Reports on own motion investigations

A report on giving effect to the recommendations arising from the Investigation into family and domestic violence and suicide

Investigation into family and domestic violence and suicide

Ombudsman releases a report on giving effect to the recommendations arising from An investigation into the Office of the Public Advocate’s role in notifying the families of Mrs Joyce Savage, Mr Robert Ayling and Mr Kenneth Hartley of the deaths of Mrs Savage, Mr Ayling and Mr Hartley

A report on giving effect to the recommendations arising from the Investigation into the handling of complaints by the Legal Services and Complaints Committee

A report on the steps taken to give effect to the recommendations arising from Preventing suicide by children and young people 2020

An investigation into the Office of the Public Advocate’s role in notifying the families of Mrs Joyce Savage, Mr Robert Ayling and Mr Kenneth Hartley of the deaths of Mrs Savage, Mr Ayling and Mr Hartley

Preventing suicide by children and young people 2020

Local government collection of overdue rates for people in situations of vulnerability: Good Practice Guidance

A report on giving effect to the recommendations arising from Investigation into ways to prevent or reduce deaths of children by drowning

Investigation into ways to prevent or reduce deaths of children by drowning

A report on giving effect to the recommendations arising from the Investigation into issues associated with violence restraining orders and their relationship with family and domestic violence fatalities

Investigation into issues associated with violence restraining orders and their relationship with family and domestic violence fatalities

Investigation into ways that State government departments and authorities can prevent or reduce suicide by young people (2014)

Investigation into ways that State Government departments can prevent or reduce sleep-related infant deaths

Planning for children in care: An Ombudsman’s own motion investigation into the administration of the care planning provisions of the Children and Community Services Act 2004

The Management of Personal Information - good practice and opportunities for improvement

The Effective Administration of Complaint Handling Systems


 

A report on giving effect to the recommendations arising from the Investigation into family and domestic violence and suicide

On 9 November 2023, the Western Australian Ombudsman, Chris Field PSM, tabled in Parliament A report on giving effect to the recommendations arising from the Investigation into family and domestic violence and suicide.

The Ombudsman undertakes the important responsibility of reviewing family and domestic violence fatalities. Arising from this work, the Ombudsman undertook a major own motion investigation, Investigation into family and domestic violence and suicide (the Investigation) tabled in Parliament on 20 October 2022.

Arising from the findings in the Investigation, the Ombudsman made nine recommendations about ways to prevent or reduce family and domestic violence deaths by suicide. The Western Australia Police Force, the Department of Communities, the Department of Justice, the Department of Health and the Mental Health Commission each agreed to these recommendations.

“In 2016-17, I gave a commitment to Parliament that, following the tabling of each major own motion investigation, my Office would undertake a comprehensive review of the steps taken by government agencies to give effect to our recommendations and then table the results of this review in Parliament twelve months after the tabling of the major own motion investigation. Accordingly, I am now pleased to provide Parliament with A report on giving effect to the recommendations arising from the Investigation into family and domestic violence and suicide, November 2023” said Mr Field.

Overall, the Ombudsman found that steps have been taken, or are proposed to be taken, to give effect to each of the recommendations. While it is noted that the Mental Health Commission has commenced work to give effect to Recommendation 8, this work commenced more than eight months after the tabling of the report of the Investigation in Parliament. Given the exceptionally serious, and extraordinarily egregious nature, of men’s violence to women, including the very welcome public attention being in relation to this violence, the fact that an eight-month period elapsed prior to commencing this work is of concern. For this reason, the Ombudsman informed the Mental Health Commission that the Office will review this matter again on 31 December 2023, and it is expected that this work will be significantly advanced, and have a clear timeline for completion, in accordance with, and giving effect to, Recommendation 8. The Mental Health Commission has, pleasingly, now prioritised work to address this recommendation and has committed to providing the Office an update on their progress, including a clear timeline for completion, by 31 December 2023.

“In recent months, there have been a number of horrifying deaths of women because of men’s abhorrent violence. These fatalities are rightly at the centre of collective public consciousness. We must all commit to this ending. I commit to continuing to work to ending men’s violence and making women and children safe, including that women never feel as though taking their own life is the only escape from a man’s violence” said Mr Field.

Read the Report


 

Investigation into family and domestic violence and suicide

On Thursday 20 October 2022, the Western Australian Ombudsman and President of the International Ombudsman Institute tabled in Parliament the report of his major own motion investigation titled Investigation into family and domestic violence and suicide
(the Investigation Report).

The investigation commenced following the Ombudsman’s identification of the need to undertake a major own motion investigation into family and domestic violence and suicide while undertaking his important responsibilities of reviewing family and domestic violence fatalities and child deaths.

The report includes a comprehensive set of state-wide data relating to 68 women and child victims of family and domestic violence who died by suicide in 2017 and their prior interactions with State government departments and authorities.

In his Foreword, the Ombudsman stated:

“To undertake this investigation, in addition to an extensive literature review and stakeholder engagement, my office collected and analysed a comprehensive set of state-wide data relating to those who died by suicide in circumstances where family and domestic violence had previously been identified by one or more State government departments or authorities. This included an examination of 68 women and child victims of family and domestic violence who died by suicide in 2017.

I have found that a range of work has been undertaken by State government departments and authorities to administer their relevant legislative responsibilities to support the safety of women and children experiencing family and domestic violence. I have found, however, that there is important further work that should be done. This work, detailed in the findings of this report, includes a range of important opportunities for improvement for State government departments and authorities, working individually and collectively, across all stages of the service spectrum to improve the identification of, and responses to, family and domestic violence in Western Australia.

