tribunal under the National Law.412 In Tasmania, this tribunal is the Tasmanian Civil and Administrative Tribunal.413 After considering a matter, the tribunal may make a range of orders, including cautioning or reprimanding a practitioner, imposing conditions on their registration, imposing a fine, or suspending or cancelling the practitioner’s registration.414

A strength of the National Registration and Accreditation Scheme is that it hosts a single database of all notifications and complaints made about registered health practitioners in Australia.415 The national database records all notifications about registered health practitioners since the National Law began, irrespective of whether the notification was made to a National Board or to another health complaints entity (such as the Tasmanian Health Complaints Commissioner).416 The database helps in assessing future complaints about registered health practitioners by enabling patterns of behaviour that have not otherwise resulted in disciplinary action to be identified—for example, repeated concerns about boundary violations.417

It is important for health services to have clear systems and processes in place that inform and guide staff about reporting to Ahpra and the National Boards.

1. Awareness of Ahpra and the National Boards

Despite Ahpra and the National Board’s role in managing notifications about health practitioners, we identified through our Inquiry that staff, former patients and the community are not aware of their regulatory functions, nor of their ability and,
in some cases, obligation, to make notifications to Ahpra and the National Boards under the National Law. In Chapter 14, Case study 3, relating to James Griffin, we find that Launceston General Hospital had no clear system, procedures or process in place to report complaints about James Griffin to external agencies.

In relation to staff at Launceston General Hospital, Ms Unwin told us that although she was aware of the obligation to report suspected abuse including mandatory reporting under child safety legislation, she had ‘always been led to believe that evidence was required to make a complaint’.418 She said it was not until 2020 that she became aware that she could have made a complaint to the former Tasmanian Nursing Board or Ahpra about Mr Griffin based on her concerns alone.419

Similarly, another former Ward 4K nurse, Annette Whitemore, said: ‘We all knew we were mandatory reporters, and I don’t think we were deliberately not told this, but until 2019 when all this happened … I never knew I could go straight to Ahpra’.420 Will Gordon, Ward 4K nurse, told us that most nurses on Ward 4K did not realise they could report their colleagues to Ahpra.421 He said: ‘We just didn’t know, we weren’t told about it, there was no education about that sort of complaint process’.422

Dr Renshaw agreed that ‘it was clear’ staff at Launceston General Hospital were not aware of their mandatory reporting obligations under the National Law.423 He confirmed that prior to the public revelation of events involving Mr Griffin, there was no training provided to staff about the National Law.424

In a statement to us, Matthew Hardy, National Director, Notifications, Ahpra, said:

Information in relation to a health practitioner’s mandatory notification obligations is widely available for health practitioners, and I would expect that registered health practitioners take reasonable steps to undertake self-directed learning to stay current with changes in their profession. Specifically, I would expect that health practitioners and students undertake a degree of training by employers or other entities, with that education supplemented by self-directed learning, including in relation to mandatory notification obligations established by their respective National Board or otherwise as published on Ahpra’s website. National Boards mandate participation in annual Continuing Professional Development to facilitate this ongoing professional learning and development process.425

In relation to awareness of Ahpra and the National Boards among patients and the community, Ms Knight, a former Ward 4K patient, told us: ‘I have never
heard of the Australian Health Practitioner Regulation [Agency], even though I’ve
spent so much of my life in hospitals’.426 Another witness and victim-survivor said she ‘wasn’t aware of the existence of Ahpra as an independent body’ and, in their experience, ‘people generally aren’t aware of Ahpra like they are with the Ombudsman, Teachers Registration Board or the Integrity Commission’.427 They said that had they known about Ahpra, they would have contacted the agency about Mr Griffin at the earliest opportunity.428

Secretary Morgan-Wicks described the Department’s promotion of Ahpra and the National Boards’ notification processes to patients as ‘limited’, adding that information is ‘more likely’ to be provided once a complaint is received.429

