CHCLEG003 Readings

Preamble

Whereas recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world,

Whereas disregard and contempt for human rights have resulted in barbarous acts which have outraged the conscience of mankind, and the advent of a world in which human beings shall enjoy freedom of speech and belief and freedom from fear and want has been proclaimed as the highest aspiration of the common people,

Whereas it is essential, if man is not to be compelled to have recourse, as a last resort, to rebellion against tyranny and oppression, that human rights should be protected by the rule of law,

Whereas it is essential to promote the development of friendly relations between nations,

Whereas the peoples of the United Nations have in the Charter reaffirmed their faith in fundamental human rights, in the dignity and worth of the human person and in the equal rights of men and women and have determined to promote social progress and better standards of life in larger freedom,

Whereas Member States have pledged themselves to achieve, in cooperation with the United Nations, the promotion of universal respect for and observance of human rights and fundamental freedoms,

Whereas a common understanding of these rights and freedoms is of the greatest importance for the full realization of this pledge,

Now, therefore,

The General Assembly,

Proclaims this Universal Declaration of Human Rights as a common standard of achievement for all peoples and all nations, to the end that every individual and every organ of society, keeping this Declaration constantly in mind, shall strive by teaching and education to promote respect for these rights and freedoms and by progressive measures, national and international, to secure their universal and effective recognition and observance, both among the peoples of Member States themselves and among the peoples of territories under their jurisdiction.

Article 1

All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.

Article 2

Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Furthermore, no distinction shall be made on the basis of the political, jurisdictional or international status of the country or territory to which a person belongs, whether it be independent, trust, non-self-governing or under any other limitation of sovereignty.

Article 3

Everyone has the right to life, liberty and security of person.

Article 4

No one shall be held in slavery or servitude; slavery and the slave trade shall be prohibited in all their forms.

Article 5

No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.

Article 6

Everyone has the right to recognition everywhere as a person before the law.

Article 7

All are equal before the law and are entitled without any discrimination to equal protection of the law. All are entitled to equal protection against any discrimination in violation of this Declaration and against any incitement to such discrimination.

Article 8

Everyone has the right to an effective remedy by the competent national tribunals for acts violating the fundamental rights granted him by the constitution or by law.

Article 9

No one shall be subjected to arbitrary arrest, detention or exile.

Article 10

Everyone is entitled in full equality to a fair and public hearing by an independent and impartial tribunal, in the determination of his rights and obligations and of any criminal charge against him.

Article 11

1. Everyone charged with a penal offence has the right to be presumed innocent until proved guilty according to law in a public trial at which he has had all the guarantees necessary for his defence.
2. No one shall be held guilty of any penal offence on account of any act or omission which did not constitute a penal offence, under national or international law, at the time when it was committed. Nor shall a heavier penalty be imposed than the one that was applicable at the time the penal offence was committed.

Article 12

No one shall be subjected to arbitrary interference with his privacy, family, home or correspondence, nor to attacks upon his honour and reputation. Everyone has the right to the protection of the law against such interference or attacks.

Article 13

1. Everyone has the right to freedom of movement and residence within the borders of each State.
2. Everyone has the right to leave any country, including his own, and to return to his country.

Article 14

1. Everyone has the right to seek and to enjoy in other countries asylum from persecution.
2. This right may not be invoked in the case of prosecutions genuinely arising from non-political crimes or from acts contrary to the purposes and principles of the United Nations.

Article 15

1. Everyone has the right to a nationality.
2. No one shall be arbitrarily deprived of his nationality nor denied the right to change his nationality.

Article 16

1. Men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family. They are entitled to equal rights as to marriage, during marriage and at its dissolution.
2. Marriage shall be entered into only with the free and full consent of the intending spouses.
3. The family is the natural and fundamental group unit of society and is entitled to protection by society and the State.

Article 17

1. Everyone has the right to own property alone as well as in association with others.
2. No one shall be arbitrarily deprived of his property.

Article 18

Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to change his religion or belief, and freedom, either alone or in community with others and in public or private, to manifest his religion or belief in teaching, practice, worship and observance.

Article 19

Everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontiers.

Article 20

1. Everyone has the right to freedom of peaceful assembly and association.
2. No one may be compelled to belong to an association.

Article 21

1. Everyone has the right to take part in the government of his country, directly or through freely chosen representatives.
2. Everyone has the right to equal access to public service in his country.
3. The will of the people shall be the basis of the authority of government; this will shall be expressed in periodic and genuine elections which shall be by universal and equal suffrage and shall be held by secret vote or by equivalent free voting procedures.

Article 22

Everyone, as a member of society, has the right to social security and is entitled to realization, through national effort and international co-operation and in accordance with the organization and resources of each State, of the economic, social and cultural rights indispensable for his dignity and the free development of his personality.

Article 23

1. Everyone has the right to work, to free choice of employment, to just and favourable conditions of work and to protection against unemployment.
2. Everyone, without any discrimination, has the right to equal pay for equal work.
3. Everyone who works has the right to just and favourable remuneration ensuring for himself and his family an existence worthy of human dignity, and supplemented, if necessary, by other means of social protection.
4. Everyone has the right to form and to join trade unions for the protection of his interests.

Article 24

Everyone has the right to rest and leisure, including reasonable limitation of working hours and periodic holidays with pay.

Article 25

1. Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
2. Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.

Article 26

1. Everyone has the right to education. Education shall be free, at least in the elementary and fundamental stages. Elementary education shall be compulsory. Technical and professional education shall be made generally available and higher education shall be equally accessible to all on the basis of merit.
2. Education shall be directed to the full development of the human personality and to the strengthening of respect for human rights and fundamental freedoms. It shall promote understanding, tolerance and friendship among all nations, racial or religious groups, and shall further the activities of the United Nations for the maintenance of peace.
3. Parents have a prior right to choose the kind of education that shall be given to their children.

Article 27

1. Everyone has the right freely to participate in the cultural life of the community, to enjoy the arts and to share in scientific advancement and its benefits.
2. Everyone has the right to the protection of the moral and material interests resulting from any scientific, literary or artistic production of which he is the author.

Article 28

Everyone is entitled to a social and international order in which the rights and freedoms set forth in this Declaration can be fully realized.

Article 29

1. Everyone has duties to the community in which alone the free and full development of his personality is possible.
2. In the exercise of his rights and freedoms, everyone shall be subject only to such limitations as are determined by law solely for the purpose of securing due recognition and respect for the rights and freedoms of others and of meeting the just requirements of morality, public order and the general welfare in a democratic society.
3. These rights and freedoms may in no case be exercised contrary to the purposes and principles of the United Nations.

Article 30

Nothing in this Declaration may be interpreted as implying for any State, group or person any right to engage in any activity or to perform any act aimed at the destruction of any of the rights and freedoms set forth herein.

Overview

This resource sheet provides members of the community with information on mandatory reporting laws, which require specified people to report suspected abuse and neglect to government child protection services in Australia¹. It provides answers to common questions asked about mandatory reporting, outlines the challenges and benefits of mandatory reporting and covers the various mandatory reporting legislation across all Australian jurisdictions.

^{1 There are legal requirements for various professionals to report other child-related conditions to various authorities (i.e. certain diseases, the occurrence of injuries in children attending schools or child care, and incidents of domestic violence related to adult victims). This resource sheet does not relate to those circumstances but is specific to the reporting of child abuse and neglect to government authorities.}

Introduction

Mandatory reporting laws aim to identify cases of child abuse and neglect, and to assist the individual children in these cases (Royal Commission into Institutional Responses to Child Sexual Abuse, [Royal Commission], 2017). They were first developed in response to the largely hidden nature of child physical abuse and neglect, with the purpose of bringing cases to the attention of child welfare agencies (Mathews, 2014a). They require selected groups of people to report suspected cases of child abuse and neglect to government authorities.

In Australia, the first laws were introduced in South Australia in 1969, and these laws have since been introduced in all Australian jurisdictions (Mathews, 2014b). However, the laws are not the same across all jurisdictions. Differences exist in who has to report, what types of abuse and neglect have to be reported, the ‘state of mind’ that activates the reporting duty (i.e. having a concern, suspicion or belief on reasonable grounds) and who the report is made to. These differences are described and discussed in this resource sheet.

Common Questions

Who has to report?

Mandatory reporting legislation generally contains lists of particular occupations that are mandated to report cases of suspected child abuse and neglect. The groups of people mandated to report range from persons in a limited number of occupations (Qld) to a more extensive list (Vic. and WA), to a very extensive list (ACT, NSW, SA and Tas.), through to every adult (NT). The occupations most commonly named as mandated reporters are those who deal frequently with children in the course of their work: teachers, early childhood education and care practitioners, doctors, nurses and police.

What types of abuse and neglect have to be reported?

Differences exist in the types of abuse and neglect that must be reported. In some jurisdictions (e.g. NSW and NT) it is mandatory to report suspicions of all five recognised types of abuse and neglect (i.e. physical abuse, sexual abuse, emotional abuse, neglect, and exposure to family violence). In other jurisdictions it is mandatory to report only some of the abuse types (e.g. WA, Qld, Vic. and ACT).

In most jurisdictions the legislation generally specifies that, except for sexual abuse, it is only cases of significant abuse and neglect that must be reported. As sexual abuse should always create a suspicion of significant harm, in practical terms all suspicions of sexual abuse must be reported. While not required by the legislation, suspicions of less severe child abuse and neglect may still be referred to child and family welfare agencies.

It is important to note that the duty to report applies to suspicions that significant abuse or neglect is likely in the future, not just suspected cases of significant abuse or neglect that have already happened.

What protections are given to mandatory reporters?

In all jurisdictions, the legislation protects the mandatory reporter’s identity from disclosure. In addition, the legislation provides that as long as the report is made in good faith, the reporter cannot be liable in any civil, criminal or administrative proceedings.

How does mandatory reporting legislation define a child?

Legislation in all jurisdictions except New South Wales and Victoria requires mandatory reporting in relation to all young people up to the age of 18 years. In New South Wales, the duty only applies to situations involving children aged under 16 years. In Victoria, the duty only applies to situations involving children under 17 years of age.

How does this type of mandatory reporting co-exist with other types of reporting laws?

This form of mandatory reporting is one of several different legal domains that require designated people to report specified types of child abuse. The reporting duties discussed here are located in child protection legislation in each jurisdiction. They are the major form of reporting duty - being primarily directed towards situations of multiple types of abuse and neglect by parents and caregivers (although, operationally, situations of non-familial sexual abuse will be subsumed under the reporting duty).

Accordingly, other types of reporting laws co-exist with the child protection reporting laws. These other laws appear most prominently in criminal laws and most often require reports of child sexual abuse, although they sometimes extend to serious physical abuse. These criminal law reporting duties do not exist in every jurisdiction, and where they do exist (e.g. in NSW, Vic., the ACT and NT) they have slightly different scope and details, although all require reports to be made to police.

The criminal law reporting duties require all adults in the jurisdiction to report the specified type of abuse. Other types of reporting duty are aimed at identifying institutional sexual abuse. All these different duties are discussed in recent research (Mathews, 2019).

Which mandated reports can child protection services act on?

A common assumption is that mandatory reporting requirements, the legislative grounds for child protection services intervention, and research classifications of abusive and neglectful behaviour are the same. In fact, mandatory reporting laws define the types of situations that must be reported to statutory child protection services. Legislative grounds for government intervention define the circumstances and, importantly, the threshold at which the statutory child protection service is legally able to intervene to protect a child. Researchers typically focus on defining behaviours and circumstances that can be categorised as abuse and neglect. These differences arise because each description serves a different purpose; the lack of commonality does not mean that the system is failing to work as policy makers had intended.

As such, not all reports of child abuse and neglect lead to immediate action from child protection services. A single report may not meet the threshold for intervention; however, this report grouped with other information on file (or that is yet to be collected) may meet the threshold and result in action being taken. Reports are not looked at in isolation, instead they work to form a body of information that determine if and how child protection services are legally able to intervene.

Can voluntary reports be made about abuse and neglect, even if not required by the legislation?

Any person is lawfully entitled to make a report if they are concerned for a child’s welfare, even if they are not required to do so as a mandatory reporter. Anyone making a voluntary (non-mandated) report is also protected with regard to confidentiality and immunity from legal liability as outlined above.

In addition to the mandatory reporting legislation, certain professional groups (such as psychologists) and government agencies (such as education departments) may have their own occupational reporting protocols outlining the moral, ethical, professional or organisational responsibility to report. These policy-based reporting duties may be narrower, broader or the same as those officially mandated under legislation. For example, in Queensland, teachers are required to report all forms of suspected significant abuse and neglect under school policy but are only mandated to report sexual abuse and physical abuse under the legislation.

Challenges with the Introduction of Mandatory Reporting

The introduction of mandatory reporting increases awareness of child abuse and neglect, which can result in a substantial increase in the number of reports being made to child protection services, especially in the short term (Mathews, Lee & Norman, 2016). There need to be adequate resources available to respond to any increased demand for staffing and services. Reporting trends generally stabilise several years after the introduction of a mandatory reporting duty (Mathews, Bromfield, Walsh, & Vimpani, 2015).

It is important that mandated reporters receive multidisciplinary training and accurate information to ensure that they know what cases they have to report, how to make a report containing the details needed by the child welfare agency intake team, and what cases they should not report. This training should occur pre-service and in-service. Since non-mandated reporters make a large proportion of all reports, it is also important for the public to be made aware of the appropriate extent of their responsibility. It is also essential that child and family support services be adequately resourced to respond to children and families in need of protection and assistance.

Benefits of Mandatory Reporting Requirements

As a public policy, mandatory reporting aims to protect children from child abuse and neglect. Mathews and Bross (2008) argue that a society without a mandatory reporting system will be far less able to protect children and assist families, as many cases of child abuse and neglect will remain hidden. Comparative studies between countries with and without a mandatory reporting system have found that substantially more cases of child sexual abuse are identified in countries with a mandatory reporting system (Royal Commission, 2017). Studies in Australia support this finding (Lamond, 1989; Mathews, 2014a; Mathews, Bromfield, Walsh, Cheng, & Norman, 2017; Mathews et al., 2016). Reports by mandated reporters identify large proportions of maltreated children and result in the provision of services to many more children and families (Drake & Jonson-Reid, 2007).

Mandatory reporting also aims to increase the awareness of child abuse and neglect in professionals who work with children and overcome any reluctance to report this abuse (Cashmore, 2002). Mandatory reporting laws set acceptable standards of behaviour for the community (Australian Law Reform Commission [ALRC], 2010), affect the policies and practices of child protection services (Tomison & Tucci, 1997), and make the protection of children from abuse and neglect a professional responsibility.

Mandatory Reporting Legislation

Commonwealth legislation

The Family Law Act 1975 (Cth) creates a mandatory reporting duty for personnel from the Family Court of Australia, the Federal Circuit Court of Australia, the Family Court of Western Australia and other designated practitioners. This includes registrars, deputy registrars, family consultants, family counsellors, family dispute resolution practitioners, arbitrators, and lawyers independently representing children’s interests. Section 67ZA(1) and (2) require that when these persons have reasonable grounds for suspecting that a child has been abused, or is at risk of being abused, and this suspicion is developed in the course of performing their duties or functions, or exercising powers, they must, as soon as practicable, notify a prescribed child welfare authority of their suspicion and its basis.

Australian Capital Territory

The Australian Capital Territory’s mandatory reporting laws cover an extensive list of professions, and the details of the reporting requirements are provided in the table below.

Legal provisions	Section 356 of the Children and Young People Act 2008 (ACT)
Who is mandated to report?	A person who is: a doctor; a dentist; a nurse; an enrolled nurse; a midwife; a psychologist; a teacher at a school; a person authorised to inspect education programs, materials or other records used for home education of a child or young person under the Education Act 2004; a police officer; a person employed to counsel children or young people at a school; a person caring for a child at a child care centre; a person coordinating or monitoring home-based care for a family day care scheme proprietor; a public servant who, in the course of employment as a public servant, works with, or provides services personally to children and young people or families; the public advocate; an official visitor; a minister of religion, religious leader or member of the clergy of a church or religious denomination; a person who, in the course of the person’s employment, has contact with or provides services to children, young people and their families and is prescribed by regulation.
What must be reported?	A belief, on reasonable grounds, that a child or young person has experienced or is experiencing sexual abuse or non-accidental physical injury; and the reasons for the belief arise from information obtained by the person during the course of, or because of, the person’s work (whether paid or unpaid)
Abuse and neglect types that must be reported	Physical abuse Sexual abuse

New South Wales

New South Wales’ mandatory reporting laws cover an extensive list of professions, and the details of the reporting requirements are provided in the table below.

Legal provisions	Sections 23 and 27 of the Children and Young Persons (Care and Protection) Act 1998 (NSW)
Who is mandated to report?	A person who, in the course of his or her professional work, or other paid employment, delivers health care, welfare, education, children’s services, residential services or law enforcement, wholly or partly, to children. A person who holds a management position in an organisation, the duties of which include direct responsibility for, or direct supervision of, the provision of health care, welfare, education, children’s services, residential services or law enforcement, wholly or partly, to children.
What must be reported?	Suspicion on reasonable grounds, obtained during the course of or from the person’s work, that a child is at risk of significant harm because of the presence to a significant extent of circumstances of: neglect, physical abuse, sexual abuse, psychological abuse, risk of harm through exposure to domestic violence, and failure to engage with services after a pre-natal report.
Abuse and neglect types that must be reported	Physical abuse Sexual abuse Emotional/psychological abuse	Neglect Exposure to domestic violence

Northern Territory

The Northern Territory’s mandatory reporting laws apply to any person, with additional provisions covering health practitioners. The details of these reporting requirements are provided in the table below.