In addition, this investigation has identified the need for State government departments and authorities to use a trauma informed approach when working with people who have experienced multiple circumstances of vulnerability, including in responding to family and domestic violence and suicidality.

There is much good work being done by State government departments and authorities to prevent men’s vile and criminal violence against women and the trauma and tragedy that results from this violence, but we can and must do more.

Arising from my findings, I have made nine recommendations to four government agencies about ways to prevent or reduce family and domestic violence related deaths by suicide. I am very pleased that each agency has agreed to these recommendations and has, more generally, been highly co-operative, responsive and positively engaged with our investigation.

The work of my Office in ensuring that the recommendations of the Investigation are given effect does not end with the tabling of this report. My Office will continue to monitor and report on the steps taken to give effect to the recommendations arising from the Investigation.

I acknowledge the ongoing effort of State government departments and authorities, our first responders, including police officers, child protection workers and health professionals, as well as non-government organisations, who work to keep victims safe and hold perpetrators accountable.

Finally, I extend my deepest personal sympathy and condolences to all Western Australian families, friends and communities impacted by the tragic and immeasurable loss of life of a loved one who has died by suicide. It is my sincerest hope that the recommendations of this investigation will contribute to preventing these tragic deaths in the future.”

Click the links below to read the Report:

Volume 1: Executive Summary

Volume 2: Understanding the impact of family and domestic violence and suicide

Volume 3: Contact between victims of family and domestic violence and State government departments and authorities

Volume 4: The need for trauma informed responses

Full Report - Volumes 1, 2, 3 and 4


 

A report on giving effect to the recommendations arising from An investigation into the Office of the Public Advocate’s role in notifying the families of Mrs Joyce Savage, Mr Robert Ayling and Mr Kenneth Hartley of the deaths of Mrs Savage, Mr Ayling and Mr Hartley

On 18 October 2022, the Ombudsman released his report on giving effect to the recommendations arising from An investigation into the Office of the Public Advocate’s role in notifying the families of Mrs Joyce Savage, Mr Robert Ayling and Mr Kenneth Hartley of the deaths of Mrs Savage, Mr Ayling and Mr Hartley.

On 2 March 2021, the Honourable John Quigley MLA, Attorney General, wrote to the Ombudsman requesting an investigation into the Office of the Public Advocate’s (OPA) role in notifying the family of Mrs Joyce Savage of the death of Mrs Savage. The Attorney General also requested that the Ombudsman include in his investigation, the circumstances of OPA’s notification to the families of Mr Robert Ayling and Mr Kenneth Hartley of the deaths of Mr Ayling and Mr Hartley.

On the same day, in accordance with section 16(1) of the Parliamentary Commissioner Act 1971, the Ombudsman initiated an investigation into OPA’s role in notifying the families of Mrs Joyce Savage, Mr Robert Ayling and Mr Kenneth Hartley of the deaths of Mrs Savage, Mr Ayling and Mr Hartley (Investigation).

As a result of the Investigation, the Ombudsman formed a number of opinions regarding OPA’s role in notifying the families of Mrs Joyce Savage, Mr Robert Ayling and Mr Kenneth Hartley of the deaths of Mrs Savage, Mr Ayling and Mr Hartley.

Arising from these opinions, the Ombudsman made seven recommendations to OPA. Pleasingly, OPA agreed to all seven recommendations. As with all of the Ombudsman’s own motion investigations, twelve months after tabling the report of an investigation in Parliament, the Ombudsman reports to Parliament on the steps taken to give effect to the recommendations arising from an investigation.

Western Australian Ombudsman Chris Field said:

“Having very carefully considered the information provided by OPA regarding their implementation of the seven recommendations, I am pleased to report that I am of the view that OPA has taken steps to give effect to each of the seven recommendations. In no instance have I found that no steps have been taken to give effect to a recommendation. This is an important and pleasing outcome.

I am also pleased to report that the Public Advocate and her staff have been highly cooperative, open and timely during the undertaking of the Investigation and this report. A preparedness to accept oversight and accountability and take positive steps to improve the provision of their essential services to some of Western Australia’s most vulnerable citizens reflects very well on OPA. 

I again express my sincerest condolences to the families on the passing of Mrs Savage, Mr Ayling and Mr Hartley. I hope it is a level of comfort for each family that the Investigation, and OPA’s response, has resulted in clear improvements to the way that OPA notifies families upon the death of a loved one”.

Read the Report


 

A report on giving effect to the recommendations arising from the Investigation into the handling of complaints by the Legal Services and Complaints Committee

On 21 September 2022, the Western Australian Ombudsman and President of the International Ombudsman Institute released his report on giving effect to the recommendations arising from the Investigation into the handling of complaints by the Legal Services and Complaints Committee.

Following a request to the Ombudsman by the Honourable John Quigley MLA, Attorney General, to consider the handling of complaints by the Legal Profession Complaints Committee (the LPCC), the Ombudsman completed an investigation into the handling of complaints by the LPCC on 11 December 2020.

In the report of the investigation (the Investigation Report), the Ombudsman set out a series of opinions regarding the handling of complaints by the LPCC. Arising from these opinions, the Ombudsman made thirteen recommendations to the LPCC. This report sets out the steps taken by the now Legal Services and Complaints Committee (LSCC) to give effect to the Ombudsman’s recommendations.

The Investigation Report identified serious problems with the timeliness of the LSCC’s handling of complaints as well as its lack of key performance indicators, inadequate public reporting and lack of a modern electronic system for complaints management. Accordingly, it is pleasing that the response to the Investigation Report by the LSCC has been timely and effective.