Mr Hardy told us that it was his expectation that ‘health consumers and the general public are aware of the existence of health professional regulation in Australia and that there are mechanisms by which complaints can be made’.430 He said health consumers and the public can access Ahpra and the National Boards’ websites, which provide information on ‘accreditation, registration and notification systems’.431

We consider that more must be done to raise awareness about the role of Ahpra
and the National Boards among health workers, patients and the broader community.
Mr Hardy agreed that although Ahpra does not have a legislated educative role,
as a model regulator, the organisation does have ‘an obligation to make sure that our practitioners are educated, that we engage with employers of those practitioners and that the community is aware of who we are and what we do’.432

Our Commission of Inquiry’s mandate does not extend to making recommendations to Ahpra or the National Boards. However, we hope that they increase their educational activities, particularly in relation to the ability of any member of the public to report concerns about the conduct of health practitioners.

The Department should ensure staff who are registered health practitioners are aware of their obligations under the National Law. This can be achieved through professional development and by implementing policies that outline what staff should do when they have concerns about a colleague who is a registered health practitioner. We make recommendations above about ensuring there are up-to-date policies on mandatory and voluntary reporting obligations, including for concerns about staff conduct, as well as strengthened professional development on child safety for different levels of staff (refer to Recommendations 15.12 and 15.15).

The Department can also play a role in increasing patient awareness of their rights to make a notification about a health practitioner to Ahpra and the National Boards by including this information in any documentation they produce about patients’ rights and expectations. We make a recommendation above about ensuring consistent information is provided to patients, including age-appropriate resources for children and young people and their families (refer to Recommendation 15.8).

1. Health Complaints Commissioner

In Chapter 13, we briefly discuss the role of the Health Complaints Commissioner under the Health Complaints Act. Richard Connock is the current Health Complaints Commissioner. Mr Connock is also the Tasmanian Ombudsman.

Mr Connock leads the Office of the Ombudsman and Health Complaints Commissioner. Together, these offices cover six separate jurisdictions—those of the Parliamentary Ombudsman, the Health Complaints Commissioner, the Energy Ombudsman, Right to Information, the Official Visitors Programs and the Custodial Inspectorate.
Mr Connock referred to his Right to Information role as a ‘de-facto’ role.433

The relevant key functions of the Health Complaints Commissioner are:

• receiving, assessing and resolving complaints about Tasmanian health service providers in the public and private sectors
• inquiring into and reporting on matters related to health service providers and health services at the discretion of the Health Complaints Commissioner or at the direction of the Minister for Health.434

1. Complaints involving children and young people

The Health Complaints Commissioner can receive complaints from a parent or guardian of a child under 14 years of age, a person appointed by a child who is aged 14 years or older, or the child directly in circumstances where the Health Complaints Commissioner agrees the child is capable of lodging a complaint.435

Matters to note about the Health Complaints Commissioner’s management of complaints involving children and young people and child sexual abuse include:

• Complaints are initially referred to Tasmania Police given the behaviour is potentially criminal in nature.436
• Complaints involving a health worker who is not registered under the National Law are considered and investigated by the Health Complaints Commissioner, but the Commissioner does not yet have any powers to impose sanctions on that worker.437
• Complaints about a health practitioner registered under the National Law are referred to Ahpra and the National Boards (discussed above).438
• The Health Complaints Commissioner has a memorandum of understanding with Ahpra that requires complaints to be managed collaboratively. Where a complaint relates to a registered health practitioner and the health service they work in, the complaint can be separated, with the Health Complaints Commissioner investigating the aspects of the complaint relating to the health service to identify broader systemic issues and Ahpra investigating the aspects relating to the individual practitioner.439

While we do not consider that the Health Complaints Commissioner should be the first port of call whenever there is a complaint of child sexual abuse within a health service, the Health Complaints Commissioner plays a unique and important role in identifying systemic risks to child safety within health care settings, particularly in relation to health services that do not do enough to address poor or unprofessional staff conduct.