Legal provisions	Sections 15, 16 and 26 of the Care and Protection of Children Act 2007 (NT)	Section 26(2) of the Care and Protection of Children Act 2007 (NT)
Who is mandated to report?	Any person	A health practitioner or someone who performs work of a kind that is prescribed by regulation
What must be reported?	A belief on reasonable grounds that a child has suffered or is likely to suffer harm or exploitation	Reasonable grounds to believe a child aged 14 or 15 years has been or is likely to be a victim of a sexual offence and the age difference between the child and offender is greater than 2 years
Abuse and neglect types that must be reported	Physical abuse Sexual abuse or other exploitation of the child Emotional/psychological abuse Neglect Exposure to physical violence (e.g., a child witnessing violence between parents at home)	Sexual abuse

Queensland

Queensland has three separate pieces of mandatory reporting legislation, each covering different occupational groups and having their own reporting requirements. The details of these pieces of legislation are provided in the table below.

Legal provisions	Part 1AA, section 13F of the Child Protection Act 1999 (Qld)	Part 1AA, section 13E of the Child Protection Act 1999 (Qld)	Sections 364, 365, 365A, 366, 366A of the Education (General Provisions) Act 2006 (Qld)
Who is mandated to report?	An authorised officer, a public service employee employed in the department, a person employed in a departmental care service or licensed care service	Doctors; registered nurses; teachers; a police officer who, under a direction given by the commissioner of the police service under the Police Service Administration Act 1990, is responsible for reporting under this section; a person engaged to perform a child advocate function under the Public Guardian Act 2014; early childhood education and care professionals.	School staff
What must be reported?	A reasonable suspicion that a child in care (a child placed in the care of an entity conducting a departmental care service or a licensee) has suffered, is suffering, or is at unacceptable risk of suffering, significant harm caused by physical or sexual abuse	A reasonable suspicion that a child has suffered, is suffering or is at an unacceptable risk of suffering, significant harm caused by physical or sexual abuse; and may not have a parent able and willing to protect the child from the harm	Awareness or reasonable suspicion that a child has been or is likely to be sexually abused; and the suspicion is formed in the course of the person’s employment
Abuse and neglect types that must be reported	Physical abuse Sexual abuse	Physical abuse Sexual abuse	Sexual abuse

South Australia

South Australia’s mandatory reporting laws cover an extensive list of professions, and the details of the reporting requirements are provided in the table below.

Legal provisions	Sections 17, 18, 30 and 31 of the Children and Young People (Safety) Act 2017 (SA)
Who is mandated to report?	Medical practitioners; pharmacists; registered or enrolled nurses; dentists; psychologists; police officers; community corrections officers under the Correctional Services Act 1982; social workers; ministers of religion; employees of, or volunteers in, an organisation formed for religious or spiritual purposes; teachers employed as such in a school (within the meaning of the Education and Early Childhood Services (Registration and Standards) Act 2011) or a preschool or kindergarten; employees of, or volunteers in, an organisation that provides health, welfare, education, sporting or recreational, child care or residential services wholly or partly for children and young people, being a person who - (i) provides such services directly to children and young people; or (ii) holds a management position in the organisation, the duties of which include direct responsibility for, or direct supervision of, the provision of those services to children and young people
What must be reported?	Reasonable grounds to suspect a child or young person is, or may be, at risk; and the suspicion was formed in the course of the person’s employment
Abuse and neglect types that must be reported	Physical abuse Sexual abuse	Mental or emotional abuse  Neglect

Tasmania

Tasmania’s mandatory reporting laws cover an extensive list of professions, and the details of the reporting requirements are provided in the table below.

Legal provisions	Sections 3, 4 and 14 of the Children, Young Persons and Their Families Act 1997 (Tas.)
Who is mandated to report?	Medical practitioners; registered or enrolled nurses; persons registered under the Health Practitioner Regulation National Law (Tasmania) in the midwifery, dental (dentists, dental therapist, dental hygienist or oral health therapist) or psychology professions; police officers; probation officers; principals and teachers in any educational institution including kindergartens; persons who provide child care or a child care service for fee or reward; persons concerned in the management of an approved education and care service, within the meaning of the Education and Care Services National Law (Tasmania) or a child care service licensed under the Child Care Act 2001; a member of the clergy of any church or religious denomination; a member of the Parliament of this State; any other person who is employed or engaged as an employee for, of, or in, or who is a volunteer in, a government agency that provides health, welfare, education, child care or residential services wholly or partly for children, and an organisation that receives any funding from the Crown for the provision of such services; and any other person of a class determined by the Minister by notice in the Gazette to be prescribed persons.
What must be reported?	Knowledge, or a belief or suspicion on reasonable grounds that: a child has been or is being ‘abused’ or ‘neglected’ or is an affected child within the meaning of the Family Violence Act 2004 (a child whose safety, psychological wellbeing or interests are affected or likely to be affected by family violence); or there is a reasonable likelihood of a child being killed or abused or neglected by a person with whom the child resides; or while a woman is pregnant, that there is reasonable likelihood that after the birth of the child: the child will suffer abuse or neglect, or may be killed by a person with whom the child is likely to reside; or that the child will require medical treatment or other intervention as a result of the behaviour of the woman or another person with whom the woman resides or is likely to reside, before the birth of the child. Note on extent of harm required to activate the duty (section 3(1) definition of ‘abuse and neglect’: for all forms except sexual abuse, reports must be made where: (i) the injured, abused or neglected person has suffered, or is likely to suffer, physical or psychological harm detrimental to the person’s wellbeing; or (ii) the injured, abused or neglected person’s physical or psychological development is in jeopardy. All instances of suspected sexual abuse must be reported.
Abuse and neglect types that must be reported	Sexual abuse (any) Physical abuse Emotional/psychological abuse	Neglect Exposure to family violence

Victoria

Victoria’s mandatory reporting laws cover an extensive list of professions, and the details of the reporting requirements are provided in the table below.

Legal provisions	Sections 182(1), 184 and 162(1)(c)-(d) of the Children, Youth and Families Act 2005 (Vic.)
Who is mandated to report?	Registered medical practitioners, nurses, midwives, a person registered as a teacher or an early childhood teacher under the Education and Training Reform Act 2006 or teachers granted permission to teach under that Act; principals of government or non-government schools within the meaning of the Education and Training Reform Act 2006; police officers, a person in religious ministry, out-of-home care workers (excluding voluntary foster and kinship carers), early childhood workers, youth justice workers and registered psychologists.
What must be reported?	Belief on reasonable grounds that a child is in need of protection on a ground referred to in section 162(1)(c) or 162(1)(d), formed in the course of practising his or her profession or carrying out the duties of his or her office, position or employment as soon as practicable after forming the belief and after each occasion on which he or she becomes aware of any further reasonable grounds for the belief
Abuse and neglect types that must be reported	Physical injury Sexual abuse Note that technically, under s. 162, the duty is limited to instances of physical injury and sexual abuse where ‘the child’s parents have not protected, or are unlikely to protect, the child from harm of that type’.

Western Australia

Western Australia has two separate pieces of mandatory reporting legislation, each covering different occupation groups and having their own reporting requirements. The details of these pieces of legislation are provided in the table below.

Legal provisions	Sections 124A and 124B of the Children and Community Services Act 2004 (WA)2	Sections 5 and 160 of the Family Court Act 1997 (WA)
Who is mandated to report?	Doctors; nurses and midwives; teachers and boarding supervisors; and police officers	The Principal Registrar, a registrar or a deputy registrar; family counsellors; family consultants; family dispute resolution practitioners, arbitrators or legal practitioners independently representing the child’s interests
What must be reported?	Belief on reasonable grounds that child sexual abuse has occurred or is occurring, where this belief is formed in the course of the person’s work, whether paid or unpaid	Reasonable grounds for suspecting that a child has been: abused, or is at risk of being abused; ill-treated, or is at risk of being ill-treated; or exposed or subjected to behaviour that psychologically harms the child
Abuse and neglect types that must be reported	Sexual abuse	Physical abuse Sexual abuse Neglect Psychological harm including (but not limited to) harm caused by being subjected or exposed to family violence.

^{2 Note: The Western Australian Government has announced its intent for this Act to be amended to introduce mandatory reporting of child sexual abuse for ministers of religion, including where this knowledge is gained through religious confession. These amendments are yet to be enacted (Government of Western Australia, 2019).}

Further Reading

Kohl, P., Jonson-Reid. M., & Drake, B. (2009). Time to leave substantiation behind: Findings from a national probability study. Child Maltreatment, 14(1), 17.

Mathews, B. (2012). Exploring the contested role of mandatory reporting laws in the identification of severe child abuse and neglect. In M. Freeman (Ed.), Current legal issues (Vol. 14: Law and Childhood Studies) (pp. 302-338). Oxford: Oxford University Press.

Mathews, B., & Kenny, M. (2008). Mandatory reporting legislation in the USA, Canada and Australia: A cross-jurisdictional review of key features, differences and issues. Child Maltreatment, 13, 50-63.

Mathews, B., & Walsh, K. (2014). Mandatory reporting laws. In A. Hayes & D. Higgins (Eds.), Families, policy and the law: Selected essays on contemporary issues for Australia (pp. 131-142). Melbourne: AIFS. Retrieved from www.aifs.gov.au/publications/families-policy-and-law/14-mandatory-reporting-laws

Melton, G. (2005). Mandated reporting: A policy without reason. Child Abuse & Neglect, 29, 9-18.

Tomison, A. (2002). Mandatory reporting: A question of theory versus practice. Developing Practice: The Child, Youth and Family Work Journal, 4, 13-17.

For more resources, visit the CFCA mandatory reporting bibliography

The Anti-Discrimination Act 1991 is a law that is about giving everyone a fair go. It means that discrimination, sexual harassment, and vilification is against the law in Queensland.

Discrimination

Discrimination is when you are treated worse than somebody else because of something about you, like your race, age, or sex.

The law says people can’t discriminate against you because of your:

Sex

This means whether you are male or female or other.

Relationship status

This means whether you are in a relationship and whether or not you are:

• married;
• single;
• divorced; or
• living with your partner (sometimes called ‘de facto’).

Pregnancy

This means that you are pregnant or have been pregnant, or if someone thinks you are pregnant (even if you’re not).

Parental status

This means whether you have children or not. It includes:

• being a step-parent;
• having adopted children;
• being a foster-parent; and
• not having any children at all.

Breastfeeding

As well as breastfeeding your child, or needing to breastfeed, this includes doing things associated with breastfeeding, like expressing milk.

Age

This means your age, or the age someone thinks you are, whether you are ‘too old’ or ‘too young’ or ‘not the right age’.

Race

This means the cultural group you belong to. Your race can include your skin colour, the language you speak, and what ethnic group you belong to.

Impairment

Impairment includes many different kinds of disability. It also includes things you might not think of as a disability but which stop you from fully participating in some things. It includes:

• physical disability;
• mental illnesses, like depression, anxiety, schizophrenia, or eating disorders;
• hearing problems or deafness;
• blindness or low vision;
• being sick or ill;
• having learning difficulties, autism or epilepsy;
• relying on a wheelchair, assistance dog, or some other type of support.

It can be something you were born with or something you develop later, or the result of an injury. It doesn’t have to be permanent to be an impairment – you might have had it in the past but not anymore.

Religious belief or activity

This means whether you have religious beliefs or not. It includes things people do as part of their religion, like taking part in religious gatherings or ceremonies, or wearing certain clothes.

Political belief or activity

This means what you believe or do about the way governments or councils are run. It includes whether you are a member of a political party, or get involved in a campaign to change a law or help someone get elected.

Trade union activity

A trade union is an official organisation made up of workers who all have the same sorts of jobs, to look after their rights. Trade union activity might include:

• being a member of the union;
• talking to your boss or workplace about workers’ rights on behalf of the union;
• going to union meetings; or
• taking part in Labour Day marches.
• It can also include not being part of the union or refusing to take part in union activities.

Lawful sexual activity

This means that you work legally as a sex worker. In Queensland, sex work is legal if you work in a licensed brothel, or work by yourself at your home or other people’s homes.

Gender identity

This means you identify as a gender which is different to the one you were assigned at birth – for example, if you grew up as a boy but now live as a woman. It can also apply to people who are intersex but wish to live as a particular gender. It is different from sex.

Sexuality

Your sexuality is about who you are attracted to. It means whether you are heterosexual, homosexual, or bisexual:

• heterosexual is when you are only attracted to people of the opposite sex. This is sometimes called ‘straight’;
• homosexual is when you are only attracted to people of the same sex. Men who like other men are sometimes called ‘gay’, and women who like other women are sometimes called ‘lesbian’;
• bisexual is when you are attracted to both men and women – sometimes this is called ‘bi’.

Family responsibilities

This means you have a responsibility to look after or support someone in your immediate family, like your:

• husband or wife (including de facto partners and ex partners);
• child (including step-children and foster-children);
• parent or grandparent; or
• brother or sister.

It can include looking after the family of your husband, wife, de facto partner or ex partner.

Association with, or relationship to, someone who has any of these characteristics

Sometimes you might be treated worse than other people because you are with someone who has one or more of the characteristics listed above. It might also be because you’re related to someone who has one or more of the characteristics. Treating you less favourably because of this is against the law.

When is discrimination against the law?

The law says you must not be discriminated against when you are:

• At work or volunteering, or when you apply for jobs;
• At school, uni or TAFE;
• Buying things in places like shops, restaurants and bars;
• Paying for services, like a mechanic or someone to mow your lawn, or seeing a doctor or dentist;
• Renting a house or unit to live in or for a holiday;
• Dealing with government services like police, Child Safety, public housing, public transport, and health care.

When isn’t discrimination against the law?

Sometimes treating people differently isn’t against the law. The law includes ‘exemptions’, or times when it is okay to treat people differently. They can be:

• to make things better for people who might be disadvantaged;
• to protect health and safety;
• to allow religions or cultures to protect their tradition.

Sometimes you might need a special service or facility because of your disability. If it is too hard or costs too much for people to make these changes for you, they might not have to. They have to prove it is too hard or costs too much. This is called unjustifiable hardship.

What else does this law prevent?

Sexual harassment

This is when someone does something that is sexual and makes you feel upset, embarrassed, or afraid. It is against the law no matter where it happens, whether you are at work or school or just walking down the street.

It includes:

• someone touching you when you don’t want them to;
• making sexual jokes or comments that make you uncomfortable;
• asking you questions about your body or your private life;
• showing or sending you unwanted nude or sexual pictures;
• asking you to go on dates or to have sex when you don’t want to;
• teasing or insulting you about your body or your sex life.

Vilification

Vilification is when someone says or does something in public, which may make other people hate or make fun of you because of your race, religion, gender identity, or sexuality.

It is against the law if it happens in public. That means:

• saying things where other people can hear;
• putting up signs;
• writing things in newspapers or putting them online;
• wearing clothes with slogans or symbols on.
• treat you unfairly because you have complained about discrimination, sexual harassment or vilification;
• ask or encourage you to discriminate against someone else, or sexually harass or vilify them;
• ask for information which they don't need but might use to discriminate against you;
• make or publish an ad which discriminates against people.

It is also against the law for someone to:

• treat you unfairly because you have complained about discrimination, sexual harassment or vilification;
• ask or encourage you to discriminate against someone else, or sexually harass or vilify them;
• ask for information which they don't need but might use to discriminate against you;
• make or publish an ad which discriminates against people.

Making a complaint

If you have experienced discrimination, sexual harassment, vilification, or victimisation, you can make a complaint.

You don’t need to complain to the person or business first, but sometimes it can help resolve the problem quicker if you do.

If you want to complain to the Queensland Human Rights Commission, you have to do it within 12 months of when it happened. You have to complain in writing. Someone can help you do this – it could be a family member, friend, support person or lawyer.

The Commission will try and resolve your complaint through conciliation. This is like a conversation between you and the person or business you are complaining about. It takes place in a safe environment with someone from the Commission there to make sure the process is fair. We will not take sides but we will try and help everyone reach an agreement about how to resolve the issue.

You can call us on 1300 130 670 to find out more or to talk to someone about your issue.

• Find our contact details
• Read more about our complaints process
• Lodge a complaint online

Fundamental Principles

Following a comprehensive consultation process, Members of AAPM have identified the following fundamental ethical principles as central to their professional practice:

Principles of Justice and Fairness

• Honesty – to be truthful, trustworthy, straightforward, fair, and sincere in all professional and business relationships.
• Integrity - to be consistent in action, values, methods, measures, principles, expectations, and outcomes.
• Respect – to acknowledge that every human being, regardless of race, religion, gender, age, sexual and gender diversity, or other individual differences is entitled to unconditional respect and has a right to maximise his or her potential providing it does not infringe upon the rights of others.
• Good Faith - to exercise his or her responsibilities reasonably and not arbitrarily or for some irrelevant purpose, having regard to the legitimate interests of other affected parties.