Western Australian Ombudsman Chris Field said:

“Following over a decade of indications that the LSCC would institute an electronic complaints management system, in the Investigation Report I recommended that the LSCC implement an electronic complaints management system by no later than the end of the financial year 2021-22 and should aim to do so by December 2021. The LSCC has given effect to my recommendation and implemented an electronic complaints management system, slightly ahead of the time I recommended, ending over a decade of delay. In the Investigation Report, I further recommended that the LSCC achieved the closure of very aged complaints. Again, the LSCC has done so, and again ahead of the time that I recommended”.

“Overall, the LSCC has either given effect, taken steps to give effect, or steps have been proposed to give effect, to all thirteen recommendations in the Investigation Report”.

Click here to read the Report


 

A report on the steps taken to give effect to the recommendations arising from Preventing suicide by children and young people 2020

As part of the Ombudsman’s responsibility to review the deaths of Western Australian children, on 30 September 2021, A report on the steps taken to give effect to the recommendations arising from Preventing suicide by children and young people 2020 was tabled in Parliament.

In the Ombudsman’s Foreword, the Ombudsman noted:

As Ombudsman, I have an important responsibility to review child deaths. Arising from my responsibility to review child deaths, I undertook a major own motion investigation, Preventing suicide by children and young people 2020 (the Investigation), tabled in Parliament on 24 September 2020. Arising from my findings in the Investigation, I made seven recommendations about ways to prevent or reduce deaths of children and young people by suicide. The Mental Health Commission, Department of Health, Department of Communities and Department of Education each agreed to these recommendations.

In 2016-17, I gave a commitment to Parliament that, following the tabling of each major own motion investigation, my Office would undertake a comprehensive review of the steps taken by government agencies to give effect to our recommendations and then table the results of this review in Parliament twelve months after the tabling of the major own motion investigation. Accordingly, I am now pleased to provide Parliament with A report on the steps taken to give effect to the recommendations arising from Preventing suicide by children and young people 2020, September 2021.

I am very pleased to report to Parliament that in relation to the recommendations I have found that steps have been taken, and are proposed to be taken, to give effect to the recommendations. In no instance have I found that no steps have been taken to give effect to the recommendations.

In undertaking the review of the steps taken by the agencies to give effect to the recommendations, it is very evident to me that there is a particularly positive and very pleasing emphasis on strong cooperation and collaboration between the agencies. This is vitally important as the tragedy of suicide by children and young people cannot be prevented by a single program, service or agency working in isolation. Accordingly, I take this opportunity to commend and thank the Mental Health Commission, Department of Health, Department of Communities and Department of Education on this approach.

The work of my Office in ensuring that the recommendations of the Investigationare given effect does not end with the tabling of this report. My Office will continue to monitor and report on the steps taken to give effect to the recommendations arising from the Investigation.

Finally, I extend my deepest personal sympathy and condolences to all Western Australian families, friends, students and communities impacted by the tragic and immeasurable loss of life of a child or young person by suicide. It is my sincerest hope that the recommendations of the Investigation, and the very positive steps that have been taken, and are proposed to be taken, by the four government agencies to give effect to the recommendations, will contribute to preventing these tragic deaths in the future.

Click here to read the Report


 

An investigation into the Office of the Public Advocate’s role in notifying the families of Mrs Joyce Savage, Mr Robert Ayling and Mr Kenneth Hartley of the deaths of Mrs Savage, Mr Ayling and Mr Hartley

On Thursday 8 July 2021, the Ombudsman released his investigation report, An investigation into the Office of the Public Advocate’s role in notifying the families of Mrs Joyce Savage, Mr Robert Ayling and Mr Kenneth Hartley of the deaths of Mrs Savage, Mr Ayling and Mr Hartley.

The report arose following a request to the Ombudsman, on 2 March 2021, by the Honourable John Quigley MLA, Attorney General, to investigate the Office of the Public Advocate’s (OPA) role in notifying the family of Mrs Joyce Savage of the death of Mrs Savage. The Attorney General also requested that the Ombudsman include in his investigation the circumstances of OPA’s notification to the families of Mr Robert Ayling and Mr Kenneth Hartley of the deaths of Mr Ayling and Mr Hartley.

On the same day, in accordance with section 16(1) of the Parliamentary Commissioner Act 1971, the Ombudsman initiated an investigation into OPA’s role in notifying the families of Mrs Joyce Savage, Mr Robert Ayling and Mr Kenneth Hartley of the deaths of Mrs Savage, Mr Ayling and Mr Hartley (the Investigation).

Mrs Savage’s daughter, Ms Kaye Davis, Mr Ayling’s son, (also named) Mr Robert Ayling and Mr Hartley’s brother, Mr Phillip Hartley, were contacted as part of the Investigation and each made themselves available during the Investigation to talk about their experiences and views. These experiences and views have informed this report of the Investigation (the Report) and it the Ombudsman’s hope that the Report can, in turn, provide information to Ms Davis, Mr Ayling and Mr Hartley that is of assistance to them.

In the Ombudsman’s Foreword, the Ombudsman noted:

“I express my sincerest condolences to the families on the passing of Mrs Savage, Mr Ayling and Mr Hartley.”