1. Strengthening the role of the Health Complaints Commissioner

The Health Complaints Commissioner also has an important role in informing and empowering consumers, including children and young people, with respect to their health care rights and the options available to them when they are dissatisfied with or have concerns about their health care. The community should be aware of this role and benefit from these options.

However, the Health Complaints Commissioner faces barriers in effectively performing its legislative functions including a lack of public awareness about the Health Complaints Commissioner’s role and inadequate funding.

1. The Health Complaints Commissioner’s response to child sexual abuse in health services

Complaints made to the Health Complaints Commissioner cover a broad spectrum of issues, which vary in nature and degree of seriousness.440 Mr Connock told us that although his office does not specifically monitor risks in relation to child sexual abuse, it is vigilant in responding to enquiries and complaints involving vulnerable groups and people.441 He also told us his office had not received any complaints about child sexual abuse in health services throughout the period our Commission of Inquiry is examining (that is, since 2000).442 However, his office has received complaints about the alleged sexual abuse of vulnerable adults in health services (refer to the Health Complaints Commissioner’s report into Ward 1E, which is summarised in Chapter 13).443

While the Health Complaints Commissioner would not ordinarily be the first point of contact for those affected by child sexual abuse (in a way that the police or Child Safety Services may be), the absence of any complaints about child sexual abuse is surprising, particularly given how enduring the complaints and concerns were about Mr Griffin and Launceston General Hospital’s response.

Mr Connock acknowledged that not receiving complaints about these matters means his office does not have insight into the extent of systemic issues relevant to child safety.444 He said the absence of complaints connected to child sexual abuse may be because of:

• a lack of awareness among health service users and the community in general of the role of the Health Complaints Commissioner and the Ombudsman, as well as the ability to make notifications to Ahpra and the National Boards
• the Health Complaints Act and Ombudsman Act 1978 being unable to guarantee anonymity in relation to complaints
• reluctance to make complaints due to fear of reprisals.445

1. Funding the Health Complaints Commissioner

Mr Connock told us that most of his office’s resources are dedicated to complaints handling, conciliation and resolution.446 Data shows that the number of complaints the Health Complaints Commissioner receives has increased considerably since 2019–20. Most recently, in 2021–22, the Health Complaints Commissioner received 769 complaints, up from 440 complaints in 2020–21.447 These figures do not include enquiries made or notifications received from Ahpra and the National Boards, which accounted for another 541 contacts in 2021–22 and 625 contacts in 2020–21.448

Mr Connock told us that the health complaints jurisdiction had historically been underfunded.449 A review of the Health Complaints Act, completed in 2003, identified funding as a key issue affecting the health complaints jurisdiction. The review concluded that ‘the Commissioner’s office had been under-resourced since it was first established’.450 Underfunding is also referenced across several of the Health Complaints Commissioner’s annual reports.451

Mr Connock also described to us the effects of having very few staff:

In the past, low staff numbers in the Health Complaints jurisdiction had not only an adverse impact on the time taken to resolve complaints but also, with a necessary focus on complaint resolution, resulted in an inability to perform other functions prescribed under the [Health Complaints] Act. These include things such as: education on health rights; building complaint resolution capacity in providers; auditing improvements to health services and conducting own motion investigations.452

All these functions—education on health rights, building health services’ capacity in relation to complaints handling, auditing and investigations—are important to ensuring health services protect consumers, including children.