Principles of Care and Empathic Understanding

• Empowerment – to facilitate autonomy, independence, and self-determination in people and communities by providing appropriate resources and support
• Dignity –to value the uniqueness of every individual and uphold the responsibility to provide services around each individual and their specific needs.
• Privacy – to value the privacy of individuals as an inherent right and acknowledge the right to privacy by maintaining confidentiality of information shared by patients and other stakeholders.
• Communication – to value communicating with individuals in ways that are meaningful to them and enables them to understand and clarify the issues at stake.

Justice and Fairness

The ethical principle of Justice asserts that people ought to be treated equally, while recognising the unique circumstances of individuals. This standard requires that everyone is afforded their basic rights and can participate in any decision-making process that might affect those rights. Fairness refers to the expectation that we are acting impartially, whatever our own emotions and interests regarding the issues in question, as well as to the outcomes of the process.

Honesty

Honesty is a principle that is closely related to justice. It means that all of the facts related to any particular issue are conveyed to others. It also means that nothing of relevance to any dealings with others are deliberately omitted or hidden. In order to observe this principle, Members of AAPM strive to be truthful, trustworthy, straightforward, fair, and sincere in their professional conduct.

They:

• Recognise that honesty forms the foundation of trust, which is essential in all their professional relations. 
• Adhere to the highest standards of accuracy and transparency in their communications.
• Comply with all relevant privacy laws and laws regarding the management of health records in the protection of personal information received from clients in a healthcare practice. 
• Ensure that their employees and associates also comply with this provision and monitor employee activities to ensure privacy and confidentiality standards are maintained.

Integrity

Acting with integrity means understanding, accepting, and choosing to live in accordance with one's principles. It is the practice of showing a consistent and uncompromising adherence to an internally consistent moral and ethical framework. It requires the avoidance of any arbitrary choices that make exceptions for a particular person or group. The sense of wholeness accompanying integrity communicates an impression of trustworthiness to others, facilitating professional relationships. To ensure integrity, Members of AAPM aim to be consistent in action, values, methods, measures, principles, expectations, and outcomes.

They:

• Act according to the values, beliefs and principles that are expected of Members.
• Fulfil their promises and commitments to their clients, employees, and colleagues.
• Show leadership in their relations with clients, employees, and colleagues by working to resolve issues constructively and in mutually acceptable ways.

Respect

The principle of respect is based on the assumption that all competent humans are autonomous and have the right to make their own decisions freely without fear of interference. Autonomous people are considered to have the capacity to determine their own destiny, and as such must be respected unconditionally. Members of AAPM acknowledge that every human being, regardless of race, religion, gender, age, sexual and gender diversity, or other individual differences is entitled to unconditional respect and has a right to maximise his or her potential, and exercise their right to free choice, providing it does not infringe upon the rights of others.

They:

• Ensure people who can responsibly make their own decisions, are given serious consideration and people who are not able to take responsibility for their own decisions are supported appropriately.
• Have regard for others’ personal space, opinions, and privacy, ensuring that harassment or bullying in any form is not tolerated.

Good Faith

Members of AAPM endeavour to exercise their responsibilities reasonably and not arbitrarily or for some irrelevant purpose, having regard to the legitimate interests of other affected parties.

• Act with honesty and impartiality when providing service or advice to others
• Provide comprehensive information that others need to know in order to make informed decisions.

Care and Empathic Understanding

Principles of care and empathic understanding reflect the view that relationships form the context in which sound ethical decisions are made. It requires that ethical decision-makers are mindful of the well-being of others and seek to act benevolently wherever possible. They emphasise the importance of each individual and the degree of interdependence between those involved in an ethical dilemma.

Care and empathic understanding imply a responsiveness to the lived experience of those in vulnerable positions rather than understanding how we might experience similar situations. Competence in providing care, not simply the awareness or acknowledgment that care is needed, becomes an imperative. Attentiveness to specific details of the context help moral agents to determine how they might safeguard and even promote the interests of those involved in such situations.

Empowerment

Members of AAPM aim to facilitate autonomy, independence and self-determination in people and communities by providing appropriate resources and support in relation to their professional undertakings.

They:

• Presume that individuals are competent in assessing and acting on their interests.
• Support individuals to make informed decisions that are in their own best interests.

Dignity

Members of AAPM value the uniqueness of every individual and uphold the responsibility to provide services around each individual and their specific needs.

They:

• Respect the inherent dignity, worth, and unique attributes of every person.
• Acknowledge the rights of each individual and engage in positive, unbiased interactions that observe those rights.

Privacy and Confidentiality

Members of AAPM value the privacy of individuals as an inherent right and acknowledge the right to privacy by maintaining confidentiality of information shared by patients and other stakeholders.

They:

• Respect and maintain the confidentiality of information acquired in the course of their professional duties and ensure policies are in place to prevent disclosure of such information, except when authorised or legally required to do so.
• Refrain from using information obtained in the course of their work for unethical or illegal advantage, personally or through a third party.

Communication

Members of AAPM aim to communicate with individuals in ways that are meaningful to them and enables them to understand and clarify the issues at stake.

They:

• Communicate truthfully, concisely, and responsibly with others.
• Listen non-judgementally to others and identify their unique perspectives and points of view.
• Communicate information to other parties fairly and objectively.
• Ensure their communications have been understood and clarify any ambiguities or address any questions that might arise.

Conflicts of Interest 

A conflict of interest occurs when a member’s personal interests’ conflict with their responsibility to act in the best interests of AAPM and any of their fiduciary and social obligations. It may also be unlawful. AAPM members:

• Identify potential conflicts of interest and manage them appropriately.
• Consult other members, particularly senior and more experience Practice Managers regarding potential conflicts of interest.

N.B. The issue of conflicts of interest is complex, and further discussion of some of the many aspects involved is provided in the appendix.

What to do if you have concerns

If informal methods of dealing with ethical concerns are deemed to be unsatisfactory by any of the parties concerned, including patients, healthcare practitioners, members of the public and fellow Members, formal complaints about the conduct of AAPM members can be raised with the Association.

This Code and the Rules and Procedures for managing complaints raised may be reviewed and updated from time to time by the National Board. The current version is provided in Appendix A. Anyone with concerns about AAPM members is encouraged to read both documents before contacting the AAPM for further information.

AAPM aims to:

1. deliver an effective complaint handling system founded on the principles of fairness, accessibility, responsiveness, and efficiency.
2. ensure individuals who make a complaint are respected and aware of the process of consideration of their complaint and the outcome.
3. provide transparency around AAPM’s process for receiving, handling, and investigating complaints. 4. enable AAPM to apply lessons learnt from complaints received for continuous improvement.

A formal complaint may be made in any form of writing including on paper, received electronically via email or through the contact form available at https://www.aapm.org.au/About-Us/Contact-Us;

Complaint Handling Policy

1 Purpose

This document sets out the AAPM Complaint Handling Policy. A complaint about an AAPM Member is subject to the AAPM By-laws for handling complaints about AAPM Members which is available at the AAPM website. The purpose of this policy is: 1. to deliver an effective complaint handling system founded on the principles of fairness, accessibility, responsiveness, and efficiency. 2. to ensure individuals who make a complaint are respected and aware of the process of consideration of their complaint and the outcome. 3. to provide transparency around AAPM’s process for receiving, handling, and investigating complaints; and 4. to enable AAPM to apply lessons learnt from complaints received for continuous improvement.

2 Who this Policy Applies to

Any person can make a complaint to AAPM regarding any aspect of AAPM’s operations. AAPM can only consider complaints that have some connection to AAPM’s operations. This policy must be considered alongside other AAPM policies. A complaint that more appropriately falls within the AAPM Whistle-blower Policy, Code of Ethical Conduct or another applicable policy, will be dealt with in accordance with the appropriate policy.

3 Matters that can be considered under this Policy

AAPM will consider any complaint that has some connection to AAPM and in respect of which it has the necessary authority or ability to enforce a decision, including complaints made about: o AAPM operations or activities. o conduct of officers, employees, agents, or contractors of AAPM; or o conduct of Members of AAPM. This policy may also be applied for consideration of work-related grievances and other complaints personal to an individual.

4 Where to make a Complaint

Where a complaint should be sent depends on the nature of the complaint:

• Complaints about Members of AAPM
• AAPM has a policy and process for complaints about members which is available from the AAPM website. Information about how to make a complaint about an AAPM Member is set out in that policy.
• Complaints about AAPM staff
• Complaints about AAPM staff should be marked “confidential” and sent directly to the office of AAPM’s CEO at ceo@aapm.org.au
• Complaints about the AAPM CEO or a Board member
• Complaints about the CEO or a Board member should be marked “confidential” and sent directly to the Chair of the AAPM Board at president@aapm.org.au
• Complaints about the President or Chair
• Complaints about the President should be marked “confidential” and sent directly to the office of AAPM’s CEO at ceo@aapm.org.au
• Other complaints can be made via email addressed to any one of the following:
  • State committee – ceo@aapm.org.au
  • CEO - ceo@aapm.org.au
  • Board - president@aapm.org.au

Any complaints received at a State Branch Committee level should be referred to the AAPM National Office promptly for management to promote national consistency in complaints handling. Any complaint received can be escalated to the CEO or the Board at the discretion of an AAPM National Office employee who received the complaint.

5 How to Make a Complaint

Complaints should be made in writing to assist in record keeping, assessment and investigation. AAPM may decline to consider any verbally received complaint.

A complaint:

• may be in any form of writing including on paper, received electronically via fax or email or through the contact form available at https://www.aapm.org.au/About-Us/Contact-Us;
• must include sufficient information to enable AAPM to property assess the complaint. o may include any additional information the complainant considers relevant; and
• must include the name and contact details of the complainant, and a statement about whether the complainant wishes to remain anonymous. o must state the outcome being sought.

Complaints that do not include the name and contact details of the complainant may not be investigated.

Details such as dates, times, locations, and other persons present may be necessary information to enable a person who is the subject of a complaint to properly respond, and for AAPM to properly investigate the complaint.

Where a complaint is made about operations or activities of AAPM, a complainant should be encouraged to provide alternative options to any issues raised, rather than simply identifying a problem.

6 Acknowledging a complaint

AAPM aims to acknowledge receipt of a complaint within three (3) business days of receipt, and to provide to the complainant a copy of this policy for reference.

7 Assessing a complaint

Within seven (7) business days of receipt, the recipient of the complaint will assess the complaint to:

• identify that AAPM has the necessary authority or power to consider the complaint and enforce any decision made in respect of the complaint.
• determine whether the complaint should be handled in accordance with this policy or another more appropriate AAPM policy.
• identify whether another person or entity is mentioned in the complaint and should be provided an opportunity to respond.
• determine who is best positioned to investigate and respond to the complaint.

Having assessed the complaint, the person then designated to handle the complaint must notify the complainant and any person or entity required to respond to the complaint of their findings and the process and timing to be followed from that point forward.

Where the assessor’s finding is that AAPM has no authority or power to consider the complaint, the complainant must be notified of that finding and advised that the complaint process is then at an end.

Where a person or entity impacted by the complaint is given an opportunity to respond, they will be requested to provide their written response to the complaint within seven (7) days of receipt of that notice.

8 Responding to a complaint

Anyone responding to a complaint must provide a written response to the complaint within seven (7) business days of the request for their response.

A written response to the complaint:

• should be succinct and factual o must be addressed to the person requesting the response o must be in writing o must address the complaint
• may include any information the respondent considers relevant
• may include supporting statements from other people, and
• may request further time to respond, provided that a fixed date for the response is nominated at the time of that request and is not more than 30 days later than the original date to respond.

9 Investigation

If additional information is required by the investigator, that person may request that information from any person, seeking a response within seven (7) days, and notifying the person from whom information is requested that the complaint will be considered without that information if it cannot be provided within that timeframe.

10 Fair assessment and investigation of a complaint

AAPM acknowledges that this policy will not be meaningful and effective unless it is implemented and applied consistently throughout AAPM in practice.

A complainant must be treated fairly. Fairness comprises three qualities—impartiality, confidentiality, and transparency.

Impartiality – a person receiving, assessing, or investigating a complaint must aim to:

• avoid a conflict of interest
• avoid defensiveness
• avoid seeking to prove right or wrong
• avoid bias (conscious or unconscious) or prejudice o remain open minded o remain objective
• give equal consideration to information received from different sources
• disregard any prior complaints from, or relationship with, the complainant

Confidentiality – a person receiving, assessing, or investigating a complaint must aim to:

• keep the complaint confidential and secure
• limit access to the complaint to those directly involved and required to assess or investigate the complaint
• not share or discuss the complaint other than in accordance with this policy

Transparency - a person receiving, assessing, or investigating a complaint must aim to:

• inform any person impacted by the complaint of the process and timing of for handling the complaint
• ensure the complainant and any person impacted have contact details of the person handling the complaint
• keep the complainant and any person impacted reasonably informed of the progress of the complaint handling process
• provide an explanation of the outcome of the complaint handling process

The principles of natural justice and procedural fairness should be applied in the receipt and consideration of any complaint, and as part of the investigation process before any adverse action is taken against person or entity that may be the subject of a complaint.

Procedural fairness involves being afforded the opportunity to respond to a comment or allegation made, within a reasonable time. This means that if any complaint is received in respect of a person or entity, that person or entity must be notified promptly, and given reasonable opportunity to present their response to the complaint. Procedural fairness does not require the decision maker to find any information provided to it as factual, true, or persuasive.

To ensure that these principles can be adhered to, a complainant may be advised that their complaint cannot be properly investigated or responded to if they decline to share sufficient details for a person named, to respond.

AAPM may appoint an independent third party to investigate a complaint at its discretion.

11 Determination of a complaint

Initial Findings – The investigator will prepare initial findings about the complaint and provide those findings to the complainant and any respondent. Either or both the complainant a respondent may respond in writing to the initial findings within fourteen (14) business days.

Final Determination – The investigator will consider all responses to the initial findings received within the required timeframe and prepare a final determination of the complaint.

The final determination is final and there will be no avenue of appeal from that decision.

Any actions required as a result of the final determination will take effect at the times noted in the final determination.

The investigator is under no obligation to provide reasons to any party other than the complainant or a respondent.

12 Reviewing the complaint handling process

AAPM will keep a record of complaints received including the nature of the complaint, whether the complaint was investigated and the final determination.

At the conclusion of each complaint process, the person handling the complaint will complete a short report that includes:

• the timing of the complaint and complaint handling process
• whether any unexpected problems arose in the process and how they were managed
• what worked well
• what did not work well o what could be done better – and how?

A report will be provided to the Board at least annually identifying any areas of improvement implemented as a result of the above complaint review process.

13 Ensuring the Policy is Easily Accessible

This policy is displayed on the AAPM website, in the Member’s portal of the AAPM website, and included with AAPM employment policies.

By-laws for handling complaints about AAPM Members

Complaints regarding a breach of code

1. Making a complaint

1.1	The National Board can only investigate a written complaint about a member. Verbal complaints will not be treated as a complaint for the purpose of these bylaws.
1.2	Upon receipt of a written complaint, the National Board (through the CEO) will investigate the complaint and the conduct of the Member being complained about.
1.3	If a complaint is received from an eligible whistle-blower about a disclosable matter, then the complaint will be dealt with in accordance with the AAPM Whistle-blowers Policy rather than these by-laws and the complainant will be advised accordingly.
1.4	A written complaint: must be addressed to the CEO or the AAPM National Board and received at the principal place of business of AAPM. may be in any form of writing including on paper, received electronically via fax or email or through the contact form available at https://www.aapm.org.au/About-Us/Contact-Us; must include the name of the Member about whom the complaint is made. must summarise the behaviour complained about, including the date and location where the behaviour occurred. where possible, should make reference to the particular provision in the AAPM Code of Ethical Conduct which it is alleged the Member has contravened; may include any additional information the complainant (the person making the complaint) deems relevant to the National Board’s investigation of the complaint and must include the name and contact details of the complainant, and a statement about whether the complainant wishes to remain anonymous. Complaints that do not include the name and contact details of the complainant will not be treated as a complaint under these bylaws.

2. Principles for investigating complaints

2.1

The complaint and investigation process will be conducted by the National Board in accordance with the following five principles: Confidentiality for all parties, where practicable and appropriate, until the investigation process is completed. Investigations will be handled expeditiously. Procedural fairness for both the complainant and the Member. Procedural fairness involves being afforded the opportunity to respond to a comment or allegation made, within a reasonable time. Procedural fairness does not require the decision maker to find any information provided to it as factual, true, or persuasive. V9 Updated 12 October 2022 The National Board may inform itself as it sees fit, including seeking external expert opinion or delegating any part of whole of the investigation to nominated AAPM staff members or consultants engaged for the purpose. The National Board is not bound by any rules of evidence. The National Board may expand or limit the scope of its investigation as it sees fit.