“A person for whom OPA has been appointed as their guardian is a ‘represented person’. This was the case for Mrs Savage, Mr Ayling and Mr Hartley. Each was a represented person. But Mrs Savage, Mr Ayling and Mr Hartley were more than represented people. Each led a long life, was a family member and a contributor to their communities. Any delay in notifying a family of the death of a family member will, of course, be upsetting for a family. Further, the delay does not give the dignity to the person’s passing that they should, and must, be afforded.”

“As a result of the Investigation, I have formed a number of opinions regarding OPA’s role in notifying the families of Mrs Joyce Savage, Mr Robert Ayling and Mr Kenneth Hartley of the deaths of Mrs Savage, Mr Ayling and Mr Hartley.”

“Arising from these opinions, I have made seven recommendations to OPA. I am very pleased that OPA has agreed to all seven recommendations. I will actively monitor the steps taken by OPA to give effect to my recommendations. In my view, these seven recommendations, when implemented, will be responsive to the families of Mrs Savage, Mr Ayling and Mr Hartley, but also ensure that in the future OPA does, without delay, notify family upon the death of a loved one.”

Click here to read the Report.


 

Preventing suicide by children and young people 2020

As part of the Ombudsman’s responsibility to review the deaths of Western Australian children, on 24 September 2020, Preventing suicide by children and young people 2020 was tabled in Parliament. The report is comprised of three volumes: Volume 1 an executive summary; Volume 2 an examination of the steps taken to give effect to the recommendations arising from the report of my 2014 major own motion investigation, Investigation into ways that State government departments and authorities can prevent or reduce suicide by young people (the 2014 Investigation); and Volume 3, the report of my 2020 major own motion investigation, Investigation into ways that State government departments and authorities can prevent or reduce suicide by children and young people (the 2020 Investigation).

In the Ombudsman’s Foreword of Preventing suicide by children and young people 2020, the Ombudsman noted:

The 2014 Investigation examined the deaths of 36 young people aged 14 to 17 years. Arising from my findings, I made 22 recommendations to four agencies, namely, the Mental Health Commission, Department of Health, Department of Education and the (then) Department for Child Protection and Family Support, all of which were accepted by these agencies. I am very pleased to report to Parliament that I have found that steps have been taken or are proposed to be taken (or both) for each of the 22 recommendations as set out in Volume 2 of the report.

The 2020 Investigation examines a further 79 deaths by suicide that occurred following the 2014 Investigation, as set out in Volume 3. The 2020 Investigation examines what is known about suicide and self-harm by Western Australian children and young people, the research literature, current strategic frameworks, and data obtained during our investigation. Significantly, it also collates State-wide suicide and self-harm data relating to Western Australian children and young people over the 9 years from 1 July 2009 to 30 June 2018 for the first time, including:

  • deaths by suicide; and
  • hospital admissions and emergency department attendances for self-harming and suicidal behaviour. 

Arising from the findings of the 2020 Investigation, the Ombudsman made seven recommendations to four government agencies about preventing suicide by children and young people, including the development of a suicide prevention plan for children and young people to focus and coordinate collaborative and cooperative State government efforts.

The Ombudsman is very pleased that each agency has agreed to these recommendations and has, more generally, been positively engaged with our investigation. These recommendations are notable not by their number, but by the fact that we have sought to make highly targeted, achievable recommendations regarding critical issues. Further the Ombudsman has ensured that the recommendations do not duplicate the work of other investigations and inquiries.

The new information gathered, presented and comprehensively analysed in the 2020 Investigation will be, the Ombudsman believes, a very valuable repository of knowledge for government agencies, non-government organisations and other institutions in the vital work that they undertake in developing and assessing the efficacy of future suicide prevention efforts in Western Australia.

Preventing suicide by children and young people is a shared responsibility requiring collaboration, cooperation and a common understanding of past deaths, risk assessment and responsibilities. The complex and dynamic nature of the risk and protective factors associated with suicide requires a varied and localised response, informed by data about self-harm and suicide, and other indicators of vulnerability experienced by our children and young people. Ultimately, suicide by children and young people will not be prevented by a single program, service or agency working in isolation. Preventing suicide by children and young people must be viewed as part of the core, everyday business of each agency working with children and young people.

The 115 children and young people who died by suicide considered as part of my 2014 and 2020 Investigations will not be forgotten by their parents, siblings, extended family, friends, classmates and communities. The Ombudsman extends his deepest personal sympathy to all that continue to grieve their immeasurable loss.

It is the Ombudsman’s sincerest hope that the extensive new information in this report about suicide by children and young people, and its recommendations, will contribute to preventing these most tragic deaths in the future.

Read more about the Ombudsman’s report Preventing suicide by children and young people 2020:

Volume 1: Ombudsman’s Foreword and an Executive Summary

Volume 2: A report on giving effect to the recommendations arising from the Ombudsman’s Investigation into ways that State government departments and authorities can prevent or reduce suicide by young people 2014

Volume 3: Investigation into ways that State government departments and authorities can prevent or reduce suicide by children and young people

Preventing suicide by children and young people 2020 - Volumes 1, 2 and 3


 

Local government collection of overdue rates for people in situations of vulnerability: Good Practice Guidance

The office of the Western Australian Ombudsman has, over a period of time, received complaints regarding the collection of overdue rates for people in situations of vulnerability. Following an investigation by the Ombudsman, including considering relevant legislative and regulatory requirements, a review of relevant literature, analysis of good practice and consultation with local governments, the Ombudsman has developed Good Practice Guidance for local governments regarding their role in collecting overdue rates owed by people in situations of vulnerability.