Mr Connock told us that a lack of funding is a key barrier to his office’s ability to improve complaints handling procedures in Tasmanian health services.453 While his office provides feedback to health services about how complaints might be better handled in the course of day-to-day management of health complaints, Mr Connock explained that he has not been able to exercise his broader functions in educating health services on how to manage complaints internally because ‘we’ve got so many complaints; we’re really just dealing with those’.454 Mr Connock also indicated that there have been occasions when he would have undertaken more substantive investigations but did not have the funding and staff available to do so.455

Mr Connock told us that the Office of the Ombudsman began receiving extra three-year funding in 2021 to be spread across all six jurisdictions of the Office of the Ombudsman and Health Complaints Commissioner identified above. This was the first increase to funding the Office of the Ombudsman and Health Complaints Commissioner had received since 2014 (apart from dedicated funding for the Right to Information jurisdiction in 2019).456

Mr Connock said he was ‘hopeful’ but ‘hesitant’ to say that the increased funding, which was significant, would enable the Office of the Health Complaints Commissioner to adequately perform its legislated functions. He noted that the increased funding will ‘certainly be a vast improvement’ but ‘[the Office] will just have to see how we go’ because an increase of this scale had not occurred before.457 He did, however, indicate that the funding would ‘make a meaningful change’ to the performance of functions across all jurisdictions, including the health complaints jurisdiction.458

1. Appointing a separate Health Complaints Commissioner 

The Health Complaints Act permits a person who holds the position of Ombudsman to also be appointed to the position of Health Complaints Commissioner.459 Mr Connock was appointed to the role of Ombudsman and Health Complaints Commissioner in July 2014. He told us that, since the Office of the Health Complaints Commissioner was established in 1997, both appointments have always been held by the same appointee.460

The 2003 review of the Health Complaints Act identified distinct advantages in amalgamating review bodies. These advantages included the ability to offer the community the same range of review services present in larger jurisdictions, as well as cost savings associated with salaries, shared premises and shared administrative and infrastructure support.461

Since the review, the Ombudsman’s roles have greatly increased. Mr Connock said that with responsibilities for six jurisdictions, he only dedicates about one day a week to the performance of the Health Complaints Commissioner role.462 All other Australian states (although not territories) have appointed a separate Health Complaints Commissioner (or Director, as is the case in Western Australia).463

Mr Connock also referred to the potential for conflicts of interest to arise when the Ombudsman is investigating the administrative actions of the Health Complaints Commissioner. He said:

There have been issues recently in the past with potential conflict of interest because, as Ombudsman, Health Complaints Commissioner comes within my jurisdiction, so we have had complaints against the Health Complaints Commissioner. We’ve managed that, it’s not been— there has not been a problem, but the perception is there and the capacity for conflict.464

1. Code of conduct for unregistered health workers

Health services often employ registered and unregistered health workers.
The conduct of registered health practitioners is subject to Ahpra and National Board oversight. A National Board must refer registered health practitioners located in Tasmania to the Tasmanian Civil and Administrative Tribunal where it reasonably believes the practitioner has behaved in a way that constitutes professional misconduct.465 Our case studies primarily focused on nurses and doctors who are registered in this way.

There is currently no similar professional misconduct process for health workers in Tasmania who are not registered under the National Law.

Health workers who are not registered under the National Law include counsellors, social workers, massage therapists, dietitians, speech pathologists, naturopaths, alternative therapists, personal care attendants and pharmacy assistants.466 People in these roles often have contact, including close physical contact, with children and enjoy significant community trust. These factors can increase the risks of child sexual abuse.

A complaint can be made to the Health Complaints Commissioner about a health worker who is not registered under the National Law. The Commissioner may investigate and make recommendations in relation to such a complaint, but the Commissioner does not have any disciplinary powers to impose sanctions on the worker.467 Unregistered health workers who are employed in the State Service are subject to Employment Direction processes (discussed in Chapter 20) or may also face consequences associated with losing, or not obtaining, their registration to work with vulnerable people, including children. However, the Health Complaints Commissioner has no ability to ensure these processes are followed.468 Because unregistered health workers are not overseen by Ahpra or any National Board, there is a regulatory gap for this group.

