Improvements - Office of the Health Complaints Commissioner

These improvements were initiated by this office during 2019-2020:


  • Improved processes and further training for dispensing and high risk medications (drugs that have a heightened risk of causing significant patient harm).
  • All staff were instructed to review product literature about all critical drugs.
  • Alerts were installed on the dispensing software so that messages automatically pop up saying, for example, ‘once weekly only’ (and also promotes the use of evidence based supplements).
  • Additionally, posters containing information detailing drugs which have detrimental side effects if taken incorrectly, even over a short period of time were put up in areas where staff could see them.

General Practice

  • Improved record keeping following  a complaint about the failure of a general practitioner to properly diagnose a patient, it was revealed that the practitioner’s record keeping was unsatisfactory and he was required to undertake further training.
  • Greater awareness and tolerance of the impact of certain neurological disorders on some patients’ communication ability and the barriers to healthcare which the disorder engendered.
  • Greater awareness of the impact of the disorder on the communication skills of the patient and the barriers to healthcare which the disorder engendered.
  • A general practice acknowledged that they lacked the capacity to manage communication with some patients with neurological disorders as a result of the assessment of a complaint from a patient with this form of disability.
  • Practice staff were unaware of the impact of the disorder on the communication skills of the patient and the barriers to healthcare which the disorder engendered.


  • Improved policies and procedures to reduce the risks of adverse events for non-verbal in‑patients with significant intellectual and physical disabilities.
  • Improved communication systems to reduce the risk of referral for unnecessary invasive investigations requiring, for example, the insertion of an indwelling catheter.
  • Improved communication with patients to avoid negative outcomes from insertion of intrauterine devices.
  • Improved referrals for MRIs and orthopaedic clinic treatment for patients with fractures presenting to the emergency department.
  • Improved access to training in communication skills and de-escalation techniques for staff to manage interactions with patients with neurological disorders.
  • Improved monitoring of inmates prescribed medication to treat complex mental health disorders.

Specialist Services

The Medical Advisory Committee within a specialist eye services clinic responded to a complaint by directing all staff to adopt new policies in regard to patients’ privacy when completing forms that may be potentially misunderstood by patients.

Statewide Mental Health Services

  • Mistakes rectified in their booking system that had resulted in patients being incorrectly discharged from the service.
  • Administration staff received upskilling in maintaining privacy after a patient overheard a derogatory conversation.

Unregistered practitioners

A massage therapist developed insight into his lack of professional skills and decided to cease practice until he had completed a nationally accredited training program.

Registered Nurse

A registered nurse developed insight into her lack of professionalism when speaking with another registered nurse who was an in-patient.

Reimbursement of Costs

In addition we had four matters where the consumer was seeking reimbursement of costs and/or compensation as the only outcome to the complaint.  These matters were resolved early without referral to conciliation.  This outcome meant the matter was resolved quickly and to the satisfaction of all parties to the complaint.

Where to next?

Improvements from Conciliation

Updated: 30th April 2021