The Good Practice Guidance is designed to assist local governments to consider their own policies and practices for the collection of rates and overdue rates in respect to people in situations of vulnerability and identify any aspects of these policies and practices that may present opportunities for improvement to ensure that the process is efficient and effective for local governments and is fair and equitable for all ratepayers, subject to the following two overarching principles.

Overarching Principle 1: Overdue rates must be paid, nonetheless, fair, reasonable and flexible approaches to payment are beneficial.

All ratepayers have a responsibility to pay overdue rates. The guidance in no way overrides, detracts from, or diminishes, the responsibility of ratepayers to pay overdue rates, consistent with the Local Government Act 1995. Nonetheless, a large body of research demonstrates that a fair, reasonable and flexible approach leads to better repayment outcomes and fewer resources expended in the collection of payments. Greater efficiency and predictability in the collection of rates thereby assists local governments to plan and fund their service delivery priorities. Furthermore, addressing overdue rates through an early intervention approach without resorting to court recovery processes minimises legal and court costs to individual ratepayers, councils and ultimately, to the wider community who fund the court system through the payment of taxes.

Overarching Principle 2: Good Practice Guidance should not impose unreasonable regulatory cost burdens on local governments and should be fit for size and circumstance.

Implementation of the Good Practice Guidance can, and should, be done in a way that does not impose any unreasonable or inappropriate regulatory costs on local governments (which, of course, are paid for by ratepayers).

It is absolutely appropriate for local governments to consider the relevance, costs and benefits of implementing the four Good Practice Principles and tailor areas of the Good Practice Guidance to their specific circumstances. In particular:

  1. Local governments may have already implemented good practice frameworks in relation to assisting people in situations of vulnerability, including in the collection of overdue rates. Where this is the case, the Good Practice Guidance can be used to ensure these existing frameworks adequately address the issues contained in the Good Practice Guidance, rather than the need to write new guidance;
  2. Local governments may have either more or less ratepayers in situations of vulnerability and therefore the extent of adoption of guidance underpinning principles may appropriately vary; and
  3. It is completely appropriate and reasonable for smaller local governments to consider the practicalities and resources required to tailor the guidance to their specific circumstances.

Click here to read the Report


A report on giving effect to the recommendations arising from Investigation into ways to prevent or reduce deaths of children by drowning

The Ombudsman, has an important responsibility to review certain child deaths, identify patterns and trends arising from these reviews and make recommendations about ways to prevent or reduce child deaths. 

On 23 November 2017, the Investigation into ways to prevent or reduce deaths of children by drowning (the Report), was tabled in Parliament. In the Foreword of the Report the Ombudsman noted:

I have found that a range of work has been undertaken by the Department of Mines, Industry Regulation and Safety and the Building Commissioner to administer their respective responsibilities in relation to swimming pool safety. I also found, that there was important further work that should be done. This work is detailed in the findings of this report. It will be critical that this work is undertaken with strong cooperation between the Department of Mines, Industry Regulation and Safety, the Building Commissioner, local governments and other key stakeholders, including intra-agency, inter-agency and cross‑sectoral arrangements – this is the most efficient and effective way to achieve positive change.

Arising from the findings in the Report, the Ombudsman made 25 recommendations about ways to prevent or reduce deaths of children by drowning. The Department of Mines, Industry Regulation and Safety and the Building Commissioner agreed to these recommendations.

In 2016-17, the Ombudsman gave a commitment to Parliament that, following the tabling of each major own motion investigation, the Ombudsman’s office would undertake a comprehensive review of the steps taken by government agencies to give effect to the Ombudsman’s recommendations and then table the results of this review in Parliament. Accordingly, the Ombudsman has now provided Parliament with a report on giving effect to the recommendations arising from the Ombudsman’s 2017 major own-motion investigation, Investigation into ways to prevent or reduce deaths of children by drowning.

The Ombudsman is very pleased that in relation to all of the recommendations, the Department of Mines, Industry Regulation and Safety and the Building Commissioner have either taken steps, or propose to take steps (or both) to give effect to the recommendations. In no instance has the Office found that no steps have been taken to give effect to the recommendations.

Following the Report, the Department of Mines, Industry Regulation and Safety, the Building Commissioner and local governments have made particularly positive progress in the areas of improving consistency and quality of swimming pool inspections and the training and professional development of swimming pool inspectors. The very evident level of national collaboration in relation to portable swimming pools, and Western Australian leadership in relation to this, is also very pleasing.

The death of a child by drowning is a tragedy – for the child’s life lost and for the parents, families and communities who have been personally affected by the tragic death. It is the Ombudsman’s sincerest hope that the recommendations of the Report, and the positive steps that have been taken to give effect to the recommendations, will contribute to preventing and reducing these tragic deaths in the future.

Click here to read the Report


 

Investigation into ways to prevent or reduce deaths of children by drowning

The Western Australian Ombudsman has an important responsibility to review certain child deaths, identify patterns and trends arising from these reviews and make recommendations about ways to prevent or reduce child deaths. Of the child death notifications received by the Ombudsman since commencing the child death review responsibility, 42 have been deaths of children by drowning. 

To undertake the investigation, the Ombudsman conducted an extensive literature review, comprehensively considered 34 deaths of children by drowning notified to the office of the Ombudsman over a six-year investigation period, surveyed all local governments in Western Australia (to which the office received a 99 per cent response rate), selected five local governments for further investigation, collected and analysed comprehensive information regarding the number of private swimming pools in local government districts and the quality of the swimming pool barrier inspection process, engaged with the (now) Department of Mines, Industry Regulation and Safety, the Building Commissioner, the Department of Health, the (now) Department of Local Government, Sport and Cultural Industries and relevant non-government and not-for-profit organisations.

