Ombudsman's Reports
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.
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 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.
The Ombudsman 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. However, the Ombudsman found that there is important further work that should be done, including a range of opportunities across all stages of the service spectrum to improve the identification of, and responses to, family and domestic violence in Western Australia.
The Investigation Report also 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.
Read the Ombudsman's Foreword and Executive Summary (Volume 1)
Read the Investigation into family and domestic violence and suicide:
Volume 2: Understanding the impact of family and domestic violence and suicide
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”.
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”.
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.
The Ombudsman is very pleased to report to Parliament that in relation to the recommendations that steps have been taken, and are proposed to be taken, to give effect to the recommendations. In no instance have was it found that no steps have been taken to give effect to the recommendations.
The work of the Office in ensuring that the recommendations of the Investigation are given effect does not end with the tabling of this report. The Office will continue to monitor and report on the steps taken to give effect to the recommendations arising from the Investigation.
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.
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. The OPA has agreed to all seven recommendations. The Ombudsman will actively monitor the steps taken by OPA to give effect to the recommendations.
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 the Ombudsman’s 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 the Ombudsman’s 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).
The Ombudsman is very pleased to report to Parliament that steps have been taken or are proposed to be taken (or both) for each of the 22 recommendations arising from the findings of the 2014 Investigation, as set out in Volume 2.
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.
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.
Click here to read the 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
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.
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.
A report on the monitoring of the infringement notices provisions of The Criminal Code
Summary: In accordance with the relevant provisions of The Criminal Code, the Ombudsman had an important function to keep under scrutiny the operation of the infringement notices provisions of The Criminal Code, relevant regulations made under The Criminal Code and the relevant provisions of the Criminal Investigation (Identifying People) Act 2002 in relation to infringement notices (Criminal Code infringement notices). Importantly, this scrutiny included review of the impact of the operation of the provisions on Aboriginal and Torres Strait Islander communities. The infringement notices provisions of The Criminal Code and the relevant regulations allow authorised officers to issue Criminal Code infringement notices for two prescribed offences, with a modified penalty of $500.
Investigation into ways to prevent or reduce deaths of children by drowning
Summary: 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.
This investigation aimed to develop an understanding of the deaths of children who died by drowning. Informed by this understanding, the investigation further aimed to examine the actions of local governments and state government departments and authorities in administering the relevant laws of the Western Australian Parliament and relevant regulations and standards. Moreover, the investigation aimed to develop an understanding of non-fatal drowning incidents involving children.
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
Summary: 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. The Ombudsman has now provided Parliament a report on giving effect to the recommendations arising from 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.
Investigation into issues associated with violence restraining orders and their relationship with family and domestic violence fatalities
Summary: The office of the Western Australian Ombudsman reviews family and domestic violence fatalities, identifies patterns and trends arising from these reviews, and makes recommendations about ways that state government departments and authorities can prevent or reduce family and domestic violence fatalities.
In undertaking the family and domestic violence fatality review function, the Ombudsman decided to undertake a major own motion 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
Summary: The Western Australian Ombudsman reviews certain investigable 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 a major own motion investigation into ways that State government departments and authorities can prevent or reduce suicide by young people.
Investigation into ways that State Government departments can prevent or reduce sleep-related infant deaths
Summary: The Western Australian Ombudsman reviews certain investigable 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’.
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 (2011)
Summary: 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 Management of Personal Information - good practice and opportunities for improvement (2011)
Summary: In 2010-11, the Ombudsman's office investigated the management of personal information by three State Government agencies.
2009-10 Survey of Complaint Handling Practices in the Western Australian State and Local Government Sectors (2010)
Summary: In November 2009, the Ombudsman's office surveyed all organisations within its jurisdiction to examine complaint handling by Western Australian state and local government organisations.
Report by the Ombudsman on complaints management processes in the Department of Education and Training (2006)
Progress report (November 2007)
Report on Allegations Concerning the Treatment of Children and Young People in Residential Care (2006)
Own Motion Investigation into the Department of Corrective Services' Prisoner Grievance Process (2006)
An investigation into the Police Response to Assault in the family home (2003)
The Management, Supervision and Control of Operation Safe Trains (2002)
Report on an investigation into a complaint by the Town of Cambridge concerning the City of Perth (2001)
Report on complaint handling in the Western Australian public sector:
Second survey (2001)
First survey (1999)
The Falsification of Random Breath Testing Statistics in the Western Australia Police Service (2001)
Reporting Police Misconduct (2001)
Report on an investigation into deaths in prisons (2000)
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