Casebook 2026: Helping agencies to improve decision-making

Our investigative role

The Queensland Ombudsman investigates complaints about Queensland Government agencies, which are state government departments, local councils and public authorities. Sometimes agencies use non‑government entities to deliver services to the community. We can also investigate those entities.

Our investigative service is free and confidential. We are independent – not an advocate for either complainant or agency. The Ombudsman’s work helps agencies to improve decision-making.

How the complaints system works

Environmental health concerns need to be addressed earlier 

Rachel was concerned her neighbour’s constructed embankment was creating environmental harm to her property and contaminating her dam. She noted the embankment was constructed from fill of unknown origin and a large amount of sediment had been washed into her dam, which was downhill from the neighbour’s embankment.

Rachel engaged a professional water tester. Results from dam water and sediment samples showed the presence of a toxin. 

Rachel complained to her local council alleging the embankment:

• was contaminating her property
• had no retaining wall or drainage, resulting in significant soil runoff onto her property. 

The council’s complaint investigation found the embankment was not an approved development. The council issued an enforcement notice for a planning offence.

Months after the enforcement notice was issued, Rachel’s property and dam water continued to be affected by sediment runoff during rain events. 

Rachel lodged another complaint with the local council because she believed it had not taken adequate action to address her contamination concerns. 

The council’s internal review found her allegations did not amount to the type of environmental harm a local government could investigate under the Environmental Protection Act 1994 (EP Act). 

Rachel considered the council was not taking appropriate action and complained to this Office. 

The result

This Office investigated the council’s responses to Rachel’s environmental harm complaint. Following the investigation, the council agreed to:

• engage a consultant to investigate the environmental harm claims
• review policies and procedures for complaints that involve overlap between Planning Act offences and environmental harm allegations to ensure different departments at council work together to resolve them
• engage environmental health officers earlier in matters that involve EP Act matters. 

Council agrees to develop new compliance and enforcement policies 

Isack was building a new home. When it came time to connect the electricity, Isack discovered his neighbour’s front gate and fence were encroaching onto the road reserve, obstructing the power pole. Isack complained to the local council about the boundary encroachment. 

Initially, the council indicated to Isack that the fence and gate would be removed. However, the council then wrote to Isack a few months later, advising of a workaround solution that would allow the fence and gate to remain. The council indicated to Isack they would continue to work with his neighbour to address the boundary encroachment. 

Isack was unhappy with the council’s response and requested a review. In response, the council advised that its previous advice to Isack was incorrect, and no action had been taken regarding the boundary encroachment. The council advised it would seek an application from the neighbour to have the encroaching fence approved under its local laws.

Isack complained to this Office because he thought the council should have addressed the boundary encroachment instead of finding a workaround. He also thought the council had already decided to allow the fence and gate to remain, even though it had not assessed any application from his neighbour.

The result

This Office investigated Isack’s concerns and met with the council to discuss how they had handled the matter. At the meeting, the council provided explanations for some of the concerns raised. Subsequently, the council provided further information to address the concerns.

This Office then sought the council’s agreement to: 

• carefully consider the criteria in the relevant local law when assessing the neighbour’s application and keep an adequate record of its assessment 
• carefully consider Isack’s concerns and how the encroachment has or would impact his interests 
• create a form letter or fact sheet for complainants for these matters, outlining the various pathways the council could take
• develop a compliance and enforcement policy as a priority to provide guidance to officers and ensure appropriate resourcing to properly implement the policy
• for similar applications in future, clearly communicate its position using plain language and avoiding terms or phrases not easily understood by the public. 

The council agreed to these proposed actions. 

Due consideration of a complaint’s key issues can lead to systemic improvements

Michelle lodged a noise complaint with her local council. The noise nuisance chiefly related to air conditioning plant noise from a residential care facility that had been recently built next door. Michelle provided her own recordings/samples of the excessive noise to council and advised council that the noise was impacting on her ability to enjoy the ordinary use of her home and disturbing her sleep.

The council eventually closed the complaint without Michelle receiving any resolution to the noise nuisance. Michelle lodged a request for an internal review of the decision to close the complaint, and this review upheld the decision to close the file.

Michelle complained to this Office on the basis that she had been given no specific and clear reasons for the case being closed. Michelle considered that council should re-open the complaint. 