3. Remaining anonymous

3.1	If a complainant asks to remain anonymous (i.e., unidentified to the member about whom the complaint is made), the National Board or its delegate will make a determination as to whether the Member complained about will have sufficient ability to address and respond to the complaint without the disclosure of the identity of the complainant, if the complainant remains anonymous.
3.2	If the determination of the National Board is that the Member complained about will have sufficient ability to respond to the complaint, the details of the complainant will not be provided to the Member complained about.
3.3	If the determination of the National Board is that the Member complained about will not have fair opportunity to respond to the complaint without the identity of the complainant being disclosed, the National Board will advise the complainant that the complaint cannot be investigated and will come to an end unless the complainant is prepared to be identified as the complainant.
3.4	The National Board may at any time throughout the investigation process close any complaint without further investigation or determination, and notify the complainant accordingly, where the complainant refuses to be identified and the Member complained about cannot adequately respond without that information.

4. Procedure for investigating complaints

4.1	Within 3 business days of receipt of a written complaint: a written acknowledgment of receipt will be provided to the complainant and the National Board will be notified that the complaint has been received.
4.2	Within 7 business days of receipt of a written complaint: a copy of the complaint will be provided to the National Board. the CEO or other delegate of the National Board will provide a report to the National Board that: confirms the person complained about is a financial Member of AAPM or was a financial member of the AAPM at the time the alleged conduct occurred. identifies the category of membership of the Member. identifies what provisions of this Code may have contravened. identifies any other Members or third parties who may be involved in the investigation process, where the complaint has been received about a current or former Member, a copy of the complaint will be provided to that person via post and electronic means sent to the address details on record at AAPM.
4.3	If the person complained about is not a current Member or was not a member at the time of the alleged conduct, the complainant must be promptly notified that the National Board has no authority to consider the complaint. This will bring the complaint to a close.
4.4	At the same time as acknowledging receipt of the complaint or providing a copy of the complaint to the Member complained about, the parties will be provided with an information statement outlining the investigative process and likely timeframes.

5. Responding to a complaint

5.1

The Member complained about must provide a written response to the complaint within 7 business days of his/her receipt of the complaint.

5.2

The written response to the complaint: must be addressed to the CEO or the AAPM National Board and received at the principal place of business of AAPM. o may be in any form of writing including on paper, received electronically via fax or email or through the contact form available at https://www.aapm.org.au/About-Us/Contact-Us; must include the name of the Member who the complaint is about and refer to the complaint. must include an introductory summary of the Member’s response including any aspects of the complaint the Member agrees with. may include any information the Member deems relevant to the National Board’s investigation of the complaint. may include supporting statements from other people, and o may request further time to respond, provided that a fixed date for the response is nominated at the time of that request and is not more than 30 days later than the original date to respond.

6. Considering the complaint material

6.1	Upon receipt of the response, the National Board or its delegate will review and consider the information received from the complainant and in the response and determine whether any further additional information is required or should be obtained in order to determine the complaint.
6.2	If additional information is required the National Board may request that information from any person, seeking a response within 7 days, and notifying the person from whom information is requested (whether the complainant, the Member complained about or another person) that the complaint will be considered without that information if it cannot be provided within that timeframe.
6.3	Where additional information requested under 6.2 is not provided within the 7-day deadline, the Board will proceed with the complaint based on the information to hand.

7. Initial Findings

7.1

The National Board or its delegate will prepare initial findings about the complaint and provide those findings to the complainant and the Member complained about. Either or both the complainant and the Member complained about may respond in writing to the initial findings within fourteen (14) business days. Provision of initial findings are deemed to satisfy the requirements of rule 10.5(b) of the Constitution.

8. Final Determination

8.1	The National Board or its delegate will consider all responses to the initial findings received within the required timeframe and prepare a final determination of the complaint. The National Board or its delegate may publish a final determination that is the same as the initial findings, despite receipt of information in response to the initial findings.
8.2	The final determination is final and there will be no avenue of appeal from that decision.
8.3	Any actions required as a result of the final determination (e.g., Member suspension) will take effect immediately. The National Board may notify the AAPM membership of the results of its determination but is under no obligation to provide reasons to any party other than the complainant or the Member complained about.

9. Consequences of finding a contravention of the Code

9.1

Where the National Board determines that there has been a contravention of this Code by a Member, the National Board may do any one or more of the following: take no action. issue a warning to the Member. suspend the Member’s rights as a member for a period of time of no more than twelve (12) months, meaning the Member will be excluded from access to all member benefits, and not able to hold themselves out as being a Member of AAPM during the period of suspension, as well as being excluded from AAPM events. suspend the Member’s ability to access any one or more of the benefits of membership (e.g., nominating to serve on a state committee, nominating for a particular category of membership etc.) for a specified period of time of no more than twelve (12) months, and for period of suspension no fees will be refunded or extended. place conditions on the Member’s membership, including requiring the Member to repeat or undertake additional education or training within a specified timeframe. change or revoke a category of membership previously awarded to that Member. expel the Member from AAPM. refer the decision to an unbiased, independent person on conditions that the Board consider appropriate (however, the independent person can only make a decision that the Board could have made pursuant to these by-laws), and o make a recommendation on how AAPM Members can be educated to avoid the misconduct or breach of the Code of Ethical Conduct in the future.

10. Complaint process – likely time frames

0 days	Receipt of written complaint by AAPM.
+ 3 business days from AAPM’s receipt of complaint	Written acknowledgement of receipt of complaint to complainant with information statement about process. National Board notified that a written complaint is received.
+ 7 business days from AAPM’s receipt of complaint	Copy of complaint provided to National Board with confirmation of Membership status of person complained about. Copy of complaint provided to Member complained about, with information statement about process
+ 14 business days from AAPM’s receipt of complaint	Member complained about provides written response to the complaint.
+ 17 business days from AAPM’s receipt of complaint	National Board considers complaint and response and the Board or its delegate may request additional information from any person
+ 21 business days from AAPM’s receipt of complaint	Additional information received by National Board and considered.
+ 23 business days from AAPM’s receipt of complaint	National Board prepares initial findings and provides to complainant and Member complained about for consideration.
+ 37 business days from AAPM’s receipt of complaint	Complainant and Member complained about may provide a response to the initial findings of the National Board.
+ 40 business days from AAPM’s receipt of complaint	National Board considers responses to initial findings and prepares final determination of complaint
+ 45 business days from AAPM’s receipt of complaint	Final determination of complaint is provided to complainant and Member complained about, with notification of any aspects of the complaint that will published (e.g., Member sanctioned).

APPENDIX

CONFLICTS OF INTEREST

Conflicts of interest form a particularly fraught area of ethical debate for Practice Managers. It requires specific consideration in the Code of Ethics.

A conflict of interest occurs when a member’s personal interests’ conflict with their responsibility to act in the best interests of AAPM, clients, colleagues, and other professionals. Personal interests include those of family, friends, or other organisations a person may be involved with (for example, as a consultant). It also includes a divergence between a member’s responsibilities as a member of AAPM and another duty that the Member has, for example, to another organisation.

A conflict of interest may be actual, potential, or perceived. It may be financial or non-financial. It represents potential risks to reputation, good governance, accountability, transparency, and organisational dynamics. It may also be unlawful.

• The impact of a potential or perceived conflict of interest may well be as damaging to the reputation or management of AAPM as an actual conflict of interest. Each potential event must be assessed and managed accordingly.
• A perceived conflict of interest requires input from impartial third parties. Careful consideration of the perspective of someone who is not directly involved in the perceived conflict is vital. One possible course of action is to undertake consultation and discussion with other members, particularly senior and more experience Practice Managers. Promoting a culture of disclosure helps facilitate constructive consultations.
• A perceived conflict of interest can often be best addressed by removal or avoidance of the perceived conflict itself.

Members of AAPM:

• Conduct relationships in a manner which gives assurance to all parties concerned that their position will not be compromised, and their interests given fair consideration.
• Disclose to potential clients or employers any direct or indirect personal interest which might cause conflict, either real or perceived.
• Neither accept nor offer gifts or benefits with the expectation, or likely consequence of influencing, decision making.
• Do not promote themselves in a self-laudatory manner.
• Do not publicly criticise other members of AAPM.

For more detailed discussion, members are recommended to consult the following document: Australian Charities and Not-for-profits Commission (2015). Conflicts of Interest. Download from: www.acnc.gov.au

Case Studies

Initial Problem creating Ethical Concern	Clarifying The Ethical Considerations	Exploring Possible Strategies & Solutions
A Patient who has engaged in selfharming behaviours has been referred to see a psychologist but is refusing to do so. The patient’s family is unaware of the self-harming behaviour. The patient states they only trust the GP and refuses to see anyone else. Despite the best efforts of the GP, the patient continues to selfharm and refuse referrals.	You are concerned that the patient, without effective treatment, may eventually die. This raises issues around principles of Care and Empathy. The stress on the GP is understandable and might affect other patients. This also raises issues of Care, as well as Justice Principles, as first we must “do no harm”. The Practice has responsibility for the patient’s treatment. Refusing to continue treatment, because of noncompliance with the GP’s recommendations, might amount to withdrawing the only current source of treatment. Justice principles are again invoked because it is unfair to withdraw treatment without valid reasons. There are legal implications for the GP and for the practice if treatment is suspended or if it is continued for the noncompliant patient. These might raise further issues impacting on staff and patients.	Contact Professional Indemnity Provider for advice and consult experience colleagues for their input. This would ensure best practice standards can be considered. Engage the patient in a strategic conversation, exploring all points of view. As well as understanding the patient’s reluctance better, it also allows the needs of the Practice to be considered, including: Inviting the patient to see another GP in the Practice for a second opinion. This would protect the patient’s dignity and respect their autonomy, while Explaining again to the patient why it is essential they receive specialist treatment from a psychologist. This would ensure the patient makes fully informed decision about their health care options. Advising the patient that the Practice has a policy that a condition of continuing to treat them as a patient is contingent upon a patient following the GP’s treatment recommendations. Carefully document all conversations with the patient to record all efforts to persuade the patient to get specialist help. Discuss the issues with the GP and consider ways that the GP could empower the patient to engage with other health professionals.

Initial Problem creating Ethical Concern	Clarifying The Ethical Considerations	Exploring Possible Strategies & Solutions
A doctor is requesting the Practice Manager allow a patient to bulk bill a telehealth care plan, even though this would be incorrect.	The doctor is aware of the patient’s financial and clinical circumstances and is trying to help. The care plan item number activates access to other MBS services from other providers potentially contributing to patient health outcomes. The patient may miss any opportunity for allied health care if the patient cannot pay privately for all services. The principle of Beneficence is raised in this case, as the doctor is motivated by the intention to “do good” for the patient. The principle of care and empathy is apparently driving the doctor’s decision making, blurring the importance of other principles. Aspects of Integrity are also raised by the implications of the course of action proposed by the doctor.	One approach might be to initiate a conversation with the GP to discuss the decision-making process. It can provide an opportunity to review the ethical issues: How do we ensure we help patients in acceptable ways? What is the ‘bigger picture’ regarding the patient’s welfare? How are other key stakeholders potentially affected by the solution proposed by the GP? How do we ensure the integrity of the practice is preserved and its reputation not put at risk? It can provide opportunities for information sharing – e.g.: Print MBS guidelines for GP on how to bill correctly. Establish Practice policy for all GPs on billing procedures. Suggest the GP has a conversation with patient about costs and relevant rebates - as per RACGP and MBS requirements. Document any conversation that occurs and spell out the billing instructions of GP.

Initial Problem creating Ethical Concern	Clarifying The Ethical Considerations	Exploring Possible Strategies & Solutions
A current patient’s parent is seeking access to Medicare rebates for a Mental Health Care Plan and referred Better Health via Telehealth for the patient who is not presently in Australia.	The Patient is affected by Covid restrictions, and his mental health is deteriorating, creating issues of care and empathy for the patient, parents, and health professionals. Access to Psychology/Psychiatrist services through referral would minimise the cost services through the Medicare rebate. It introduces aspects of Justice Principles. Legal constraints on the Practice Manager raise ethical issues around Integrity and trustworthiness.	Practice Managers will probably feel concern and empathy for the patient yet will realise they cannot comply with the parents’ request. Nevertheless, they are able to discuss their dilemma with them and provide clarification. Explain the Medicare requirements in plain language to ensure they are understood effectively. Discuss accessing service providers local to the patient’s current location overseas. Explore the possibility of the parents offering financial support for patient’s immediate care.

Initial Problem creating Ethical Concern	Clarifying The Ethical Considerations	Exploring Possible Strategies & Solutions
An employee reports that a colleague is experiencing workplace harassment and bullying from a doctor within the practice. The colleague is reluctant to approach the Practice Manager directly but is distressed and unsure what to do	There is potential for deleterious impact on employee physical, mental, emotional wellbeing, raising issues of Care and Empathy. There is potential for deleterious impact on employee workplace performance and absence, raising concerns of fairness for all employees. There is impetus for an impartial investigation of allegation invoking the principle of Justice. Possible legal claims against doctor and practice arise, e.g. a WH&S claim. The employee is reticent to report the claim due to concern of its impact on future workplace opportunities and treatment by employer and colleagues. Raising equity and fairness concerns. A formal complaint could impact on the GP’s physical, mental, emotional wellbeing raising concerns of care and empathy for the GP. There is potential impact on the practice reputation, prompting concerns for the welfare of all practice associates.	Provide support to the employee as they encourage the colleague to approach you for a confidential interview. Having interviewed the colleague, consider all claims of workplace bullying as serious and take immediate action to investigate and resolve quickly and fairly while ensuring support for the colleague and the GP from appropriate individuals throughout the process. Contact Professional Practice Indemnity Provider for advice. Ensure owners/managers of the practice are aware of any claim arising from the interview while maintaining confidentiality. Review/Develop a practice Code of Conduct that clearly details the policy regarding response to bullying claims. Ensure all doctor and employees are aware of and have agreed to abide by the practice Code of Conduct Nominate impartial individuals/parties to investigate the veracity of claim. Manage the expectations of all parties, ensuring clear communication regarding the process for investigation, and potential actions in response to the findings. Respond to the findings of the investigation in accordance with the practice Code of Conduct. Provide and facilitate access to educational resources regarding bullying for practice associates. Provide and facilitate access to wellbeing supports as required (e.g., the use of an Employee Assistance Program) Take reasonable steps to ensure that if parties are required to work together that neither experiences difficulties at work as a result of any claim and subsequent process.

Initial Problem creating Ethical Concern	Clarifying The Ethical Considerations	Exploring Possible Strategies & Solutions
A daughter was appointed as a power of attorney for her mother who suffered from dementia. Two other daughters came to speak to the Doctor concerned that the first daughter was not fit to have hold the power of attorney. They were wanting to access the mother’s funds and her daughter would refuse access as the costs were not related to the mother’s expenses. The daughter holding the power of attorney was not a regular patient of the practice, although the two daughters and their mother were long-term patients of the Doctor.	The Doctor had to decide where her alliance was regarding this request by the other two daughters. She had to process the principles of confidentiality and privacy while at the same time wishing to assist her patients, touching on principles of care and empathic understanding. The principles of Justice also require consideration, as the mother could not make autonomous decisions. What is fair treatment for the mother in this context must be determined.	While the doctor might feel a great deal of sympathy and concern for her patients, any attempts to “do good” might cause ethical and legal complications and managed accordingly. Recognising and honouring the complex boundaries between the doctor, the patients, and the third sister is critical to the doctor being able to resolve this ethical dilemma effectively The outcome was that as legally the GP could not provide any assistance regarding her patients’ wish to access their mother’s funds, she informed the others of the limits of her professional responsibilities. The mother had granted power of attorney to the third daughter and that decision must be honoured. She suggested that the two patient/daughters could consider starting a discussion with their Solicitor.

Initial Problem creating Ethical Concern	Clarifying The Ethical Considerations	Exploring Possible Strategies & Solutions
A long term elderly patient asks the Practice Manager to help them lodge a complaint about one of the doctors, who the patient claims has been rude to them.	Principles of care and empathic understanding are raised in this case. The patient will benefit from support while they explain their concerns. Both the patient and the doctor are entitled to be treated fairly and impartially in regard to this dilemma. Even if the patient has proved to be difficult in the past, or if other patients have raised concerns, the matter cannot be prejudged in any way.	Providing the patient with the opportunity to explain her concerns and listening non-judgmentally might allow the Practice Manager to defuse the conflict and reassure the patient. Documenting the specifics of the issues involved might provide clarity and options for resolving the patient’s concerns effectively without pursuing a formal complaint Hearing the doctor’s side of the story might also shed valuable light on the matters at hand and assist the Practice Manager in any attempts to reconcile the differing perspectives.