In June 2013, at a meeting of the Commonwealth Parliamentary Standing Committee on Health, Australia’s health ministers agreed in principle to establish the National Code of Conduct for Unregistered Health Care Workers (‘the Code’).469 Drafting the Code was also agreed at a meeting of the former Council of Australian Governments’ Health Council in 2015.470 Each Australian state and territory is responsible for giving effect to the Code.471 Regimes have been introduced in New South Wales, Queensland, South Australia and Victoria.472 The Tasmanian Parliament passed amendments to the Health Complaints Act to implement the Code in 2018, but no date has been set for them to begin.473 The Health Complaints Commissioner will be responsible for administering the Code in Tasmania.474

The Code outlines minimum standards of conduct and practice for unregistered health workers who provide a health service.475 Implementation of the Code in Tasmania will allow the Health Complaints Commissioner to act against unregistered health workers who fail to comply with the standards of conduct and practice set out in the Code. The Health Complaints Commissioner will have powers to make public warning statements and publish prohibition orders in relation to unregistered health workers who have breached the Code and who pose a risk to public health and safety, including to children.476

Mr Connock told us that the administration of the Code will be different from the work his office currently undertakes.477 He described the Health Complaints Commissioner becoming ‘in effect, the equivalent of Ahpra for unregistered practitioners’ and that investigations ‘required to justify the making of prohibition orders and public statements will be more in the nature of a prosecution than an investigation’.478 In his 2021–22 annual report, Mr Connock observed that any complaints related to the Code ‘would mean an added strain on resources that are already stretched’ and require ‘extensive modifications to our case management system to accommodate workflows related to the administration of the Code’.479

1. Review of the Health Complaints Act

At the time of establishing the Health Complaints Commissioner in 1997, the role was modelled on health complaints entities in Victoria and Queensland.480 These entities focused heavily on resolving and conciliating complaints.481 Mr Connock told us that, as a result, the Health Complaints Commissioner in Tasmania has traditionally dedicated most of its time to conciliating rather than investigating complaints.482

The role of health complaints entities in other Australian jurisdictions has since evolved to become ‘more of a watchdog’ body.483 The Health Complaints Act has not, however, been reviewed or updated to reflect this more contemporary role, nor has it been substantially reviewed since the National Registration and Accreditation Scheme began in 2010.

When the Health Complaints Act first began, it contained a provision requiring the Health Complaints Commissioner to review the Act three years after its commencement and at five-year intervals thereafter.484 This provision was repealed by the Justice and Related Legislation (Miscellaneous Amendments) Act 2006.485

Mr Connock told us that the Health Complaints Act had only been the subject of one legislative review, which, as noted above, was published in 2003.486 This review resulted in 35 recommendations, including in relation to the early resolution of complaints, the Commissioner’s powers of investigations, the appointment of a separate Health Complaints Commissioner, increased responsiveness to the needs of the community and resource allocation. Most of the report’s recommendations were incorporated into the Health Complaints Amendment Act 2005.487

1. Our observations

In our view, it is unsatisfactory that the Health Complaints Commissioner appears unable to perform its legislated functions appropriately due to a lack of funding and resources.

Given what has emerged about Launceston General Hospital’s inability to respond to and manage complaints from health service users and staff in relation to child sexual abuse, there is an urgent need to resource the Health Complaints Commissioner to provide education to the community about its role and to undertake capacity-building work in health services about internal complaints management processes. The Health Complaints Commissioner must also be equipped to undertake investigations when needed. Ensuring health services are safe and trusted is an important contribution to public health objectives and will contribute to keeping children safe from harm.

The current time dedicated to performing the role of the Health Complaints Commissioner (estimated by Mr Connock as the equivalent of one day a week) is inadequate and should be increased.488 Performing the role with such little time cannot ensure sufficient oversight of the health complaints jurisdiction or the effective acquittal of the Health Complaints Commissioner’s legislated functions so far as they relate to complaints connected to child sexual abuse.