The Ombudsman also collected and analysed de-identified information regarding the number of children admitted to a hospital or who attended an emergency department at a hospital following a non-fatal drowning incident. The Ombudsman found that 258 children were admitted to a hospital and 2,310 children attended an emergency department at a hospital following a non-fatal drowning incident.

The Ombudsman has found that a range of work has been undertaken by the Department of Mines, Industry Regulation and Safety and the Building Commissioner to administer their respective responsibilities in relation to swimming pool safety. The Ombudsman also found that there is important further work that should be done. This work is detailed in the findings of this report. It will be critical that this work is undertaken with strong cooperation between the Department of Mines, Industry Regulation and Safety, the Building Commissioner, local governments and other key stakeholders, including intra-agency, inter-agency and cross-sectoral arrangements – this is the most efficient and effective way to achieve positive change.

Arising from the findings, the Ombudsman has made 25 recommendations about ways to prevent or reduce deaths of children by drowning. The Ombudsman is very pleased that the Department of Mines, Industry Regulation and Safety and the Building Commissioner have agreed to these recommendations. In keeping with the Ombudsman’s commitment to Parliament to ensure Parliament is informed about the implementation of the Ombudsman’s investigations, the Ombudsman will actively examine the steps taken to give effect to the recommendations and report the results of this examination to Parliament in 2018.

The Ombudsman notes his appreciation to the Department of Mines, Industry Regulation and Safety, the Building Commissioner and local governments – their cooperation through the investigation has been particularly positive and reflects their genuine willingness to engage in review, reflection and improvement.

The death of a child by drowning is a tragedy – for a child’s life lost and for the parents, families and communities that have been personally affected by the tragic death. It is the Ombudsman’s sincere hope that the investigation will, through its research and analysis and its recommendations, make a meaningful contribution to the prevention and reduction of this tragic loss of life.

Click here to read the full Report

Click on the links below to read the Report by Section:

Table of Recommendations
Ombudsman's Foreword
1 Executive Summary
2 About the Investigation
3 Deaths of children by drowning in Western Australia
4 Preventing and reducing deaths of children by drowning
5 Private swimming pools in Western Australia
6 Inspection of private swimming pool barriers by local governments in Western Australia
7 Quality of inspections
8 Enforcement of regulation 50(1) of the Building Regulations 2012
9 Swimming pool barriers that may not be inspected by local governments
Appendix 1: Number of recorded private swimming pools in Western Australia

 

A report on giving effect to the recommendations arising from the Investigation into issues associated with violence restraining orders and their relationship with family and domestic violence fatalities

The Western Australian Ombudsman undertakes an important responsibility to review family and domestic violence fatalities. Arising from this work, the Ombudsman identified the need to undertake a major own motion investigation into issues associated with violence restraining orders (VROs) and their relationship with family and domestic violence fatalities.

On 19 November 2015, the Ombudsman tabled the Investigation into issues associated with violence restraining orders and their relationship with family and domestic violence fatalities (FDV Investigation Report) in the Western Australian Parliament. Through that investigation, the Ombudsman found that a range of work had been undertaken by state government departments and authorities to administer their relevant legislative responsibilities, including their responsibilities arising from the Restraining Orders Act 1997. The Ombudsman also found, however, that there is important further work that should be done. This work, detailed in the findings of the FDV Investigation Report, includes a range of important opportunities for improvement for state government departments and authorities, working individually and collectively, across all stages of the VRO process.

The Ombudsman also found that Aboriginal Western Australians are significantly overrepresented as victims of family violence, yet underrepresented in the use of VROs. Following from this, the Ombudsman identified that a separate strategy, specifically tailored to preventing and reducing Aboriginal family violence, should be developed. This strategy should actively invite and encourage the full involvement of Aboriginal people in its development and be comprehensively informed by Aboriginal culture.

Furthermore, the FDV Investigation Report identified nine key principles for state government departments and authorities to apply when responding to family and domestic violence and in administering the Restraining Orders Act 1997. Applying these principles will enable state government departments and authorities to have the greatest impact on preventing and reducing family and domestic violence and related fatalities.

Arising from the findings in the FDV Investigation Report, the Ombudsman made 54 recommendations to four government agencies about ways to prevent or reduce family and domestic violence fatalities. Each agency agreed to these recommendations.

Importantly, the Ombudsman also indicated that the Ombudsman's office would actively monitor the implementation of these recommendations and report to Parliament on the results of this monitoring. Accordingly, the Ombudsman has now provided Parliament ‘A report on giving effect to the recommendations arising from the Investigation into issues associated with violence restraining orders and their relationship with family and domestic violence fatalities’.

The Ombudsman is pleased that in relation to all of the recommendations, the relevant state government departments and authorities have either taken steps, or propose to take steps (or, in some cases, both) to give effect to the recommendations. In no instance has the office found that no steps have been taken, or are proposed to be taken, to give effect to the recommendations.

It is particularly pleasing that, in giving effect to the recommendations, important improvements have been achieved when compared to the findings identified in the FDV Investigation Report.

This report sets out the steps taken, or proposed to be taken, to give effect to the recommendations arising from the FDV Investigation Report, however, the work of the Ombudsman's office in ensuring that the recommendations of the investigation are given effect does not end with the tabling of this report.

The Ombudsman's office will continue to monitor, and report on, whether steps continue to be taken to give effect to the recommendations arising from the FDV Investigation Report. The next such report will be provided in the Ombudsman's office’s 2016-17 Annual Report.