Initial Problem creating Ethical Concern	Clarifying The Ethical Considerations	Exploring Possible Strategies & Solutions
An elderly patient has contacted the practice, asking for a driving medical. A member of the family later contacts the practice to say the patient is “unfit to drive and the doctor needs to know that fact when assessing the relative”.	The patient is entitled to be treated fairly and impartially, as the principles of Justice would indicate. Providing the patient with the benefit of presumed capacity to drive, unless the evidence proves otherwise, is an essential aspect of this process. The relative might have details regarding the patient’s driving history and any documentary evidence, such as facts of a recent accident, might be invaluable. The relative must therefore not be dismissed out of hand but given a chance to contribute to the process. To ensure impartiality, the doctor has to assess the case on its merits and not be biased by the relative’s opinions.	The relative could be invited to submit any documentary evidence that might assist the doctor in her assessment of the patient. The patient can be supported through the medical assessment process, to minimise any stress and the subsequent impact that might have on performance. If the doctor has a Iong-standing relationship with the patient, there might be an unintentional bias towards assessing the patient favourably. Informing the doctor of the call from the relative and providing any documentation that the relative is able to provide can perhaps help ensure that the doctor is able to evaluate the patient’s performance more impartially. The patient might react negatively to losing his licence and grieve the loss of independence. Appropriate referrals to support services might be an option worth exploring with the patient once the assessment is completed.

Initial Problem creating Ethical Concern	Clarifying The Ethical Considerations	Exploring Possible Strategies & Solutions
One patient has offered a gift of more than minor value to staff at the practice. Initially, the patient gave a small bunch of flowers to the reception to thank them for being so helpful with changing the patient’s appointment times. Over time, this gesture grew to bouquets of flowers for the reception desk and a box of chocolates to be shared by the staff members. This time, the patient has suggested buying a few bottles of champagne for the annual break-up lunch	It might be helpful to establish the patient’s motivation for donating presents in this manner. Principles of care and empathic understanding come into focus here. A respectful, supportive conversation can help the Practice Manager understand the patient’s point of view more comprehensively. Concerns regarding conflicts of interest for staff members are worth considering. While small gifts may seem harmless and a refusal might offend the patient, the Practice Manager has to be conscious of the ‘slippery slope’ that can arise from accepting gifts that cross the line and lead to boundary violations. The integrity of the Practice Manager could then come into question. The wellbeing of the patient is an aspect to consider in this dilemma. Feeling obliged to keep giving better gifts could cause emotional or financial concerns.	Conducting a respectful and supportive conversation with the patient might assisting the Practice Manager in understanding the patient’s motivation and understanding of the issues involved. Clear boundary setting and explicit statements regarding the acceptability of presents and gifts could help the patient understand why gift-giving in this context might not be as beneficial as perhaps intended. While the patient might be well-meaning, it is important to distinguish between doing good for others and such gestures having adverse consequences even if unintended. Explaining the legal and ethical constraints that the practice would face if this gift was accepted. If done in a way that does not embarrass or shame the patient, it might open up opportunities for exploring other ways in which the patient can express gratitude to the staff without compromising their ethical and legal standards.

Initial Problem creating Ethical Concern	Clarifying The Ethical Considerations	Exploring Possible Strategies & Solutions
An elderly doctor who has been a member of the practice for many years has been reported by several patients to be out of date and appearing senile during some consultations, forgetting details, and losing track of the conversation. The doctor has needed to retire for several years now but there is a shortage of doctors in this particular region of rural Australia	The primary ethical consideration in this scenario would be to ensure that no harms occur to patients. The risk of harm is unknown at present, although there is circumstantial evidence suggesting the doctor is creating a hazardous situation. There is also risk of harm to the community, as the shortage of appropriate health care might be exacerbated if the doctor is prematurely prevented from practising. The wellbeing of the doctor and of patients happy with their care are factors that need to be considered. Principles of care and empathic understanding can be invoked.	A timely conversation with the doctor raising the concerns voiced by the patients in question and addressing the doctors’ capacity to practise at this time, could be initiated by the Practice Manager. All or none solution might not be called for at this point. It might be appropriate, for example, to negotiate with the doctor about voluntarily adopting restrictions on limits to practice. The doctor might then find a valuable niche role within the practice that does not overly deplete its professional resources. Organising, with the doctor’s cooperation, a comprehensive assessment of the doctor’s current capabilities would offer reassurance to the practice members that the doctor is not placing patients at risk. On the other hand, it can potentially open discussions for a more formal investigative process to commence.

Initial Problem creating Ethical Concern	Clarifying The Ethical Considerations	Exploring Possible Strategies & Solutions
A doctor is refusing to see a patient who is an adult sex worker and there are no other suitable referrals that can be made for the patient.	It is possible that the doctor is refusing to see the patient because of their own moral concerns. Understanding the doctor’s point of view would benefit suitable management of this conflict, suggesting that Principles of care and empathic understanding are involved. There might be other reasons why the doctor is refusing to treat the patient, and this possibility can be fruitfully explored in a frank and open discussion with the doctor. Principles of Justice and fairness also apply to the doctor, and need to be considered. Ultimately, the patient has a right to be treated fairly, without moral judgement on the part of health care workers. This consideration has to be borne in mind throughout the process, as matters of justice and fairness for the patient do come into the equation. There is also the aspect of health and welling of the community. Failing to treat this patient might potentially lead to increased prevalence of sexually transmitted infections in the community. Thus, questions of justice and fairness for others are also raised by the facts of this case.	Initiating a conversation with the doctor to establish more clearly the basis for their refusal to see this patient would be valuable. If the refusal is based on moral grounds such as religious values, then the process might involve inviting the doctor to consider the implications of their position on treatment options for these patients. It might also be possible to explore other issues that could be affecting the doctor’s decision. For example, it might be worth considering the possibility that unconscious biases, e.g. based on gender, are at play here. The doctor’s wellbeing also needs to be considered in any such conversations. They might be deeply distressed by having to confront difficult decisions of this sort, and appropriate support and understanding would be appropriate in such circumstances. There is opportunity for creative problem-solving here and the answer might not be a single yes or no decision. For example, a solution might be as straightforward as a referral to another doctor in the practice who is prepared to take on the patient’s care. It would be important not to neglect the patient in a scenario such as this. Depending on how the initial refusal was communicated to the patient, if it has been, they might be feeling shamed by the decision, or desperate to seek essential health treatment. If the patient is aware of the doctor’s initial position on providing treatment to them, an interview with the patient might help with short-term problem solving to ensure the health and wellbeing of the patient.

Policy name	Mission Australia Code of Conduct
Policy date	May 2021
Authorisation	Board
Policy owner	Executive, People and Culture
Policy type	Enterprise Policy and Governance
Policy Setting	Ethics

1 Purpose

1.1.1	To assist Mission Australia, maintain a harmonious and ethical work environment, which upholds Mission Australia’s Founding Purpose and Values
1.1.2	The Code of Conduct sets out the basic principles and rules that all members of the Mission Australia team must follow in the performance of their work.
1.1.3	Mission Australia may amend or vary this Code of Conduct, in its absolute discretion, from time to time.

2 Scope

2.1.1

The Code of Conduct applies to all members of the Mission Australia team comprising Mission Australia Directors, employees, volunteers, student placements and contractors of Mission Australia (MA People or “you”).

3 Guiding Principle

All MA People are expected to behave in ways that are aligned with our Founding Purpose and Values.

3.1 Founding Purpose

3.1.1

Inspired by Jesus Christ, Mission Australia exists to meet human need and to spread the knowledge of the love of God.

3.2 Our Values

3.2.1

Our core values underpin all that we do. They are: Compassion - We are sensitive, understanding and caring in our service of all people. Integrity - We are honest and transparent in our relationships and are accountable for our performance. Respect - We treat people with respect, recognising them as they are and always offering compassionate support. Perseverance - We are dedicated to serving and helping people to overcome their challenges, no matter how hard it is. Celebration - We readily celebrate the efforts and successes - large and small - of the people we help, our volunteers, supporters, and colleagues.

4 Policy

4.1.1	The Code of Conduct outlines the required standard of acceptable conduct and behaviour that we expect of all MA People in the performance of your duties and interactions at work no matter where you are performing your duties. This required standard of acceptable conduct and behaviour supports our ability to maintain public trust and confidence in the integrity and professionalism of the services we provide to the community, and our ethos as a non-denominational Christian organisation.
4.1.2	The Code of Conduct and the behaviours outlined within it are fundamental to Mission Australia building healthy, positive, and respectful relationships with our clients. The Code of Conduct also governs the way in which all MA People are expected to relate to one another, external professionals, clients, visitors, and all stakeholders.
4.1.3	The Code of Conduct is not intended to provide a detailed and exhaustive list of what to do in every aspect of work. Instead, it represents a broad framework that will help guide conduct and behaviour in the performance of duties and interactions in the workplace.

5 Responsibilities

5.1 All MA People

5.1.1	Responsibilities Be aware of, and comply with, the Code of Conduct. Model our Values of Integrity, Respect, Perseverance, Compassion and Celebration Perform your defined duties to the best of your ability. Report behaviour that may be contrary to the Code of Conduct and required standards of behaviour. Comply with mandatory reporting requirements, including but not limited to, mandatory reports of domestic and family violence, reportable incidents involving children and vulnerable people or other regulatory requirements. Keep all records, documents and communications accurate, truthful, and up to date. Inform yourself and comply with all Mission Australia policies and procedures relevant to your position
5.1.2	Personal & Professional Behaviour Uphold the highest standards of honesty, integrity, and transparency in theconduct of duties. Treat others, including other MA People, funders and clients with respect, dignity, fairness, and courtesy. Exercise best judgment in the interests of Mission Australia and our clients. Make decisions ethically, fairly and without bias, using the best information available. Never act in a discriminatory, harassing, or violent way towards others. Never use your position to gain an advantage over or exploit the vulnerability of others. Avoid putting yourself or Mission Australia in a real or perceived conflict of interest. Conduct all business activities in a responsible manner, consistent with ethical obligations of stewardship and in accordance with all applicable laws, policies, and procedures.  Always strive for the highest health, safety and environmental standards in all facilities, sites, and work areas.  Use information technology, including internet and email, in a professional and appropriate manner, in accordance with relevant Mission Australia policy.  Never participate in, or assist others to participate in, any illegal and/or criminal activities.  Comply with any legislative, industrial, or administrative requirements, and all lawful and reasonable directions given by persons in authority.  Act responsibly in the event of becoming aware of any unethical behaviour or wrongdoing by any other member of the Mission Australia team and report such conduct or activities to the appropriate level of management.
5.1.3	Use of Mission Australia resources Never destroy or take for personal use any items belonging to Mission Australia without prior written approval. Use Mission Australia equipment, funds, facilities and other resources effectively, economically and carefully and for the benefit of Mission Australia.
5.1.4	Public comment Ensure that public comments (either verbal or written) made in a private capacity are not attributed as official comment of Mission Australia. In this regard, the use of official stationery, email addresses, text messages or any other electronic identifiers is not permitted for private correspondence or for purposes not related to official Mission Australia duties.
5.1.5	Use of information Collect, use, and disclose confidential information only in accordance with Mission Australia policy and applicable privacy laws. Protect confidential information. Only access confidential information when it is required for work purposes. Not use confidential information for any unofficial or non-work purposes.  Only release confidential information if authorised to do so. Confidential information is information obtained or developed in the course of the conduct of Mission Australia’s business and which if disclosed will or could lead to risk, damage or injury to Mission Australia, MA People, clients or third parties.

5.2 People Leaders

5.2.1

People leaders have an additional responsibility to ensure this Code of Conduct is accessible, understood and complied with by all people they are responsible for at all times by: Taking appropriate steps to resolve conflict that arises in the workplace to ensure a healthy and harmonious work environment. Taking appropriate action to address breaches of the Code of Conduct by employees, volunteers, or contractors. Complying with mandatory reporting requirements, including but not limited to, mandatory reports of domestic and family violence, reportable incidents involving children and vulnerable people or other regulatory requirements.

6 Conflicts of Interest and Relationships

The Code of Conduct is to be read in conjunction with the policies listed below, including the Conflict of Interest Policy and the Good Working Relationships Policy, which apply to all MA People.

In addition, the Code of Conduct considers appropriateness of certain personal relationships.

6.1 Personal Relationships

6.1.1

Under no circumstances are you permitted to develop personal relationships with clients, including after-hours and through the use of digital and social media. This includes where the personal relationship develops within a two-year period after the client is no longer accessing Mission Australia services. A personal relationship is an association between two or more people that may be based on liking, love, some other type of social commitment or regular business interactions. Personal relationships may include a relationship between two parties that can have the unintentional effect of influencing judgement or behaviour or creating a perception of influencing judgement.

6.1.2

Any pre-existing relationship that may lead to a conflict of interest including with the client must be disclosed to your people leader or senior manager and the Conflict of Interest Policy must be followed: A plan is to be put in place and approved by the State Director/General Manager to mitigate any potential conflict of interest. The relationship must not directly or indirectly compromise the performance of your duties or conflict with Mission Australia’s interests at any point in time. If you are involved in a decision relating to the selection, appointment, or promotion of a person with whom you share a personal relationship, for example a family member, it must be immediately declared in writing to the relevant Executive prior to the decision to hire. Mission Australia treats all conflicts of interest in this regard extremely seriously and any instance of non-disclosure may result in disciplinary action, including, termination of employment.

6.2 Secondary Employment

6.2.1	MA People, excluding members of the Executive Team, are permitted to engage in outside employment, provided that this employment does not have a detrimental impact on your ability to meet the requirements of your role, adversely affect your work performance or give rise to a conflict or potential conflict of interest.
6.2.2	Before engaging in work that could potentially raise a conflict of interest, you must seek written permission from a senior manager. Approval will not be granted where the secondary employment involves, or could involve, a conflict of interest with Mission Australia-related duties or could reasonably be perceived by a member of the public to give rise to a conflict of interest.
6.2.3	Executives are not permitted to engage in any secondary employment and must seek written approval from the Chairman of the Board before accepting any directorships.

7 Responsibilities after Leaving Mission Australia

7.1.1	MA People who leave Mission Australia must: Not disclose any official information after leaving Mission Australia that was non-disclosable during their engagement. Ensure that public comments (either verbal or written) made in a private capacity are not attributed as official comment of Mission Australia. Not use official stationery, email addresses, text messages or any other electronic identifiers of Mission Australia for any purpose.
7.1.2	MA People must be careful in your dealings with former employees and ensure you do not give them favourable treatment or access to personal, confidential, or official Mission Australia information.
7.1.3	MA people must not use your position to advance your prospects for future employment, or allow your work to be influenced by plans for, or offers of, external employment which would conflict or compromise in any way the best interests of Mission Australia

8 Failure to Comply with the Code of Conduct

8.1.1

MA People may be subject to disciplinary action, up to and including termination of employment or contract, where it is established that you have breached the Code of Conduct.

9 Authority

9.1.1	This Policy has been authorised by the Board of Directors.
9.1.2	Mission Australia may amend or vary this Code of Conduct, in its absolute discretion, from time to time.

10 Resources

10.1 MA People are expected to comply with all Mission Australia policies and procedures and are not limited to the below list of policies:

10.1.1 Speak Up & Speak Out Statement
10.1.2 Good Working Relationships Policy
10.1.3 Gifts & Benefits Policy
10.1.4 Conflict of Interest Policy
10.1.5 Grievance Management Policy
10.1.6 Managing Underperformance and Misconduct Policy
10.1.7 Domestic and Family Violence Policy
10.1.8 Social Media Policy
10.1.9 Business Technology Policy
10.1.10 Whistleblower Policy
10.1.11 Fraud Control & Corruption Prevention Policy

Benefits of good complaint handling

Complaints are an important way for the management of an organisation to be accountable to the public, as well as providing valuable prompts to review organisational performance and the conduct of people that work within and for it.

A complaint is an “expression of dissatisfaction made to or about an organisation, related to its products, services, staff or the handling of a complaint, where a response or resolution is explicitly or implicitly expected or legally required” 1 . As a matter of guidance, complaints can be made directly to an organisation by members of the public and/or customers, or through alternative pathways such as to Members of Parliament or statutory officers but otherwise about the organisation.

Effective complaint handling is fundamental to the provision of a quality service.

An effective complaint handling system provides three key benefits to an organisation:

• It resolves issues raised by a person who is dissatisfied in a timely and cost-effective way;
• It provides information that can lead to improvements in service delivery; and
• Where complaints are handled properly, a good system can improve the reputation of an organisation and strengthen public confidence in an organisation’s administrative processes.

The public wants:	The organisation needs:
a user friendly complaint handling system to be heard and understood to be respected an explanation an apology action as soon as possible	a user friendly complaint handling system to be heard and understood to be respected an explanation an apology action as soon as possible

Effective complaint handling systems

Steps:

1. Enabling Complaints
   • Arrangements for enabling people to make complaints are customer focused, visible, accessible and valued and supported by management.
2. Responding to Complaints
   • Complaints are responded to promptly and handled objectivelyt, fairly and confidentially. Remedies are provided where complaints are upheld and there is a system for review.
3. Accountability and Learning
   • There are clear accountabilities for complaint handling and complaints are used to stimulate organisational improvements.

Ten Principles for an Effective Complaint Handling System

Enabling complaints

Having a customer focused system that is visible and accessible, with a demonstrated commitment from the organisation’s management.