The result

This Office opened an investigation to determine whether the council had fairly and reasonably reviewed the noise nuisance complaint. The investigation considered complex questions regarding the assessment of development applications and council’s approach to development permit conditions as they relate to noise emissions. It also considered the adequacy of the council’s noise monitoring.

This Office formed the view that there were aspects of the council’s actions in response to Michelle’s complaint that might amount to unreasonable administrative action. Most significantly, this Office found the council had approved the development plans without adequate regard to noise emissions. In addition, it found the council had included inappropriate conditions on the development permit, which prevented effective compliance action in the event of noise complaints. It found that council had not conducted an adequate investigation of Michelle’s noise nuisance complaint after the facility had been built. 

Subsequently, the council agreed to:

• undertake improvements to its development assessment and update its standard development conditions with respect to noise emissions
• engage professional assistance to provide advice and training to council staff about responding to noise nuisance complaints and conducting noise monitoring activities
• conduct a fresh investigation into Michelle’s concerns if she remained dissatisfied about excessive noise from the facility after on-site works were completed.

Complainants must be advised of their rights to internal and external review of decisions

Irene received her rates notice and disagreed with the ratings category for her property. She lodged an objection to the rating category with the local council. The council decided that the rating category would remain unchanged. Irene lodged a further objection, which was managed by the council under its administrative action complaints process as an internal review. This review confirmed the council’s original decision.

Irene complained to this Office because she disagreed with the council’s decision. 

The result

This Office investigated whether the council’s decision to manage Irene’s objection through its administrative action complaints process was lawful, reasonable, fair or otherwise adequate.

This Office found that reviews of councils’ decisions about objections to rates categories are within the jurisdiction of the Land Court and Land Appeal Court; however, Irene was not advised of this avenue for review. This Office also concluded that, due to this statutory review pathway, there was no scope within the council’s complaints management process to consider a rates objection decision.

This Office ultimately decided no further investigation was necessary after the council agreed to:

• re-issue its decision in response to Irene’s rates objection in accordance with the process set out in the Local Government Regulation 2012, which re-enlivened her statutory review right and allowed her to lodge an appeal in the Land Court
• add information about statutory review rights associated with rates categorisation to council rates materials, including notices and website pages
• include statutory review rights regarding objections to ratings categories in council decision letters.

More details to communicate decisions can prevent confusion 

Maya was in the final stages of a recruitment process with a council and beginning to onboard when the council decided not to employ her. The council had used an external employment agency, and Maya was recruited from interstate. Maya felt she suffered adverse action because of the last-minute decision and complained to the council. 

The council’s response to Maya’s complaint stated:

• its administrative action complaints process excluded employment matters
• she could take legal action to progress the matter further.

Because the usual complaints process did not apply, Maya could not seek an internal review.

Maya complained to this Office about the decision because:

• the council had not explained its position or provided adequate information about the review rights available to her
• she wanted the council to compensate her for the loss of a work opportunity. 

The result

This Office investigated the issues raised by Maya to determine if the council’s response was reasonable. This Office agreed with the council that its normal complaints process did not apply to employment issues.

However, the investigation found the council’s response to Maya’s concerns lacked sufficient:

• detail about how her allegations were assessed, to allow her to understand the reasons for its position
• information about the available avenues of review.

The council agreed to provide Maya with: 

• a response to the issues she had raised 
• information about further review options in relation to her employment.

Reasons for decisions must be clearly articulated

Peter had contacted his local council numerous times over a number of years about a variety of issues in his local area. These contacts were made by phone and email to his local ward office, the council contact centre and individual council officers.

The council deemed that Peter’s continued and sustained contacts posed an unacceptable and unreasonable administrative burden, and that Peter’s tone and language were, in some cases, potentially harmful to the health and safety of council employees.

Subsequently, the council wrote to Peter to advise it was commencing a formal disengagement process with him. Under this process, the council would no longer accept contact from Peter on any subject. The council’s letter advised that if Peter needed to make urgent contact with the council, he could submit his concern through the council website.

Peter complained to this Office that there was no evidence to support the council’s action, the council had not provided adequate information about the basis for its decision, and his request for a review of the council’s decision had been ignored. 