Click here to read the Report


 

Investigation into issues associated with violence restraining orders and their relationship with family and domestic violence fatalities

The Western Australian Ombudsman undertakes an important responsibility to review family and domestic violence fatalities. Arising from this work, the Ombudsman identified the need to undertake a major own motion investigation into issues associated with violence restraining orders (VROs) and their relationship with family and domestic violence fatalities.

To undertake the investigation, in addition to an extensive literature review and stakeholder engagement, the office of the Ombudsman collected and analysed a comprehensive set of de-identified state-wide data relevant to family and domestic violence and examined 30 family and domestic violence fatalities notified to the Ombudsman.

The Ombudsman has found that a range of work has been undertaken by state government departments and authorities to administer their relevant legislative responsibilities, including their responsibilities arising from the Restraining Orders Act 1997. The Ombudsman has found, however, that there is important further work that should be done. This work, detailed in the findings of this report, includes a range of important opportunities for improvement for state government departments and authorities, working individually and collectively, across all stages of the VRO process. The Ombudsman has also found that Aboriginal Western Australians are significantly overrepresented as victims of family violence, yet underrepresented in the use of VROs. Following from this, the Ombudsman identified that a separate strategy, specifically tailored to preventing and reducing Aboriginal family violence, should be developed. This strategy should actively invite and encourage the full involvement of Aboriginal people in its development and be comprehensively informed by Aboriginal culture.

Furthermore, this investigation has identified nine key principles for state government departments and authorities to apply when responding to family and domestic violence and in administering the Restraining Orders Act 1997. Applying these principles will enable state government departments and authorities to have the greatest impact on preventing and reducing family and domestic violence and related fatalities.

Arising from the findings of the investigation, the Ombudsman has made 54 recommendations to four government agencies about ways to prevent or reduce family and domestic violence fatalities.  The Ombudsman is very pleased that each agency has agreed to these recommendations and has, more generally, been highly co-operative, responsive and positively engaged with the Ombudsman’s investigation.

Importantly, the office of the Ombudsman will actively monitor the implementation of these recommendations and report to Parliament the results of this monitoring.

In undertaking this investigation, the Ombudsman acknowledges the employees of state government departments and authorities, including police officers and child protection workers, as well as non-government organisations, who, on a day to day basis, work to keep victims safe and hold perpetrators accountable.

Finally, the Ombudsman acknowledges, and expresses deepest sympathy to, the families and communities who have been affected by family and domestic violence fatalities in Western Australia. Throughout this report the Ombudsman has sought to ensure that the victims of family and domestic violence are heard, including through a number of case studies titled ‘A victim’s voice’.

Click here to read the full Report

Click on the links below to read the Report by Section:

Ombudsman’s Foreword

Helpful Contact Information


1. Executive Summary

2. About the Investigation

Part 1: Family and Domestic Violence in Western Australia (includes Sections 3-6)

3. Understanding family and domestic violence

4. Family and domestic violence in Western Australia

5. Family and domestic violence in fatalities notified to the Ombudsman

6. Aboriginal Family Violence

Part 2: Administration of legislation relevant to family and domestic violence (includes Sections 7-15)

7. Violence restraining orders and their role in preventing and reducing family and domestic violence

8. Providing victims with advice and assistance regarding restraining orders

9. Taking action to protect victims of family and domestic violence

10. Applying for and obtaining a violence and restraining order

11. Serving violence restraining orders

12. Responding to alleged breaches of violence restraining orders

13, Investigating if an act of family and domestic violence is a criminal offence

14. The use of violence restraining orders to protect children from family and domestic violence

15. Actions by DCPFS to engage with adult victims and perpetrators of family and domestic violence in order to protect children

 



 

Investigation into ways that State government departments and authorities can prevent or reduce suicide by young people

The Western Australian Ombudsman reviews certain child deaths, identifies patterns and trends arising from these reviews and makes recommendations about ways to prevent or reduce child deaths.

Of the child death notifications received by the Ombudsman's office since the child death review function commenced, nearly a third related to children aged 13 to 17 years old. Of these children, suicide was the most common circumstance of death, accounting for nearly forty per cent of deaths. Furthermore, and of serious concern, Aboriginal children were very significantly over-represented in the number of young people who died by suicide. For these reasons, the Ombudsman decided to undertake a major own motion investigation into ways that State government departments and authorities can prevent or reduce suicide by young people.

The Ombudsman has found that State government departments and authorities have already undertaken a significant amount of work that aims to prevent and reduce suicide by young people in Western Australia, however, there is still more work to be done. The Ombudsman has found that this work includes practical opportunities for individual agencies to enhance their provision of services to young people. Critically, as the reasons for suicide by young people are multi-factorial and cross a range of government agencies, the Ombudsman has also found that this work includes the development of a collaborative, inter-agency approach to preventing suicide by young people. In addition to the findings and recommendations, the comprehensive level of data and analysis contained in this report will, the Ombudsman believes, be a valuable new resource for government departments and authorities to inform their planning and work with young people. In particular, the analysis suggests this planning and work target four groups of young people that the Ombudsman has identified.

Arising from this investigation, the report makes 22 recommendations to four government agencies about ways to prevent or reduce suicide by young people. The Ombudsman is pleased that each agency has agreed to these recommendations and has, more generally, been highly co-operative and positively engaged with our investigation.