Customer focused	Principle: The organisation is committed to effective complaint handling and values feedback through complaints. Organisations should be open to feedback and committed to seeking appropriate resolution of complaints and addressing policy and process inadequacies highlighted by them. This commitment should be communicated to all staff, stakeholders and clients, for example through documents such as values statements or customer service standards. Organisations should have a clearly communicated complaint handling process and management that values the benefits of an effective complaint handling system and supports the process.
Visibility	Principle: Information about how and where to complain is well publicised to customers, staff and other interested parties. Information about how and where to complain should be well publicised through a variety of service delivery points including publications, websites, at offices and at front counters. Front-line staff should be aware of the complaint handling process and the contact details of the organisation’s Complaint Handling Officer(s). The information about how to complain should identify any appropriate alternative external parties the complainant can go to with their complaint.
Accessibility	Principle: The process of making a complaint and investigating it is easy for complainants to access and understand. Complaints should be handled at no charge and this should be made clear in information provided about the complaint handling process. Information about the complaints process should be available in a variety of forms of communication, formats and languages appropriate to the needs of the customer. Complaints and all supporting documents provided during a complaint resolution or investigation process should be accepted in a number of different ways including in person, over the phone, and in writing via email, fax and letter, and, where appropriate, access to translating and interpreting services for non-English speaking people should be provided. Complaint handling systems should be accessible to members of the public who may require additional assistance such as Indigenous Australians, children and young people, people living in regional and remote areas, people with disabilities and people from culturally and linguistically diverse backgrounds. For more information, see the Ombudsman WA Guidelines Making your complaint handling system accessible.

Responding to complaints

Complaints are handled objectively and fairly with appropriate confidentiality, remedies are provided where complaints are upheld and there is a system for review for finalised complaints.

Responsiveness	Principle: Complaints are acknowledged in a timely manner, addressed promptly and according to order of urgency, and the complainant is kept informed throughout the process. Guidance should be provided to staff on how to respond to and prioritise complaints. They should be aware of internal complaint handling processes including how to assess complaints which may be resolved quickly and those which require investigation. Complaints should be acknowledged promptly. Complainants and, if applicable, the person who is the subject of the complaint, should be kept informed of progress and the outcome of the complaint. Complaints should be addressed promptly in order of urgency and staff should be aware of any target timelines for resolving complaints. Complaint Handling Officers should be empowered to either resolve complaints or be aware of, and have access to, the person who has the authority to do so. Where appropriate, special arrangements for responding to particular client groups should be put in place, for example, Indigenous Australians, children and young people, people living in regional and remote areas, people with disabilities and people from culturally and linguistically diverse backgrounds. Staff should be able to identify matters that may be public interest disclosures and refer them to the appropriate process, and should refer any identified misconduct and corrupt behaviour to the Corruption and Crime Commission (www.ccc.wa.gov.au) for serious misconduct or the Public Sector Commission (www.publicsector.wa.gov.au) for minor misconduct 2.
Objectivity and fairness	Principle: Complaints are dealt with in an equitable, objective and unbiased manner. This will help to ensure that the complaint handling process is fair and reasonable. Unreasonable complainant conduct is not allowed to become a burden. Complaint Handling Officers should deal with all complaints on their merit in an equitable, objective and unbiased manner. They must ensure that any conflicts of interest are declared. Complaint Handling Officers should ensure the complainant and, if applicable, the person who is the subject of the complaint, is given sufficient opportunity to present their position, to comment on any adverse findings and is provided with reasons for decisions on the outcome of the complaint. Complaint handling systems should have a review process in which the Complaint Handling Officer’s decision is reviewed by a suitably experienced colleague or superior before the complaint is finalised. There should also be an independent internal review or appeal process. Officers receiving and handling complaints should receive appropriate guidance or training, including for dealing with unreasonable conduct by the complainant or the subject of the complaint The Ombudsman WA publications Conducting administrative investigations, Investigation of complaints, Procedural fairness and Dealing with unreasonable complainant conduct may assist your staff in handling complaints with objectivity and fairness.
Confidentiality	Principle: Personal information related to complaints is kept confidential. The personal information of the complainant and any people who are the subject of a complaint should be kept confidential and only used for the purposes of addressing the complaint and any follow up actions.
Remedy	Principle: If a complaint is upheld, the organisation provides a remedy. Mechanisms should exist for enabling appropriate remedies to be provided when complaints are upheld and staff should be familiar with them. Staff should be able to give the complainant reasons for decisions relating to remedies. Staff should be empowered to provide these remedies at the appropriate level, for example some appropriate remedies may be provided by front-line staff.
Review	Principle: There are opportunities for internal and external review and/or appeal about the organisation’s response to the complaint, and the complainants are informed about these avenues. There should be an independent internal review or appeal process. Details of external rights of review or appeal for unresolved complaints should be made available to complainants

Accountability and Learning

There are clearly established accountabilities for complaint handling and continuous improvement opportunities are identified and implemented, as appropriate.

Accountability

Principle: Accountabilities for complaint handling are clearly established, and complaints and responses to them are monitored and reported to management and other stakeholders. There should be clear responsibilities for handling complaints. This may include officers who are specifically assigned to deal with complaints and the names of these officers should be communicated to staff. Organisations should have a ‘fit for purpose’ centralised system for recording and tracking complaints along with reasons for any decisions. This system should be able to provide information on the demographic make up of complainants to enable an assessment of differing service delivery needs for people from a range of backgrounds. Complaints can be made directly to an organisation by members of the public and/or customers, or through alternative pathways such as to Members of Parliament or statutory officers but otherwise about the organisation. Complaints and actual or proposed improvements to practices should form part of the organisation’s internal reporting and planning process through such channels as Corporate Executive meetings and Strategic and Operational Plans. Remedies and proposed improvements to practices should be followed up and acted on. All correspondence relating to feedback and complaints should be managed in accordance with the organisation’s record keeping plan, policies and procedures. For more information, see the Ombudsman WA Guidelines Good record keeping. The effectiveness of the complaint handling system should be monitored, for example, through quality assurance or internal audit processes and reported to Corporate Executive along with recommendations for system improvements.

Continuous Improvement

Principle: Complaints are a source of improvement for organisations. Organisations should analyse complaints data and feedback to identify recurrent themes that might identify systemic issues and use the information gathered through their complaint handling systems to identify service, process and information issues that need to be addressed. Where appropriate, analysis of feedback and complaint information should be used to identify and implement improved practices for particular customer groups including people with disabilities, people living in regional and remote areas, Indigenous Australians, children and young people, and people from linguistically and culturally diverse backgrounds.

Organisations may find the Ombudsman WA publication Complaint handling systems Checklist useful to assess their complaint handling system.

Fit for purpose complaint handling system

An effective complaint handling system should be a ‘fit for purpose’ system. This is a system that is varied to fit an organisation’s circumstances and is proportionate to the number and type of complaints it receives. Decisions about building a ‘fit for purpose’ system could incorporate the following considerations:

• The number and demographics of the organisation’s customers, and how they generally communicate with the organisation;
• The nature and breadth of the organisation’s interactions with the public;
• The level of complaints that is considered reasonable for the organisation (by examining trends in its level of complaints over time and industry benchmarks);
• The organisation’s risk management strategy – complaints are an important way of monitoring and mitigating any risks;
• The value the organisation derives, or wishes to derive, from complaints to improve it’s operations over time, as well as other information needs of management; and
• The cost of operating a complaint handling system.

Complainants are more likely to be satisfied with the complaint handling system if the person dealing with their complaint is competent, objective and efficient.

Complaint Handling Officers

Complaint handling is an important role in an organisation and should be recognised as such by management. Complaint Handling Officers are the most important factor in ensuring that an organisation’s complaint handling is responsive to complainants. Complaint Handling Officers should be empowered to make decisions, or have access to someone who can make decisions.

An effective resolution at the earliest opportunity will enhance the complainant’s view of the organisation and allow prompt improvement to practices. Complaints should be handled by people who have the appropriate skills and authority to resolve or investigate complaints and, where appropriate, provide remedies and identify improved practices.

Where possible, complaints are best handled by people at the point of service delivery. These people should be able to resolve complaints at first contact and should log complaint details for further analysis. More serious complaints, or complaints that cannot be resolved by front-line staff, should be referred to more senior staff or designated Complaint Handling Officers for investigation, resolution and any other appropriate action.

All staff should be made aware of their responsibilities in providing information to help investigate and resolve complaints, and to implement actions to provide remedies or systemic improvements arising from complaints. For more information see the Ombudsman WA Guidelines Guidance for Complaint Handling Officers.

Complaints investigation and resolution process

Complaints should be dealt with promptly, courteously and in accordance with their urgency. The essential steps in investigating and resolving a complaint are:

1.    Assess the complaint	Clarify the issues of the complaint and what kind of resolution the complainant is seeking. If it is not a matter that can be handled by the complaints process, refer the complainant to a more appropriate process (e.g. an appeal process) or a more appropriate body such as the Ombudsman. For example, consider whether the matter is a public interest disclosure and should be handled under that process.
2.    Continuous Improvement	Where appropriate and possible seek to achieve resolution. Where resolution is reached, document the agreed action. In this event it may not be necessary to continue with the investigation unless there are systemic issues that require further examination outside the complaint process.
3.    Select the appropriate investigative approach	If the complaint is not resolved, determine what action is required, which may include options other than a formal investigation. This can depend on factors such as statutory requirements which may apply, the nature of the issue and the likely outcome of the investigation. Where possible, complaints should be resolved without the need for a formal investigation.
4.    Plan the investigation	Define the issues to be investigated and develop an investigation plan.
5.    Ensure proper powers and authority	Assess whether the Complaint Handling Officer has the necessary powers to obtain evidence from relevant witnesses and to access relevant records. Ensure they have the authority to conduct the investigation, make a decision and resolve the complaint, or have access to a person who can make decisions and offer remedies.
6.    Obtain evidence	Carry out the investigation by gathering sufficient reliable information to enable the issue to be properly addressed by proving or disproving matters relevant to the issue being investigated, taking into account all relevant information and no irrelevant information. At this stage, it may be necessary to refer any matters that may be misconduct or corruption to the Corruption and Crime Commission.
7.    Reconsider resolution	Consider whether resolution is now possible.
8.    Reporting and recommendations	Prepare a document setting out the complaint, how the investigation was conducted, relevant facts, conclusions, findings and recommendations. Recommendations could include remedies for the complainant, action to improve the organisation’s service delivery and action to address inappropriate conduct by an officer (e.g. through training, an appropriate disciplinary process or referral to an appropriate external authority).
9.    Decide on the complaint and action to be taken	Refer the report to a person authorised to make a decision about the complaint and the action to be taken. After the decision is made arrange implementation of the agreed action and for follow up to confirm the action occurs.
10.    Inform the parties	Upon completion of an investigation, the complainant (and, if applicable, the person who is the subject of the complaint) should be given: Adequate reasons for any decision made; Any changes or action that have resulted from the complaint; A remedy, where appropriate; and Information on where to seek independent internal and external review (e.g. the Ombudsman).

For more information see the Ombudsman WA Guidelines Investigation of complaints and Conducting administrative investigations which provide more detailed ‘step-by-step’ guidance.

Providing remedies and redress

If an investigation of a complaint determines that the service provided by an organisation to an individual is unsatisfactory and the organisation has in some way contributed to this, the organisation should provide redress to remedy the situation.

Circumstances that warrant the provision of redress and remedies by an organisation to a complainant can arise in many ways, but in broad terms, are when any one, or a combination, of the following occurred:

• Poor communication resulted in misunderstandings or misapprehensions;
• An inadequate or unfair process was used to arrive at a decision or provide a service; or
• A decision or action was unfair, disproportionate or unreasonable in the circumstances.

The following principles and possible remedies may be useful in determining appropriate remedies:

Principles involved in the consideration of redress

Mistakes are admitted and put right; A sincere and meaningful apology is offered; Redress is fair and reasonable; As far as possible, redress restores the complainant to their original position; Decisions about redress are procedurally sound; and Arrangements and reasons for providing redress are made transparent.

Possible remedies that may be offered to complainants

An apology; Reconsideration of a decision; Amending or retracting documentation (e.g. publications, media statements, web pages); An offer of non-financial assistance, as appropriate (e.g. providing information or contact details); Appropriate compensation for loss; Changed policies or practices to prevent a reoccurrence; and Action to modify the behaviour of the staff member who the complaint was about, if applicable

For more information, see the Ombudsman WA Guidelines Remedies and redress.

Dealing with unreasonable complainant conduct

Most complainants act responsibly. However, some complainants are difficult to satisfy and occasionally the conduct of some complainants can be challenging because of:

• Unreasonable persistence;
• Unreasonable demands;
• Unreasonable arguments;
• Unreasonable behaviour; or
• Unreasonable lack of cooperation.

In these circumstances, special measures to deal with this conduct may be required. It is important to remember that, even where a person’s conduct may be unreasonable, they may have a valid complaint and their complaint should be handled appropriately. Fair consideration must be given to the complaint while ensuring that there is not undue use of resources to investigate and resolve the complaint.

The subject of the complaint may also show unreasonable conduct and special measures may also be needed to handle their conduct while ensuring they are treated fairly.

For more information on how to handle unreasonable conduct, see the Ombudsman WA Guidelines Dealing with unreasonable complainant conduct.

Resources

Other Ombudsman Western Australia Publications

The following Ombudsman WA publications are available on our website at http://www.ombudsman.wa.gov.au and provide further details that may be useful in the development of complaint handling systems and for staff involved in handling complaints:

• Guidance for Complaint Handling Officers
• Complaint handling systems Checklist
• Making your complaint handling system accessible
• The principles of effective complaint handling
• Investigation of complaints
• Conducting administrative investigations
• Procedural fairness
• Dealing with unreasonable complainant conduct
• Remedies and redress
• Good record keeping

The Ombudsman's Report 2009-10 Survey of Complaint Handling Practices in the Western Australian State and Local Government Sectors also provides further information on complaint handling practices in public authorities.

This Information Sheet provides guidance on Implementing organisation policies and procedures.

Policies and procedures are the foundation of quality management. They document the way in which all key activities In the organisation are to be conducted, setting standards and maintaining consistency.

Policies are concise formal statements outlining what the organisation adheres to and aims to achieve on matters of service delivery and operations. Procedures are the details and steps of how a policy is to be applied and achieved. Policies and procedures are often accompanied by supporting documents that are used in the practical application of policies and procedures (for example, the organisation’s standard forms and checklists).

Service providers need policies and procedures to communicate to and instruct the governing body and staff in consistent and good practice. They must clearly articulate expected levels of performance, activities, roles and responsibilities.

Policies and procedures are also a critical tool for ensuring the rights of customers are protected and that their safety and quality of service are guaranteed. Service providers have an ethical and legal responsibility for directing and managing procedures such as privacy protection, complaints management and critical incident or harm reporting.

The service provider should also have a policy on how to develop, Implement and review policies and procedures.

Implementing policies and procedures

Implementing policies and procedures involves several steps from identifying the need for a new policy to continuously monitoring, reviewing and improving.

Identify the need
Action: Assess policy need

• Consider the effects of changes to internal and external environment and if new policies and procedures are needed, or if existing policies and procedures need amending.
• Review self-assessment against standards and/or external audit reports to identify policy changes or development needed.

Action: Assign responsibility

• Assign responsibilities to individuals and teams for researching, developing, approving or endorsing.
• and implementing policies and procedures.
• Consider the time, knowledge and skills required and best fit with staff and their positions.

Research
Action: Research

• Analyse the potential scope of the policy, who it will affect and relationship with other policies and procedures.
• Identify minimum requirements and desired best practice as per quality standards, industry guidelines and legislation.
• Research policy topic to inform content development.

Draft and consult
Action: Draft content

• Draft content based  on  policy  need,  minimum  requirements, desired  best  practice  and  research findings.
• Use the organisation’s standard policy and procedure templates.

Action: Consult

• Consult with relevant staff and governing body members on the draft policy and procedure, particularly those that are likely to be impacted by the policy and procedure.
• Consult with customers and stakeholders on relevant draft policies and procedures.

Finalise and implement
Action: Finalise content

• Incorporate appropriate changes to finalise policies and procedures.
• Where major changes to intent or content, a second (even if limited) consultation may be required.
• Develop supporting resources.

Action: Obtain endorsement or approval

• Obtain  and  document  formal  endorsement  or  approval  from  designated  authority  (usually  the governing body or delegated senior staff).

Action: Implement
Apply version control to all documents –recording details to ensure the most current version is able to be identified and distributed and to track changes made to previous versions, e.g.

Version number	Date approved	Approved by	Summary of changes from previous version
2015/3	2 June 2019	CEO and governing body	Updated to comply with 2015 privacy legislation. Incorporates more detail on staff responsibilities.

• Notify staff of new/updated policies, procedures and supporting documents –email, internal news,
• staff meeting, etc.
• Advise customers of any new/updated policies or procedures affecting them directly (such as complaints management, privacy and confidentiality etc)
• File hard and/or electronic copies in accessible locations for relevant staff.
• Provide opportunities to raise any policy implementation issues.
• Check immediate impact and effectiveness to identify and prevent any unexpected risks.

Monitor, review and improve
Action: Monitor policy application

• Monitor new policies to ensure they are understood, applied and if they have achieved their purpose and outcomes.
• Document   significant   implementation   issues   or   policy   concerns   to   inform   review and   further development.

Action: Review and improve

• Review all policies, procedures and supporting documents as part of a scheduled cycle.