The potential for conflicts of interest to arise between the Ombudsman and the Health Complaints Commissioner in circumstances where the Ombudsman is investigating the administrative actions of the Health Complaints Commissioner is also an issue that must be addressed to ensure the community can have confidence in the exercise of functions with respect to each role. A Health Complaints Commissioner who is separate from the Ombudsman should be appointed.

A need for more funding also arises from the expected implementation of the Code of Conduct for Unregistered Health Care Workers. Implementing the Code would be a significant step to address a current gap in oversight by improving responses to the conduct of health workers who pose a risk to children and young people and who are not currently captured by existing regulatory schemes. However, implementing the Code will result in more responsibilities for the Health Complaints Commissioner and an added strain on already stretched resources. The Tasmanian Government must ensure the Health Complaints Commissioner has the resources to implement and administer the Code.

In our view, the issues we raise would be best addressed through a comprehensive review of the Health Complaints Act and the role of the Health Complaints Commissioner. We understand the Health Complaints Commissioner secured funding for a consultant to complete a review of the Act by the end of the previous financial year (2022–23).489 This review may prove a useful first step towards modernising the Act.

We consider that with the introduction of the new Commission for Children and Young People (refer to Chapter 18) and the implementation of the Reportable Conduct Scheme under the Child and Youth Safe Organisations Act (also discussed in Chapter 18), most concerns about child sexual abuse and related matters in health services will be within the jurisdiction of the new Commission for Children and Young People. We view this new Commission as the primary oversight body for the safety of children and young people in Tasmania. We also consider professional regulation of unregistered health workers a priority because they are a cohort that often provides services to children.

Recommendation 15.21

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:

1. addressing systemic issues within health services related to child safety
2. incorporating the administration, monitoring and oversight of the Code of Conduct for Unregistered Health Care Workers
3. coordinating with the role of the new Commission for Children and Young People (Recommendation 18.6), and the Independent Regulator under the Child and Youth Safe Organisations Act 2023.

1. Conclusion

The case studies our Commission of Inquiry considered make clear the enormous suffering caused to victim-survivors, their families and staff, as well as the far-reaching adverse impacts on the broader community and the health system overall, when health services fail to:

• appreciate the risks of abuse to children and young people
• prioritise the safety and wellbeing of children and young people
• respond appropriately to risks and disclosures of harm.

The recommendations we outline in this chapter, and the reforms the Department has recently adopted, represent the beginning, not the end, of the Department’s efforts to safeguard children and young people in health services. Keeping children and young people safe is not a one-off endeavour, but a process of continuous improvement that must be informed by children and young people, victim-survivors, independent experts and health workers, including those who have worked tirelessly to advocate for children’s safety. Current and future leaders and senior managers at the Department and Launceston General Hospital must be up to this task.

We wish to emphasise that all Tasmanian health services, not just Launceston General Hospital, should reflect on their own child safe practices and closely consider the findings and recommendations in this volume. The issues identified at Launceston General Hospital can, and no doubt do, occur in other health services. We would like all health services to benefit from implementing our recommendations.

We once again recognise the hard-working people in Tasmania’s health services, the great majority of whom always seek to act in the best interests of children and young people and ensure their safety. We again express our profound appreciation to the many victim-survivors, their families, current and former staff, advocates and others who contributed to our Commission of Inquiry. We acknowledge your suffering and pay tribute to your efforts to bring incidents of abuse, and the broader matters at Launceston General Hospital, to the public’s attention, motivated by a desire for justice and to ensure other children and young people do not have to experience the same trauma. We also recognise former patients and their families and carers who have experienced abuse at Launceston General Hospital or in other Tasmanian health services, and those who may have chosen, for a range of reasons, not to come forward.

The commitment of many who spoke with us about improving the safety of all children and young people in health services was palpable. We trust that this will translate into meaningful and long overdue change in Tasmanian health services.