Click here to read the full Report

Click on the links below to read the Report by Section:

Ombudsman's Foreword

Crisis counselling, support services and helpful information

1 Executive Summary

2 About the investigation

3 Suicide by young people

4 Characteristics of the young people who died by suicide

5 Patterns in the characteristics of the young people who died by suicide and their contact with State government departments and authorities, schools ad registered training organisations

6 Strategic Frameworks for preventing and reducing suicide by young people

7 Ways of preventing and reducing suicide by young people by the Department of Health

8 Ways of preventing and reducing suicide by young people by the Department of Child Protection and Family Support

9 Ways of preventing and reducing suicide by young people by Department of Education

10 To identify and assist young people at risk of suicide, State government departments and authorities will need to work together as well as separately

Appendix


 

The Western Australian Ombudsman reviews certain child deaths, identifies patterns and trends arising from these reviews and makes recommendations designed to prevent or reduce child deaths.

In undertaking the child death review function, the Ombudsman identified a need to undertake an investigation into the number of deaths that have occurred after infants have been placed to sleep. In this report, these deaths are called ‘sleep-related infant deaths’.

The investigation has principally involved the Department of Health but also involved the Department for Child Protection and the Department for Communities. The objectives of the investigation were to analyse all sleep-related infant deaths notified to the Ombudsman's office, consider the results of the analysis in conjunction with the relevant research and practice literature, undertake consultation with key stakeholders and, from this analysis, research and consultation, recommend ways the departments can prevent or reduce sleep-related infant deaths.

The investigation has found that the Department of Health has undertaken a range of work to contribute to safe sleeping practices in Western Australia, however, there is still important work to be done. This work particularly includes establishing a comprehensive statement on safe sleeping that will form the basis for safe sleeping advice to parents, including advice on modifiable risk factors, that is sensitive and appropriate to both Indigenous and culturally and linguistically diverse communities and is consistently applied state-wide by health care professionals and non-government organisations at the antenatal, hospital-care and post-hospital stages. This statement and concomitant policies and practices should also be adopted, as relevant, by the Department for Child Protection and the Department for Communities.

The investigation has also found that a range of risk factors were prominent in sleep-related infant deaths reported to the Ombudsman’s office. Most of these risk factors are potentially modifiable and therefore present opportunities for the departments to assist parents, grandparents and carers to modify these risk factors and reduce or prevent sleep-related infant deaths.

Arising from this investigation, the report makes 23 recommendations about ways to prevent or reduce sleep-related infant deaths. The Ombudsman is pleased that each department has agreed to these recommendations and has, more generally, been highly co-operative and positively engaged with the Ombudsman’s investigation.

Click here to read the Executive Summary

Click here to read the Report


 

Planning for children in care: An Ombudsman’s own motion investigation into the administration of the care planning provisions of the Children and Community Services Act 2004

The Western Australian Ombudsman reviews investigable child deaths, identifies patterns and trends arising from these reviews and makes recommendations for improvement designed to prevent or reduce investigable child deaths.

In undertaking this role, the Ombudsman identified a need to undertake an investigation of planning for children in the care of the Chief Executive Officer of the Department for Child Protection – a particularly vulnerable group of children in the community.

The investigation involved the Department for Child Protection, the Department of Health and the Department of Education and considered, among other things, the relevant provisions of the Children and Community Services Act 2004, the internal policies of each of these departments and the recommendations arising from the Review of the Department for Community Development undertaken by Ms Prudence Ford.

In the five years since the introduction of the Children and Community Services Act 2004, these three agencies have worked cooperatively to operationalise the requirements of the Act. In short, the investigation found significant and pleasing progress on improved planning for children in care had been achieved, however, there was still work to be done.

The findings of the investigation and the 23 recommendations for improvement are detailed in the Ombudsman’s report Planning for children in care: An Ombudsman’s own motion investigation into the administration of the planning provisions of the Children and Community Services Act 2004.

Click here to read the Executive Summary

Click here to read the Report


 

The Management of Personal Information - good practice and opportunities for improvement

Personal information can be defined as information that identifies an individual or could identify that individual.  State Government agencies properly require individuals to provide a range of personal information about themselves in order to deliver services, carry out law enforcement, administer regulations and perform other statutory functions.  In short, effective and efficient service delivery, including the protection of the well-being of individuals and groups of people, may require an agency to disclose or share personal information it has collected.

Inappropriate use of personal information is, however, as a matter of principle, wrong.  Practically, it can compromise an individual’s privacy leading to undesirable outcomes. 

Alleged inaccuracy and inappropriate use of personal information is a source of complaint to the Ombudsman’s office.  These complaints provided an important base of evidence to suggest that the Ombudsman should review the management of personal information by State Government agencies. 

The findings of the review are detailed in the Ombudsman’s report The Management of Personal Information – Good Practice and Opportunities for Improvement.

Click here to read the Executive Summary

Click here to read the Report


 

The Effective Administration of Complaint Handling Systems

In June 2010, the Ombudsman’s office reported on a survey of all public authorities within the Ombudsman's jurisdiction to gain an overview of their complaint handling practices. This was the third such survey conducted by the office over the past ten years. The survey questionnaire asked organisations to assess their complaint handling processes and practices against a series of principles based on, and  consistent with, the Public Sector Commissioner’s Circular 2009-27: Complaints Management and the Australian Standard (AS ISO 10002-2006: Customer Satisfaction - Guidelines for Complaints Handling in Organisations). The survey addressed ten principles for complaint handling, as set out below:

Ten principles for complaint handling

The findings of the survey are detailed in the Ombudsman's Report 2009-10 Survey of Complaint Handling Practices in the Western Australian State and Local Government Sectors.

Click here to read the Executive Summary

Click here to read the Report