This fact sheet covers:

• your organisation’s responsibility for the safety of its volunteers
• your organisation’s responsibility for the actions of its volunteers, and
• ways to minimise the risk to volunteers and others.

Your organisation is legally responsible for the safety of its volunteers and may also be legally responsible for the actions of volunteers that cause injury or loss to others.

Your organisation has a legal obligation to provide and maintain a safe working environment for its volunteers. There are also laws which provide that, in certain situations, your organisation may be held legally responsible for the actions of its volunteers.

Therefore, it is crucial for your organisation to have good volunteer management practices, policies and insurance in place.

1. Safety of Your Volunteers

   Your organisation has a legal obligation to provide and maintain a safe working environment that is without risk to the health and safety of its workers, including its volunteers, so far as is reasonably practicable to do so.

   This obligation is prescribed by Queensland’s work health and safety legislation, namely, the Work Health and Safety Act 2011 (Qld) and the Work Health and Safety Regulation 2011 (Qld) (together, QLD WHS Laws).

   The QLD WHS Laws set out various duties that organisations and individuals must comply with in the workplace that are regulated and enforced by Workplace Health and Safety Queensland (WHSQ). WHSQ may prosecute organisations and individuals who do not comply with WHS duties under the QLD WHS Laws.

   The QLD WHS Laws apply to ‘people running a business’, essentially, organisations that have employees. They do not apply to organisations that only engage volunteers and have no employees or contractors (volunteer associations).

   However, in addition to QLD WHS Laws, under the common law of negligence (established by the courts), not-for-profit organisations owe a duty of care to their volunteers to take reasonable steps to avoid foreseeable harm, injury or loss. So, even if your organisation is a volunteer association, it has an obligation under common law to provide a safe working environment.

   Organisations and officers of those organisations can satisfy this duty by:

   • identifying any risks that their volunteers face
   • assessing the level of risk they may face, that is, how likely it is that something will happen and the seriousness of that risk, and
   • implementing a process that will eliminate the risk or, if the risk can’t be eliminated, implementing a process that will minimise the risk as far as possible.

   For more information about risk management, see Section 3 below.

   EXAMPLES

   Driving a client to an appointment – it is important to ensure the vehicle is road-worthy, has appropriate insurance and the volunteer has been trained in proper lifting and handling techniques if the client requires assistance in and out of the vehicle. The volunteer may also need training in relation to dealing with medical emergencies that may arise while transporting the client.

   Collecting roadside donations – the safety risks for volunteer collectors include injuries caused by vehicles, tripping or slipping, sunburn, heat exhaustion, fatigue and verbal abuse which may potentially result in psychological harm. The organisation should provide a comprehensive briefing about the potential safety risks and strategies for their avoidance.

   RELATED RESOURCES

   For more information about whether or not the QLD WHS Laws apply to your organisation, key duties under these laws and what is required of your organisation, go to Not-for-profit Law’s Work Health and Safety guide on the Information Hub at www.nfplaw.org.au/OHS.

   For more information on the common law of negligence and the standard of care your organisation needs to meet, see Not-for-profit Law’s Negligence guide at www.nfplaw.org.au/negligence.

2. Legal Responsibility for Actions of Volunteers

   When could our organisation be liable for a volunteer’s actions?

   In some circumstances, your organisation could be held liable (legally responsible) for the actions of its volunteers.

   The QLD Civil Liability Act 2003 (QLD) (the QLD Civil Liability Act) sets out a special protection which provides that volunteers are not personally liable (legally responsible) for civil liability which arises as a result of anything they have done (or not done) in good faith and without recklessness, while doing community work that has been organised by a community organisation. Civil liability refers to liability arising out of a civil proceeding, which is a legal action between two citizens. For example, compensation for personal injury, property damage or financial loss as a result of negligence. In most other Australian States and Territories, civil liability incurred by a protected volunteer is automatically transferred to the community organisation (so that the organisation itself would have to pay any compensation). In QLD however, there is no such automatic transfer. The QLD Civil Liability Act is in fact silent on whether the organisation itself takes on the volunteer’s liability and there is no clear case law on this, so the legal position is not yet settled. It is possible that liability might transfer from the volunteer to the organisation under the legal principle of ‘vicarious liability’, where one party becomes liable for the actions of another (the usual example is that an employer is vicariously liable for its employees), but it is not clear whether this principle applies in the volunteering context.

   However, regardless of this lack of clarity, the community organisation could be liable for damage caused by a volunteer who was acting in good faith if the organisation was in breach of a ‘nondelegable duty of care’ – which is a common law duty owed by the organisation itself, rather than the volunteer, to the person who suffered the damage. The organisation’s duty of care may include providing adequate training, equipment or supervision to volunteers. So, for example, if someone is injured by a volunteer because the organisation failed to give the volunteer appropriate safety training, the organisation could be liable to pay compensation to the injured person.

   This is a complicated area of law and your organisation should seek legal advice about its own potential liability in such circumstances.

   Note there are certain exceptions to the special protection for volunteers, discussed further below (see Step 6).

   NOTE

   If your organisation has volunteers operating in another state or territory, generally they will be subject to the laws in that jurisdiction. It does not matter that the volunteer is resident in Queensland or that the community organisation is registered in Queensland. Determining which law a volunteer will be subject to can be complicated and may require legal advice.

   Liability under the QLD Civil Liability Act

   There are 6 steps your organisation can follow to assess whether or not a volunteer might gain the benefit of protection under the QLD Civil Liability Act. In summary, a volunteer will gain protection if:

   • the work is being done by a ‘volunteer’ (as defined under the QLD Civil Liability Act)
   • your organisation is a ‘community organisation’
   • the work being done by the volunteer is ‘community work’
   • the community work being done has been ‘organised’ by the community organisation, or the volunteer is an office holder
   • the volunteer’s action (or failure to act) was done in ‘good faith’, and
   • no exception applies.

   If the above steps do not all apply, the volunteer may be personally liable for their actions. Each of the steps is outlined in more detail below.

   STEP 1 - Has the community work been undertaken by a ‘volunteer’?

   The QLD Civil Liability Act defines a ‘volunteer’ as an individual who does community work on a voluntary basis or donates food in certain circumstances. A person is considered to work on a ‘voluntary basis’ if he or she receives no remuneration for the work other than reimbursement for out-of-pocket expenses.

   A person doing work under court ordered volunteering is not a volunteer under the QLD Civil Liability Act definition.

   EXAMPLE

   Fred is employed as a gardener. Fred volunteers his services to Community House Inc (a Queensland incorporated association) for one day a month. Fred drives to Community House and every so often buys plants for its garden. Community House pays Fred for petrol and the cost of the plants. Fred is regarded as a volunteer for the purposes of the QLD Civil Liability Act whilst performing services for Community House Inc because the only remuneration he receives is reimbursement for out-of-pocket expenses.

   STEP 2 - Is your organisation a ‘community organisation’?

   The QLD Civil Liability Act defines a ‘community organisation’ as:

   • a corporation
   • a trustee acting in the capacity of trustee
   • a church or other religious group
   • a registered political party as defined under the Electoral Act 1992 or the Commonwealth Electoral Act 1918 (Cth)
   • a public or other authority as defined under section 34 of the QLD Civil Liability Act, or
   • a parents and citizens association formed under the Education (General Provisions) Act 2006, chapter 7.

   Regulations to the QLD Civil Liability Act can also specify (‘prescribe’) that certain types of entities are ‘community organisations’, but there are no such regulations as at October 2017.

   STEP 3 - Is the work being done by the volunteer ‘community work’?

   Community work is broadly defined as work that is not for private financial gain and that is done for a charitable, benevolent, philanthropic, sporting, recreational, political, educational or cultural purpose (and includes making donations of food).

   The protection under the QLD Civil Liability Act applies to a volunteer when he or she is undertaking ‘community work’, i.e. the focus is on the purpose of the activity the volunteer is performing, not the overall purpose of the organisation. Whether a volunteer is performing ‘community work’ will depend on what work the volunteer is actually doing, rather than the objects of the organisation they are doing the work for.

   Some of the fields of community work set out above have a technical legal meaning (e.g. charitable purposes). You may need to seek legal advice about whether the work falls into one of these categories. For further information on what types of activities may be considered to be charitable, refer to Not-for-profit Law’s Information Hub page on Registering as a charity at www.nfplaw.org.au/charity.

   STEP 4 – Is the volunteer an office holder or has the community work been ‘organised’ by a community organisation?

   A volunteer is protected if he or she carries out the community work as an office holder of the organisation (for example a director or secretary), or if the community work undertaken is ‘organised‘ by the community organisation. The definition of ‘organise’ includes ‘to direct and supervise’, but this is non-exhaustive and may extend to situations where there are no specific directions or supervision given, for example, where volunteers are given general discretion to organise a fundraising event. However, the protection does not extend to spontaneous acts of volunteers or activities the organisation has not authorised. (See also the exceptions at Step 6 below: the volunteer will not be protected if he or she acted contrary to instructions or outside the scope of the activities authorised by the organisation.)

   STEP 5 - Were the volunteer’s actions (or failure to act) done in ‘good faith’?

   The volunteer’s actions (or failure to act) must have been done in ‘good faith’. Generally, to act in good faith is to act honestly and without fraud. Where a volunteer endeavours to act in the best interests of the community organisation and is not involved in any dishonest or fraudulent behaviour, it is likely the volunteer is acting in good faith.

   EXAMPLE

   ‘in good faith’

   A volunteer attends a community sports day to assist with minor first aid. A child falls and fractures their arm, and as a result of the volunteer’s care, their injury is worsened. The volunteer will be acting in good faith if they were trying to help the injured person and believed that was the correct first aid action. However, they will not be acting in good faith if they gave this assistance in order to impress their friend, when they knew they had no idea of what first aid action to take.

   STEP 6 - Does an exception apply?

   Even if a person is a volunteer and they have been undertaking community work organised by a community organisation, there are exceptions set out under the QLD Civil Liability Act. In general, a volunteer will not be protected where:

   • the volunteer knew or ought to have reasonably known that he or she was acting:
     • outside the scope of the activities authorised by the community organisation concerned, or
     • contrary to instructions given by the community organisation
   • the volunteer was intoxicated (i.e. under the influence of alcohol or drugs) and failed to exercise due care and skill when doing the work
   • the volunteer was required under a written law of the State to be insured against the liability, or
   • the liability would be covered by a CTP (compulsory third party) insurance policy under the Motor Accident Insurance Act 1994, or be recoverable from the Nominal Defendant under that Act.

   There are specific legal definitions and interpretations of many of the terms used in these exceptions (e.g. ‘ought reasonably to have known’, ‘drugs’ and ‘alcohol’). If potentially relevant, your organisation may need to seek legal advice about these issues.

   A volunteer will not be protected from liability for criminal actions (actions between a person and the state) while volunteering. These include traffic infringements as well as more serious crimes. For example, if a volunteer physically assaults someone while they are volunteering, this may result in criminal charges and possible criminal compensation. The QLD Civil Liability Act won’t protect the volunteer from criminal liability in this situation.

   EXAMPLE

   A person volunteers at a community sports day and is instructed to assist with refreshments only, The volunteer starts to help with marshalling participants without instructions to do so. An injury occurs as a result of the volunteer’s marshalling activities. As the volunteer was not acting according to instructions, it is likely that an exception under the QLD Civil Liability Act applies and that the volunteer will not be protected from liability.

   What could our organisation be liable for based on QLD Civil Liability Act provisions?

   To summarise, the QLD Civil Liability Act provides that, if a volunteer is protected (that is, all of the tests set out above have been met) the volunteer will not be personally liable to pay any compensation to anyone whom they may have caused personal injury, property damage or financial loss, as a result of their own actions or failures to act. The QLD Civil Liability Act does not state whether the organisation itself becomes liable on a volunteer’s behalf. However, under the common law, if an organisation does not fulfil its own duty of care and this leads to a volunteer causing injury or damage, it could become liable.

   What happens if our organisation (or a volunteer) makes an apology or expresses regret? Under the QLD Civil Liability Act, a volunteer or community organisation may make an apology to another person about an incident without fearing it will be construed as an admission of liability in a claim or proceeding arising out of the incident.

   The QLD Civil Liability Act specifies that an apology is an expression of sympathy or regret, or of a general sense of benevolence or compassion, in connection with any matter, whether or not it admits or implies an admission of fault in relation to the matter. The QLD Civil Liability Act expressly states that an apology:

   • does not constitute an express or implied admission of fault or liability by the person in connection with the matter
   • is not relevant to the determination of fault or liability in connection with that matter, and
   • is not admissible in any civil proceedings as evidence of the fault or liability of the person in connection with that matter.

   Note that there are some exceptions to this, such as in cases of defamation, unlawful sexual misconduct and unlawful intentional acts causing person injury.

3. Managing the Risk

   Your organisation could potentially be liable for the actions of its volunteers and for any injuries that its volunteers experience as a result of their volunteering. Therefore, volunteer risk management procedures and insurance are very important risk management strategies.

   As a part of your risk management strategy, we suggest that your organisation:

   • creates a safe physical environment and has appropriate safety policies and training in place
   • ensures safe procedures when providing goods or services to the public
   • implements staff and volunteer safety guidelines, which include incident reporting procedures
   • creates safety instruction manuals (where appropriate)
   • consults with your volunteers about these safety guidelines and the importance of them sticking to their authorised duties (you can include this in their volunteer agreement and discuss these issues in their induction)
   • provides your volunteers with copies of written policies and/or instruction manuals
   • conducts regular training, including refresher training, on safety issues
   • undertakes regular risk assessments to identify potential risks to health and safety and takes steps to eliminate these risks. Ideally these risk assessments will be for each different activity undertaken by volunteers and each site where volunteers undertake work. If the work or site changes, any new risks associated with the change should be considered.
   • clearly defines the role and tasks of your volunteers in a written document (volunteer position description) and specifies any prohibited actions (e.g. giving clients medical advice),
   • reviews your insurance policies to make sure they adequately cover injuries to and actions of your volunteers, and
   • from time to time, checks that the above processes are being implemented. Are your volunteers following these processes? Are these processes being enforced?

   FURTHER READING

   Safe Work Australia (the national WHS policy body) has published resources relating to work health and safety of volunteers, including an Essential Guide to Work Health and Safety for Volunteers and an Essential Guide to Work Health and Safety for Organisations that Engage Volunteers.

   WHSQ has published numerous resources relating to workplace safety and minimising risk. These can be located at www.worksafe.qld.gov.au/forms-and-resources.

   RELATED RESOURCES

   For a Sample Volunteer Position Description, go to the Information Hub at www.nfplaw.org.au/volunteers.

   For a checklist covering what to do when an incident or accident happens in your organisation, go to our Not-for-profit Law Incident and Accidents checklist on the Information Hub at www.nfplaw.org.au/negligence.

   Can we get our volunteers to agree to reimburse our organisation for any compensation payable as a result of their actions?

   The QLD Civil Liability Act is silent on the effect of these types of agreements (known as indemnity agreements), but contains a general provision which allows parties to enter into a contract which makes ‘express provision for their rights, obligations and liabilities’. However, if your organisation asks a volunteer to sign an indemnity agreement, note that it may not protect your organisation from liability in all circumstances, especially where there has been gross negligence or breaches of specific laws.

   Insurance considerations

   Insurance is a way of managing risks your organisation can’t avoid or minimise, by paying another party (the insurer) to bear the costs if certain risks eventuate.

   Common types of insurance include:

   Protects:	Type of insurance:
   Volunteers	Volunteer personal accident insurance
   Employees	Workers’ compensation insurance
   Committee members	Directors’ and officers’ liability insurance
   Members of the public	Public liability insurance
   Experts or advisors	Professional indemnity insurance
   Property and assets	Building and contents/occupiers/fraud insurance
   Selling goods or products	Product liability insurance
   Vehicles	Motor vehicle insurance

   Volunteers often fall between the gaps as they are not covered by an organisation’s insurance policies when they suffer injuries in their role unless the organisation holds specific insurance for this purpose. It is important to remember that:

   • workers’ compensation insurance does not cover volunteers (except in rare circumstances), and
   • public liability insurance will usually cover injuries a volunteer causes to others but may not cover injuries caused to volunteers.

   Case Study

   A volunteer serving food at a local fundraiser does not properly cook the chicken, which results in a significant number of people contracting food poisoning and ending up in hospital, including the volunteer. The organisation’s public liability insurance will cover members of the public who attended the fundraiser, but not the volunteer.

   Tip

   • check your organisation’s existing insurance policies to find out whether your volunteers are covered. If in doubt, pick up the phone to your insurer.
   • consider taking out a volunteer personal accident insurance policy to make sure your volunteers are covered for any injuries they sustain while volunteering.
   • check age limits under your policies and, if necessary, negotiate with your insurer to extend coverage to all of your volunteers.
   • let all volunteers know what they are covered for and what they are not and the process for making a claim. If there are any extra costs payable, make sure you are clear about whether the organisation or individual will have to pay.

   Caution!!!

   Insurance should not be the cornerstone of your organisation’s risk management strategy. Ultimately, it should be relied upon as a matter of last resort and other measures should be implemented with the goal of never having to make a claim. Insurance can cover any costs arising from a claim but it cannot restore any damage caused to your organisation’s reputation or culture.