The result

This Office contacted the council for information about Peter’s complaint. The council provided information and confirmed its decision was based on what it considered as Peter’s unreasonable customer conduct. This Office discussed with the council its concerns about the process the council had used to impose restrictions on Peter. 

This Office decided no further investigation was necessary after the council agreed to:

• provide Peter with further reasons for its decision and invite him to make a submission if he disagreed with the restrictions
• take into account any submission from Peter before making any decision about ongoing restrictions
• implement a separate unreasonable customer conduct policy framework, to provide a formal opportunity for customers to respond to council’s intention to impose restrictions.

*From 1 February 2025, the National Student Ombudsman (NSO) commenced as an independent national complaints service for students to resolve complaints about the actions of their higher education provider. Case studies in this edition are prior to the commencement of the NSO. We will continue to manage complaints about Vocational Education and Training. For more information, please visit our website.

Decision reversed because relevant evidence was not considered

Daniel was a student at a Queensland university when he was granted approval to sit a deferred examination. He experienced unexpected health challenges and was unable to attend his deferred exam. The university dismissed Daniel’s application to reschedule the deferred exam due to his health issues, despite providing medical certificates as supporting evidence. 

Daniel appealed the decision, emphasising that written medical advice from doctors stated he was unfit to sit the deferred exam on the scheduled date. The university dismissed his appeal and confirmed its original decision as it considered him capable of sitting the deferred exam because he had sat an exam for a different subject the day before.

Daniel believed the university dismissed his request without properly considering the medical evidence provided. Daniel complained to this Office that the university had unfairly and wrongly assessed his case.

The result

The investigation found the university had failed to properly consider the evidence provided by Daniel and the decision made was not consistent with its policy. This Office wrote to the university outlining concerns that the university had not reasonably considered the evidence.

In response, the university reversed its decision and agreed to reconsider Daniel’s request to sit a rescheduled deferred exam.

Clear communication is essential during times of change

Ania was an online student at a university and had been studying for 4 years while working full time. She had paid $20,000 in tuition fees and had 2 years remaining on her course when the university changed its academic calendar from 2 semesters to a more condensed 3 trimesters per year. 

The university advised that shorter study periods would provide more flexibility and availability of subjects, but Ania did not find this to be the case when the trimester timetables were released. Due to her work commitments and lack of flexibility, the new academic calendar structure was not compatible with her work schedule. She did not feel able to complete her course in the time available, and this was affecting her mental health. 

Ania was unhappy with the lack of communication or assistance offered by the university about the transition and lodged a complaint with the university. They advised she had not met the threshold for an individualised transition plan at the time. They provided further information, including study support programs and assessment extension applications available through the university. They advised that further improvements would be made to the transition process for the future. Ania felt this decision did not appropriately address her concerns and approached this Office.

The result

Following discussions between this Office and the university, they advised:

• Ania could apply for assessment extensions, as required, under special circumstances
• a team was established to support students in addressing any academic challenges arising from the restructure
• the program director would meet with Ania to discuss her options for completing her degree.

Ania was satisfied with the university’s offer and the investigation was closed.

Hospital and Health Service apologises for inconsistent decision-making

Nico was injured during a medical procedure and required specialist medical care. Nico lived in regional Queensland and the closest specialist who could treat his condition was in another state. 

From 2022 until mid-2024, Nico was granted approval for financial assistance under the Patient Travel Subsidy Scheme (PTSS) to travel interstate for treatment. After this approval expired, Nico applied to the Hospital and Health Service (HHS) for further PTSS assistance to travel interstate for another medical procedure. Nico provided the HHS with a letter from a specialist at a hospital in Brisbane, which said he needed specialist care that could not be provided in Queensland. 

The application was denied because Nico did not provide sufficient supporting information. On appeal, the HHS approved PTSS assistance for Nico to travel to Brisbane for a clinical review. 

Nico complained to this Office because he was worried he would miss his interstate medical procedure due to a lack of PTSS assistance. 

The result

This Office sought information from the HHS about its reasons for denying Nico’s application. Unfortunately, Nico could not attend the interstate procedure he originally sought PTSS assistance for. 

During the investigation, Nico applied again to the HHS for PTSS assistance for a procedure interstate, which was approved. On this basis, this Office decided that further investigation of the original refusal for PTSS assistance was not justified. 

