Making a difference for vulnerable people - Casebook 2022 examples

15 Sep 2022 Case studies

The Office continues to promote awareness and accessibility for communities in regional and remote areas, Indigenous, culturally and linguistically diverse communities, the homeless and prisoners.

Following are a few examples from Casebook 2022 that resulted in positive outcomes for vulnerable people.


Improvements to Queensland Corrective Services hearing processes (p. 13)

Each year, the Queensland Ombudsman conducts a correctional centre visits program as part of the administrative improvement function under the Ombudsman Act 2001. It is important that closed environments are scrutinised to ensure that satisfactory compliance with key operational systems is demonstrated.

In response to the changed environment created by COVID-19, visits to correctional centres as part of the program are being conducted virtually, using videoconferencing technology to meet with QCS officers and prisoners.

We use information gained from prisoner complaints and previous visits to the correctional centres to form focus areas for the visits. An example of this is Queensland Corrective Services’ (QCS) breach of discipline processes.

Over the past year, we viewed recordings of 34 breach of discipline hearings and 16 breach of discipline review hearings across the six correctional centres we visited.

We found that while the hearings were largely compliant, there was room for improvement, particularly in the quality of communication. Identified issues included:

  • In hearings, the breach of discipline process is explained and the alleged breach is read to the prisoner, along with the evidence being relied upon. In some instances, this information was read quite quickly and this may have affected the prisoner’s ability to understand the material. In some instances, the officer conducting the breach of discipline hearing did not read the evidence to the prisoner during the hearing.

  • Hearings and review hearings are conducted in rooms that sometimes have disruptive levels of noise from external sources. For those in the room at the time, this can be distracting. When reviewing the hearings, it can be difficult to hear the person speaking on the recording.

  • In breach of discipline review hearings, the review officer did not always provide a clear explanation of the process.

Observations from the correctional centre visits program are reported to the Commissioner of QCS. Visit reports include suggestions for improvement, which are not formal recommendations under the Ombudsman Act. This Office monitors the issues through future visits and whether complaints are received about the identified issues.


Clear communication of reasons and transparency in decision-making and recordkeeping (p. 8)

Following Morris’s surgery, there were complications that meant he required further surgery which was not available in the regional town where he lived.

Morris contacted a number of surgeons in Brisbane but found no one was willing to operate. He found an interstate specialist who was willing to provide the surgery. This resulted in a number of trips interstate for treatment and further surgery over eight months. Both his doctor and solicitor wrote to the Hospital and Health Service (HHS), part of Queensland Health, stating that he required Patient Travel Subsidy Scheme (PTSS) help for his interstate travel and accommodation costs.

Morris telephoned the PTSS office on a number of occasions during the months of treatment and was verbally advised that his application would be accepted.

When he applied in writing, the HHS refused his application for PTSS help. He appealed this decision and HHS refused his appeal. Morris complained to this Office.

The result
This Office’s investigation found a number of issues with the HHS’s decision and appeal responses.

The application refusal did not:

  • clearly explain how the decision was reached, and included an irrelevant section of the PTSS Guideline as justification
  • contain information about appeal rights
  • include the name and position of the person who made the decision.

The application decision was initially recorded as approved in internal HHS documents. As Morris received a letter advising that his application was refused, it was clear the original decision was changed but there was no record of what happened to change that decision.

The HHS acknowledged that it had not managed all aspects of decision-making appropriately and agreed to reimburse Morris for his PTSS application. The HHS agreed to consider the highlighted areas for improvement.

Ombudsman insight
Good decision-making involves the provision of reasons to an applicant to allow them to understand why their application has not met the relevant criteria. It amounts to more than a statement of an outcome and should include all steps of reasoning, linking the facts of a decision and the material relied on, so an applicant can understand how the decision was reached. If an applicant is unable to understand a decision, they cannot then properly prepare an appeal for that decision.


Providing an internal review observes natural justice for complainant (p. 11)

Emily was under 18 years old and had previously been identified as a child in need of protection by the Department of Child Safety, Youth and Women. There were barriers and a range of complexities to Emily living with either her father and mother who were separated, however she wished to reside with her mother. The department had no current intervention with the family and the family was receiving a number of community based supports. Emily sought help to reunite with her estranged mother. Emily said that the department had previously advised her that it would provide support to her family to help this happen. When Emily made the request, the department provided her with a list of services to enable her to live independently.

Emily was dissatisfied with the department’s response and complained to this Office. This Office referred her back to the department for an internal review as she had not yet used that right.

The department assessed her request was out of scope of the department’s Complaints Management Policy and Procedure for a complaint process to occur as there was no ongoing or active intervention for her and her family. Emily complained again to this Office, specifically that the department did not conduct the internal review.

The result
The Office’s investigation made further enquiries with the department. These enquiries established that the department had not exhausted all avenues of their complaint management system and the Office referred the matter back to the department for investigation.

The department undertook an internal review and found that the department’s decision not to progress Emily’s complaint on the basis that it was outside of the scope of the department’s policy was incorrect.

In response to this Office’s Management of child safety complaints – second report, the department established an internal review process that complies with the Australian/New Zealand Standard. The department took the opportunity provided by Emily’s complaint to remind its staff about internal reviews, and specifically about why an internal review in this case was appropriate and it should have been undertaken.

The department’s original decision was replaced with a decision that Emily’s concerns were within scope of the policy. A complaints management process was then conducted to address Emily’s request for help her reside with her mother. Emily was satisfied with the outcome of her complaint.

Ombudsman’s insight
Complaints are useful sources of information for agencies about how to improve their services. Learnings from complaints can be used to communicate areas for improvement to staff.

Last updated: Tuesday, 22 November 2022 12:30:33 PM