   RELATED RESOURCES

   For more information on insurance and risk management, including volunteer personal accident insurance, read our Not-for-profit Law’s Risk Management and Insurance guide on the Information Hub at www.nfplaw.org.au/riskinsurance.

Indicator 4.3: The organisation has processes for reporting and responding to potential or actual harm, abuse and/or neglect that may occur for people using services.
The interpretation of this indicator: Harm includes self-harm.

As a part of meeting Indicator 4.3, organisations must demonstrate the common mandatory evidence requirements and relevant service specific requirements detailed below
Common	Processes for reporting and responding to potential, suspected, alleged or actual harm, abuse and/or neglect of service users are documented, implemented, monitored and reviewed. Processes ensure that all people working in or for a service (including employees, subcontractors, agency staff, students and volunteers47) are aware of: what constitutes, harm, abuse and neglect and how to respond in a manner that is consistent with any legislative requirements how to record and report allegations or incidents, including reporting of harm, abuse and neglect through internal processes and to any external agencies, as appropriate their responsibilities to support people, or make referrals to appropriate supports the importance of responding to allegations of harm, abuse and/or neglect in a manner that observes the principles of natural justice, and for all parties to be supported during the investigation of an allegation of harm, abuse or neglect. The organisation has an incident reporting system which ensures that incidents are assessed, managed and reported in a timely manner to internal stakeholders and relevant external agencies such as Queensland Police, DCYJMA, Coroner and/or funding bodies48.
Child Protection Placement Services	The organisation has a policy/procedure which ensures that harm, suspected harm and concerns about standards of care are identified, managed, recorded, and reported in accordance with legislative requirements and DCYJMA policy. This policy/procedure must be kept up to date and: include a definition of harm which is consistent with the definition in section 9 Child Protection Act 1999 facilitate reporting and recording by staff members of all harm/suspected harm (as defined in Section 9 Child Protection Act 1999) and concerns about the standards of care being provided to a child, and which meets the requirements of section 6 Child Protection Regulation 2011 ensure compliance with the mandatory reporting requirements specified in sections 13F, 13G, 13H and 13I Child Protection Act 1999 and in section 10 Child Protection Regulation 2011 ensure that all harm/suspected harm and concerns about standards of care are reported to DCYJMA in a timeframe and in sufficient detail to enable the safety, wellbeing and best interests of the child or young person to be addressed by the Department as soon as possible and ensure that the standard of care provided complies, and will continue to comply, with the Statement of Standards. outline the organisation’s process for reporting the emergency use of restrictive practices and prohibited practices in line with DCYJMA’s Positive Behaviour Support and Managing High Risk Behaviour Policies outline the organisation’s process for reporting and recording disclosures of harm that relate to historical harm, or harm that was not a result of services provided by the organisation. This must include processes for how support is provided to the young person following disclosures state what staff are to do if DCYJMA deems an incident to require a Standards of Care Review or Harm Report Investigation and Assessment specify how the organisation provides support to a child or young person, staff, or foster and kinship carers during and following an incident, disclosure of harm, Standards of Care Review or Harm Report Investigation and Assessment. This must include providing information about what external support can be accessed outline how the organisation will provide training to staff regarding identifying, preventing, responding to, and reporting harm or suspected harm and standard of care concerns, positive behaviour support and managing high risk behaviours ensure that the management of incidents is consistent with DCYJMA policy and procedural documents and relevant protocols including: Provide and review care procedure Child Safety Practice Manual Reporting missing children: Guidelines for approved carers and care services Responding to Concerns About the Standards of Care Policy Positive Behaviour Support and Managing High Risk Behaviour Policies Additionally, for non-family based placement services: Incident management for residential care services Incident reporting guide for residential care services Joint agency protocol to reduce preventable police call-outs to residential care services Records demonstrate that: all incidents have been managed and reported in accordance with the organisation’s policies, DCYJMA policy and procedures requirements and relevant protocols including: Provide and review care procedure Child Safety Practice Manual Reporting missing children: Guidelines for approved carers and care services Responding to Concerns About the Standards of Care Policy Positive Behaviour Support and Managing High Risk Behaviour Policies. Additionally, for non-family based placement services: Incident management for residential care services Incident reporting guide for residential care services Joint agency protocol to reduce preventable police call-outs to residential care services written reports have been provided to DCYJMA in relation to all reportable suspicions (as defined in section 13F Child Protection Act 1999) as soon as reportable suspicions have been formed written reports provided to DCYJMA in relation to reportable suspicions contain all information as prescribed in section 13G Child Protection Act 1999 and section 10 Child Protection Regulation 2011 Non 13G harm/suspected harm and concerns about the standards of care have been reported to DCYJMA in sufficient detail to enable the safety, wellbeing and best interests of the child to be addressed by DCYJMA as soon as possible and ensure that the standard of care provided has complied and will continue to comply with the Statement of Standards. any use of prohibited practices has been reported to DCYJMA immediately in accordance with DCYJMA’s Managing High Risk Behaviour Policy. These incidents must have also been reported in accordance with section 13F Child Protection Act 1999 when applicable. the use of emergency restrictive practices and details of the circumstances in which it occurred has been reported to DCYJMA within 24 hours of the incident occurring (or immediately where the use of restrictive practices may be a breach of the standards of care, or actions may have resulted in harm to the child or young person) in accordance with DCYJMA’s Managing High Risk Behaviour Policy. These incidents must have also been reported in accordance with section 13F Child Protection Act 1999 when applicable. where incidents, disclosures of harm, Standards of Care Reviews or Harm Report Investigation and Assessments have occurred, support has been provided to children and young people, staff and foster and kinship carers in accordance with the organisation’s policy, and they have been informed of external supports that they may access.

Below are suggestions of how this indicator may be demonstrated, depending on the size and complexity of an organisation and the type of services delivered

• Policies and procedures about:
  • incident management including reportable incidents
  • preventing and responding to harm, abuse and neglect
• Registers/databases tracking the organisation’s responses to:
  • incidents including reportable incidents
  • potential, suspected, alleged or actual harm, abuse and neglect
• Records (e.g. training register/database) of systematic staff and volunteer training in:
  • incident management including, reportable incidents
  • what constitutes harm, abuse and/or neglect; how to identify and respond to actual or suspected instances; and how to record and report allegations
  • culturally safe and appropriate responses
• Records of reporting to external agencies where harm, abuse or neglect has been identified or suspected (e.g. Queensland Police Service, DCYJMA)
• Records of communication with guardians/advocates/carers regarding incidents
• Action plans which outline strategies to prevent future risk (e.g. Safety Plans for people using services)
• Feedback from people using services confirms the responsiveness of the organisation to allegations or concerns about harm, abuse and/or neglect and the support provided
• Feedback confirms that responses to incidents and allegations of harm, abuse and neglect are culturally appropriate
• Staff and volunteers can describe processes for
  • managing and reporting incident including reportable incidents
  • preventing and responding to harm, abuse and neglect.

Policy Statement:

All children and young people need to be supported to grow, develop skills and to participate in their social, school and community life. For children in care arrangements, carers often provide the majority of that support, which should be strengths-based, modelled on positive behaviours and which should incorporate appropriate discipline within a safe and caring relationship.

A child or young person’s behaviour may be developmentally appropriate and seen in children of a similar age. Other times, the behaviour may be impacted by factors such as trauma, disability, mental health, drugs and alcohol, or the environmental context.

When supporting children and young people who engage in at-risk or challenging behaviour, it is important to understand why they need to engage in the behaviour. Effective strategies can then be developed to reduce this need. Without effective strategies, the child or young person is at risk of being supported in ways that are restrictive, or result in their exclusion from everyday activities.

The Department of Children, Youth Justice and Multicultural Affairs (Child Safety) is committed to, and promotes the use of positive behaviour support to all children and young people in care, in accordance with the legislated standards of care outlined in the Child Protection Act 1999 (the Act), sections 74 and 122 and the Charter of Rights for a child in care, which is set out in Schedule 1 of the Act.

The safe care and connection of Aboriginal and Torres Strait Islander children with family, community, culture and country will be a key consideration when undertaking positive behaviour support with Aboriginal or Torres Strait Islander children and families.

Child Safety is committed to respecting, protecting and promoting human rights. Under the Human Rights Act 2019, Child Safety has an obligation to act and make decisions in a way that is compatible with human rights and when making a decision, to give proper consideration to human rights.

This policy is to be read in conjunction with the Managing high risk behaviour (646) policy.

Principles:

• The safety, wellbeing and best interests of the child, both throughout childhood and the rest of the child’s life are paramount
• Child Safety staff will act and make decisions in a way that is compatible with human rights and obligations under the Human Rights Act 2019
• Children and young people, including those with disabilities have the same right to be supported in a way that is in their best interests
• Children and young people will be supported in a way that takes into account their age, developmental level and cultural needs
• Carers have a legal duty of care to take positive steps to protect children when there is foreseeable harm
• Children and young people have the right to protection from strategies that may constitute abuse, torture or inhumane and degrading treatment and high risk practices when supporting them to develop positive behaviours
• The five elements of the child placement principle (prevention, partnership, placement, participation and connection) under section 5C of the Act, apply to processes, decisions and actions taken for an Aboriginal or Torres Strait Islander child.

Objectives:

This policy aims to ensure that children and young people:

• are supported to build and develop skills to maintain relationships and develop positive behaviours
• are supported in environments that meet their needs and reduce the need for the child or young person to use challenging or at-risk behaviour
• have access to appropriate specialist supports to assist with supporting their behaviour when they present with more complex or high risk behaviours
• keep themselves and others safe with trauma-informed strategies.

Scope:

This policy refers to:

• children and young people subject to a care agreement, an assessment order, or an order granting custody or guardianship to the chief executive under the Act, including a temporary custody or transition order, and who are placed in a care arrangement under section 82 (1) of the Act, and
• approved foster carers, kinship carers and staff employed by Child Safety and non-government organisations to provide direct care to a child or young person placed under the authority of section 82(1) of the Act.

Challenging or at-risk behaviour is understood to be behaviour that:

• is typically not seen in children or young people of a similar age
• is inappropriate to the context in which it occurs
• is of such frequency, intensity and duration that it presents risk to the child or young person or others
• has a negative influence on the child or young person’s quality of life such as restricting learning opportunities, limiting access to everyday community activities or impacting negatively on relationships.

Positive Behaviour Support

Positive Behaviour Support (PBS) is an evidence-based approach to supporting children and young people who engage in at-risk or challenging behaviour in a range of settings. PBS:

• recognises that at-risk or challenging behaviour is often related to environmental factors, such as interpersonal relationships, physical environment, responses from others and the way in which services are delivered
• is a holistic approach with a focus on understanding the purpose of the behaviour and increasing positive behaviours through skill development rather than punishing negative behaviours
• uses proactive rather than reactive or crisis driven strategies. The focus is on skill development and modifying the environment or context to better support the child or young person and reduce the need for them to engage in at risk or challenging behaviour.

PBS is a framework which aims to:

• develop an understanding of why the child or young person displays the at-risk or challenging behaviour based on an assessment of the social and physical environment and broader context within which it occurs. It also considers individual factors such as trauma, intellectual disability, general health and mental health that may contribute to at risk behaviours
• involve all stakeholders in the assessment process to develop an understanding of the behaviour and identify appropriate strategies
• use the understanding to develop, implement and evaluate the effectiveness of a PBS Plan
• provide supports to enhance the quality of life for both the child or young person and those that support them.

Positive Behaviour Support Plans

Within a PBS plan, there are multi-element approaches to support the child or young person and their behaviour, including:

• Primary preventative strategies that aim to change the environment and improve quality of life to reduce the need for the child or young person to engage in at-risk or challenging behaviour. These strategies include building strong relationships, recognising positive behaviours rather than negative ones, focussing on strengths, clear and consistent boundaries and assisting with problem solving.
• Secondary strategies that aim to alleviate the situation when behaviours are low risk and to prevent the behaviour from escalating. They are used when there are early warning signs of at-risk or challenging behaviour.
• Non-aversive reactive strategies that aim to bring about resolution and return to safety including de-escalation strategies.

Case planning and review processes will identify children and young people displaying at-risk behaviours, or who are at risk of displaying such behaviours, and the negative consequence for the child or young person and/or others. Where the child or young person is assessed as having significant needs in the behaviour and/or emotional stability domains, as an outcome of the Structured Decision Making (SDM) Child Strengths and Needs Assessment, a PBS plan will be developed as part of the case plan. The child or young person is to be involved through the assessment and development of any PBS Plan to the best extent possible taking into account their age and level of understanding. Reflecting on behaviour after it occurs provides a learning opportunity for children and young people to identify triggers, thoughts and feelings. This is only to occur once the child or young person has returned to a regulated state. When children and young people engage in behaviour of such intensity, frequency and duration that it presents immediate, foreseeable risk of harm to themselves or others, please refer to the Managing high risk behaviour (646) policy.

The use of psychotropic medication for mental health

Children and young people exposed to trauma and neglect are at risk of developing mental health issues. These children may require the prescription of medication to support their mental health. Where a doctor is prescribing a psychotropic medication:

• information should be sought from the prescribing doctor to clarify the purpose of the medication and ensure it is being prescribed for a mental health diagnosis
• consent should be obtained from the child or young person’s guardian
• a PBS plan should be developed and the child or young person should be supported to access appropriate mental health services to reduce the use of psychotropic medication where possible 
• children should be supported to have six monthly reviews by medical professionals to determine if the medication is still required.

The use of any medication to manage the behaviour of a child or young person in the absence of a diagnosed health or mental health condition is not supported by the department. This is considered chemical restraint. Please see the prohibited practices section and the Managing high risk behaviour (646) policy.

Safe transport

Drivers are responsible for ensuring that all passengers are safely restrained in cars and should follow the relevant guidance around types of child restraints. The following types of devices required to support safe transport are appropriate and are not considered restrictive practices under the Managing high risk behaviour (646) policy:

• use of a device or harness to support the safe transport of a child with a physical disability. These should be prescribed by an appropriate professional and adhere to the appropriate legal requirements.
• the use of standard safety features within cars including the ‘child lock’ option on a door or the ‘window lock’ option.

The National Disability Insurance Scheme

For children and young people with a disability who engage in at-risk or challenging behaviour, their National Disability Insurance Scheme (NDIS) plan should include funding for:

• the development of a PBS Plan and staff training to implement the plan
• funding for other allied health funding as required to support the assessment and development of a PBS Plan and skill development e.g. occupational therapy, speech therapy.

Carers and direct care staff should discuss any concerns about a child or young person’s behaviour during the NDIS planning or review meeting.

NDIS registered behaviour support practitioners and NDIS registered providers must be familiar with this policy and the Managing high risk behaviour (646) policy and work with Child Safety to develop and implement their PBS Plans in a way that aligns with these policies. NDIS behaviour support practitioners and NDIS registered providers have requirements to maintain registration and to meet the requirements outlined in the National Disability Insurance Scheme (Restrictive Practices and Behaviour Support) Rules 2018. Child Safety works with the NDIS Quality and Safeguards Commission in these matters.

For information regarding the NDIS Commission requirements on behaviour support see https://www.ndiscommission.gov.au/providers/behaviour-support

Prohibited practices:

Prohibited practices are unlawful and unethical practices which present a high risk of causing high level discomfort and trauma. Any action which is contrary to section 122 of the Act because it frightens, threatens or humiliates a child or young person is a prohibited practice. Prohibited practices must not be used in responding to the behaviour of children who are placed in care under section 82(1) of the Act. Prohibited practices include:

• corporal punishment
• unethical practices to modify a child or young person’s behaviour
• planned use of physical restraint
• planned use of restriction of access to items (environmental restraint)
• containment (environmental restraint)
• seclusion
• chemical restraint
• mechanical restraint
• aversive strategies

Please refer to the Managing high risk behaviour (646) policy for further information about these practices including the reporting and recording of prohibited practices.

Roles and Responsibilities:

• Behaviour support planning will occur through genuine consultation and participation with the child or young person, their parents (where appropriate), carers or direct care staff, Child Safety and Specialist Services staff and other specialist providers including Evolve Therapeutic Services, Child and Youth Mental Health Services, NDIS funded service providers and sexual abuse services.
• Behaviour Support planning will seek to maintain family relationships and be supportive of individual rights and ethnic, religious and cultural identity or values.
• Child Safety staff will work in partnership with approved carers and direct care staff to provide quality care in a safe and stable living environment to meet children and young people’s needs, in accordance with the statement of standards and the Charter of Rights established in the Act
• Child Safety and licensed care services will work in partnership to provide training and professional supervision and support to assist carers and direct care staff to provide positive behaviour support to all children and young people in care arrangements.
• Child Safety staff will inform approved carers, direct care staff and all relevant service providers of this policy. Child Safety recognises its responsibility to monitor that the policies of licensed care services are consistent with this policy and that incidents of the use of restrictive practices and prohibited practices are reported. This will be done through the licensing and quality assurance process.

Authority:

Child Protection Act 1999, section 5A, Chapter 2A, Chapter 4 and section 122
Child Protection Regulation 2011, Part 7

Delegations:

Refer to instruments of delegation for delegations relevant to positive behaviour support.