However, this Office wrote to the HHS to outline concerns identified during the investigation and asked the HHS to apologise to Nico for the distress caused. The HHS apologised to Nico and acknowledged its errors. 

Every decision requires good recordkeeping 

Greg lived on a property that neighboured a large-scale livestock producer. Unpleasant odours originating from the livestock producer led Greg to suspect poor carcass disposal management. After getting no response to complaints to the livestock producer, Greg lodged a complaint to the Department of Agriculture and Fisheries (now the Department of Primary Industries (DPI)).

DPI responded to Greg’s complaint stating they had inspected the property and issued a compliance letter. DPI considered the matter closed. However, the unpleasant odours continued. After not receiving an adequate response to follow-up enquiries, Greg requested an internal review. Greg complained to this Office that the internal review response did not address his concerns. 

The result

This Office’s investigation found DPI’s recordkeeping was insufficient to support its position because it:

• did not adequately record the property inspection
• did not adequately record decisions or reasons for decisions relating to Greg’s complaint
• closed the issue without any record of follow up with the livestock producer to ensure completion of the carcass disposal compliance requirements after the inspection. 

As a result of the investigation, DPI agreed to:

• complete follow up with the livestock producer to ensure completion of the carcass disposal compliance requirements since the inspection
• use software to ensure complete, concurrent recordkeeping at inspections
• review and improve recordkeeping to adequately capture the matters considered and decisions made during compliance investigations.
   

Improvements to the management of prisoner property

Luciana was transferred between correctional centres with her personal items in 3 separate bags. When Luciana arrived at the receiving centre, she discovered that one of her bags was missing. Luciana wrote to both correctional centres to request the return of the missing bag. 

Both correctional centres told Luciana they had no record of the bag at their centres and told her they would not compensate her for the missing items. 

Luciana asked this Office to investigate.

The result

When a prisoner’s property goes missing during transfer, the receiving centre is responsible for investigating and liaising with the transfer centre to locate the missing property. This is described in Queensland Corrective Services (QCS) internal policies. If property goes missing while in the care of QCS, QCS must reimburse or compensate the prisoner for the property under the Corrective Services Act 2006. 

During this Office’s investigation, QCS took reasonable steps to properly investigate Luciana’s concerns about the missing property and decided to reimburse her. The investigation was coordinated between Luciana’s departing centre and receiving centre.

Centres are required to maintain complete and accurate records of prisoner property, so that if property goes missing, the responsible centre can be identified. As there were insufficient records of the property, QCS decided to reimburse Luciana. 

The Commissioner advised this Office that he has issued a reminder to the general managers of each centre to ensure they adhere to QCS internal policies. 

Reasons for decisions must reflect statutory provisions and be clearly communicated

Elijah built a vehicle and was ready to have it registered. He engaged an engineer to assess the vehicle, and the engineer’s report was submitted to the Department of Transport and Main Roads (TMR) with a request for a new vehicle identification number (VIN). 

TMR denied the application because the vehicle already had a VIN and met the criteria for a modified vehicle. The modified vehicle could not be approved for a number of other reasons. This decision was later upheld on internal review. 

Elijah complained to this Office. In his view, he had followed advice received from TMR some years earlier about the required process. 

The result

This Office investigated the issues raised by Elijah to determine whether TMR’s decision to deny the application was unlawful, unreasonable, unfair or otherwise wrong.

The investigation found that the initial advice provided by TMR was not definitive and was based on information that did not reflect the final built vehicle. It was later open to TMR to deny the application on that basis.

However, the investigation also identified that TMR’s decision notice referred to the statutory process for assessing and deciding a Vehicle Modification Application, which Elijah had not submitted. Therefore, TMR had issued the decision in the incorrect form, under the incorrect statutory provision. 

TMR agreed to reissue its decision in response to Elijah’s application for a VIN, using the correct form. TMR also agreed to correspond with Elijah about submitting a Vehicle Modification Application, and to advise him about the requirements his vehicle would need to meet for approval. This Office decided that further investigation was not required.

More broadly, TMR also agreed to review and amend its vehicle modification approval policy, procedures and forms to clarify the processes required for the different modification classifications. 

Complainants who are dissatisfied with agency decisions have a right to know how to seek a review

Natalie’s son attended a local childcare facility. Natalie had concerns about interactions between an educator at the facility and her son. She submitted a complaint to the Early Childhood Regulatory Authority, which is the section of the Department of Education responsible for regulating early childhood education and care services.

In its response to Natalie’s complaint, the authority advised it had discussed the complaint with its area manager and the nominated supervisor at the facility. It determined the facility had appropriate processes in place to monitor interactions between educators and children and no further action was necessary. 

The authority advised Natalie that if she was dissatisfied with its decision, she was entitled to contact this Office.

Natalie submitted a complaint to this Office on the basis that the authority had not adequately investigated her complaint.

The result

This Office sought information from the authority about Natalie’s complaint. The authority acknowledged that, while it had an internal review process for individuals dissatisfied with the outcome of their complaint, it had not advised Natalie of that process. Section 23(1)(d) of the Ombudsman Act 2001 provides that this Office can decide not to investigate a complaint if other rights of review remain.

With the authority’s agreement, this Office wrote to Natalie advising of her right to internal review, and, consequently, this Office decided no further investigation was necessary.

Failure to enquire with an applicant leads to a rebate being incorrectly denied

Steve applied to the Queensland Rural and Industry Development Authority (QRIDA) through its Climate Smart Energy Savers scheme for a rebate for a recent appliance purchase. QRIDA advised Steve that his purchase was ineligible for a rebate because it appeared that the appliance had not been fully paid for within the required scheme dates.

Steve requested a review of the decision and provided evidence that the appliance was fully paid for. He also provided a photograph of the appliance, showing it had been installed. QRIDA again declined Steve’s application because the energy rating sticker shown in the photograph indicated the rating was 3.5 stars, below the scheme’s threshold of 4 stars. 

Steve complained to this Office that QRIDA had not sought to confirm the appliance’s energy rating with him, the store or the manufacturer. He asserted the appliance did, in fact, have a 4-star energy rating, and the sticker was incorrect. He provided evidence showing the appliance was advertised as having a 4-star rating. 

The result

This Office contacted QRIDA to present the evidence Steve had provided and ask for more information about QRIDA’s decision. This Office also contacted Steve to ask if he could provide a picture of the model number located on the appliance. When he provided this, research indicated this model of appliance did have a 4-star energy rating. This Office sent this information to QRIDA, asking if it would be willing to review its decision on this basis. 

In response, QRIDA advised it had reversed its decision and Steve’s rebate would be paid. This Office decided no further investigation was necessary.

Procedural inconsistency led to an applicant’s review being overlooked

Nicole was party to a matter in the Family Court. A court order had been granted in the matter, but Nicole considered her ex-partner in breach of that order. She applied to Legal Aid Queensland (LAQ) for assistance in pursuing enforcement of the court order.

LAQ denied this application on the basis that it did not meet guidelines for providing legal assistance. Nicole complained to this Office. This Office asked LAQ to explain the reasoning behind its decision.

In its response, LAQ indicated it would have the external review officer reconsider Nicole’s application for legal aid and would issue a new decision letter once that was completed. This Office decided no further investigation was necessary on the basis that LAQ were reconsidering the application.

When no further correspondence was received from LAQ after several months, Nicole again complained to this Office about the delay in reconsidering her application.

The result

This Office contacted LAQ for information on the status of Nicole’s application. LAQ identified that, due to an administrative oversight, it had not reconsidered the application. LAQ confirmed the application was returned to the external review officer, and Nicole was advised of this. 

The outcome of the external review was to approve Nicole’s application for legal aid.

Complaint policies and procedures must be adhered to when making and communicating decisions

Luke was facing a police charge and made an appointment with Legal Aid Queensland (LAQ) for legal advice on the matter.

When Luke attended his appointment, LAQ copied his legal documents. At the start of the advice appointment, Luke questioned the copying of his documents. He stated that he did not consent and felt the legal adviser’s response to his question was abusive and dismissive. He asked that the copies of his legal documents be deleted and left the appointment.

Luke later called LAQ to confirm the copies of his legal documents had been deleted and was advised someone would get back to him. Luke then lodged a complaint about the copying of his documents and the behaviour of the legal adviser. 

In its response, LAQ indicated that Luke’s complaint would be investigated, but that it could not disclose the outcome as it related to a staff member’s personal information. 

Luke’s complaint was then escalated to the Senior Complaints Officer, who maintained contact with Luke throughout the investigation. Within one month, LAQ confirmed the conduct alleged had been investigated. LAQ found that the alleged abuse against Luke had not been substantiated. In addition, LAQ confirmed that documents had been moved from the records system and would be destroyed, and that Luke would be advised when the documents were destroyed. No reasons or review rights were included in the complaint outcome letter.

Luke complained to this Office, seeking an apology from LAQ and an opportunity to receive the legal advice he had first sought from a different adviser.

Luke’s complaint was escalated for internal review.

The result

This Office investigated to determine whether LAQ’s response to Luke was reasonable, having regard to LAQ’s Feedback and Complaints Policy and Feedback and Complaints Management Procedure. This Office also viewed the information about the policy available on the LAQ website and found that only a policy summary was available. 

This Office found the LAQ complaints policy and procedure require that responses to complainants should outline the investigations process, the information considered during the investigation and the reasons for its decision. It should also advise on review options available to the complainant.

Following discussions with this Office, LAQ agreed to write to Luke with the information required by its policy. As part of the finalisation of its internal review, LAQ apologised to Luke and confirmed they were in contact with this Office to ensure continuous improvement in the complaints process.

LAQ agreed to publish the full Feedback and Complaints Policy on its website to inform future complainants. 

This Office decided that no further investigation was necessary in light of the actions agreed to by LAQ.

Complainants need to know their concerns have received due consideration

Laurie relied on advice provided by a certified professional. Laurie considered that, in providing the advice, the professional had acted in a way that was contrary to the relevant professional conduct standards and statutory requirements. Laurie complained to the relevant public authority with oversight for the profession.

The public authority made an initial decision and advised Laurie there was no evidence the professional had engaged in professional misconduct. Laurie requested an internal review, setting out detailed submissions explaining why she considered professional misconduct existed. 

The public authority responded and advised that Laurie’s submissions had been considered, with a determination made that no further action was necessary. The public authority explained it was constrained by statutory requirements for privacy, which prevented further explanation of the outcome or reasons for the decision. Accordingly, the public authority had closed Laurie’s complaint.

Laurie complained to this Office that the public authority had failed to take any action about the conduct of the professional. 

The result

During the course of the investigation, this Office sought information from the public authority about how it reached its decision that there was no evidence of professional misconduct.

This Office explained to the public authority that while they may have correctly identified Laurie’s concerns, the decision letters sent to Laurie did not communicate the issues they considered in reaching a decision.

The decision letters did not provide Laurie with information about:

• how her complaint to the public authority was progressed
• what evidence the public authority considered
• how they viewed the evidence.

Further, this Office concluded that the overarching administrative principle of fairness included providing reasons for the decision.

The public authority agreed to consider Laurie’s complaint afresh and document its deliberations leading to the decision. They also agreed to provide Laurie with sufficient reasons for the decision, including explaining the evidence that was before them and how they assessed that evidence. 

This Office decided no further investigation was necessary in light of the actions agreed to by the public authority.

Failure to respond to concerns leads to multiple complaints

Amna lodged a workers’ compensation claim. She made a complaint to WorkCover Queensland (WorkCover) about its management of the claim and the conduct of the officer who dealt with her claim. WorkCover finalised the complaint, but did not clearly respond to each of Amna’s concerns. 

Amna complained to this Office about WorkCover’s inadequate response. This Office contacted WorkCover to raise concerns about its response, and as a result, WorkCover agreed to provide a further response to Amna to properly address her concerns. On that basis, this Office decided further investigation was unnecessary. 

A few months later, Amna again complained to this Office concerning other issues with WorkCover’s management of her claim. During this investigation, it became clear that WorkCover had verbally responded to her concerns. A formal response was not provided as promised. 

The result

This Office contacted WorkCover to seek information and raise concerns about the management of Amna’s complaints. After some discussion, WorkCover committed to a complete review of Amna’s claim file. WorkCover also decided to change the officer dealing with Amna’s claim. 

This Office decided to monitor WorkCover’s agreed actions and requested WorkCover inform us when the claim file review was completed and a further response had been provided to Amna. WorkCover completed the review and apologised to Amna for how her claim had been handled.