Notifications

If a practitioner is practising in New South Wales, Norfolk Island, Christmas Island or Antarctica, we cannot manage a notification about them. The Health Professional Councils Authority (HPCA) and the Health Care Complaints Commission (HCCC) manage complaints and concerns about practitioners in NSW. The Office of the Health Ombudsman (OHO) receives notifications about registered and unregistered practitioners in Queensland. We manage notifications about registered health practitioners if they are referred to us by OHO or if, under the new joint consideration process, they are assigned to us. 

On 6 December, following an amendment to the National Law, Ahpra and OHO began jointly considering notifications in Queensland. Together we considered more than 2,100 new notifications, and just over half of those were referred to Ahpra to manage. 

OHO closed more than 700 notifications about registered health practitioners following joint consideration, after agreeing with Ahpra that the concerns raised were not likely to result in regulatory action. A further 282 notifications were retained by OHO for further action; for example, investigation or other complaints-resolution activities. 

The average time from OHO receiving the notification to the completion of the joint consideration process was 12 calendar days. This meant that, for matters that were retained by OHO to close, notifiers and practitioners were advised of the outcome in a significantly more timely way than was possible before joint consideration.

There were 18,710 notifications made about 14,313 practitioners across all jurisdictions. That’s 1.7% of all registered health practitioners in Australia, and an increase of 6.2% from 2020/21. Some practitioners received more than one notification. 

We received most notifications (54.6%) from patients, their families and friends, and other members of the public; this is slightly higher than last year (50.8%). 

We received some notifications (16.3%) from health practitioners and employers. 

We received 2,251 confidential and anonymous notifications. Confidential notifications are when we know the identity of the notifier and are asked not to disclose it. Anonymous notifications are when we don’t know the identity of the notifier.

Clinical care was the most common type of complaint received either as a single concern or one of multiple concerns in a notification. 

In 2021/22, 6,983 (64.6%) notifications were about a single concern, 2,520 notifications (23.3%) were about two concerns, and 1,300 (12.03%) about three or more concerns.

There are a number of possible outcomes for notifications. The aim is to ensure that the public is protected and that practitioners are safe to practise.

We know that timeliness in managing notifications is important to notifiers and practitioners. It is important to us also and we continue to work to improve our timeliness. 

There was an 8.2% increase in open notifications. Several factors placed pressure on our notifications timeframes: 

• There was an increase in the number of cases referred to tribunal. These cases usually require more effort to manage than lower risk, lower complexity cases. 
• There was an increase in the number of notifications we received about behaviour associated with public health responses to the COVID-19 pandemic. We established a COVID Taskforce, diverted some resources to this area, and developed strategies to manage these notifications. 
• Like many organisations, Ahpra dealt with COVID-related resource challenges throughout the year, and this sometimes had an impact on our performance. 

We closed more than 70% (7,749) of notifications following assessment. 

Just over 70% of all closed notifications were closed on average in less than six months.

The healthcare experiences of patients and carers can have a real and lasting impact on them. When care does not go as expected, it is important that they have the trust and confidence to raise their concerns with us. At the same time, health practitioners need confidence that those concerns will be managed in a fair and appropriate way. 

Since 2017, we have asked all notifiers and practitioners to participate in an end-of-notification survey. Through this survey, we listen systematically to the voices of both notifiers and practitioners to better understand their experience of our notifications process. We also conduct semi-structured interviews with people who have recently been through the experience. These voices have helped to shape many improvements to the way we manage notifications. 

We have heard that both groups want the process to be (and to feel) fair. They want our communication to be helpful, informative and regular. And it is important to them that we work in a timely way. We have also heard that the experience is stressful, particularly for practitioners. 

We began a project in late 2021 to better understand the factors contributing to practitioners' distress and how we might decrease it. The work focuses on practitioners who experience extreme distress and whose health and wellbeing may be significantly affected as a result. Working with an expert advisory group, we have conducted first-person practitioner interviews and analysis of recent serious incidents affecting practitioners who were going through a regulatory process. We expect to have practical recommendations arising from this work by the end of 2022. 

Both notifiers and practitioners have told us they want the process to feel more ‘human’, and one of the best ways to achieve that is to speak directly to them, rather than relying on written correspondence. We have responded by making a commitment to telephone all notifiers and practitioners and to build that commitment into our updated Service charter. 

Another example involves notifiers expressing frustration with the outcome of their matter. Notifiers often raise matters with us that we assess as not requiring regulatory action due to no ongoing risk to the public. But we know that the healthcare experience was disappointing for that patient or carer. In the past, these matters might have been closed by us relatively quickly with no further action. However, in certain circumstances, we recognise that it is most appropriate for the matter to be referred to a health complaints entity (HCE) for consideration. HCEs can help facilitate other outcomes, such as an apology, which can be very important for patients and carers. This is part of our commitment to helping ensure that matters are dealt with by the most appropriate agency based on both the concerns raised and the outcomes sought by the notifier.

The COVID-19 pandemic presented significant challenges for us all. 

We received 1,303 notifications about practitioners in which the notifier raised a health, conduct or performance concern related to the COVID-19 pandemic. This accounted for 12% of all notifications received. 

We categorised a notification as ‘COVID-19 related’ if it included a concern about: 

• clinical care when seeking or receiving COVID-19 advice, vaccination or treatment 
• COVID-19 impacting a patient’s ability to seek help or treatment from a practitioner or service 
• inappropriate practitioner behaviour relating to the pandemic; for example, that the practitioner failed to comply with public health orders such as mask mandates 
• a practitioner’s practice not being COVID-safe 
• a practitioner providing false or misleading information to patients or the public about COVID-19 
• a practitioner undermining a public health campaign by providing false vaccination certificates or providing exemptions that were not in accordance with Australian Technical Advisory Group on Immunisation (ATAGI) guidelines 
• a practitioner’s online behaviour in debate about the pandemic breaching a National Board code of conduct. 

During the peak period of September to December 2021, we received an average of 36 COVID-19-related notifications each week. 

To triage, assess and manage the additional notifications, we created a COVID-19 Taskforce. 

Creating this team and ensuring we had enough staff to manage the notifications took some time. This meant lower-risk concerns related to COVID-19 were not acted on immediately. We responded first to cases where we believed there was an ongoing risk to the public. 

Not all of the COVID-19 notifications we received required regulatory action to be taken. No action was taken in approximately 50% of all COVID-19- related notifications. We were able to resolve a small number of complaints quickly after contacting the practitioner and discussing the matter with them. 

There were 186 open COVID-19 investigations at 30 June. While some of those may also be closed without action, others will be referred to responsible tribunals. 

By June 2022, receipt of COVID-19-related notifications reduced to an average of approximately 5 per week. 

The COVID-19 Taskforce will conclude early in 2022/23. Cases that remain open after this date will continue to be managed within our regular teams.

Some cases are closed quickly 

When someone raises a concern that is not grounds for a notification or not about a person registered under our National Law, it is closed within a few days of being received. 

When this happens, we let the person who raised the concern know, explaining why it has been closed. 

If the subject matter of the concern is better dealt with by a complaints body, we refer it to that body. This was the case with 1,041 notifications, which were 10.3% of notifications received. 

We close cases earlier when the concern: 

• is a one-off occurrence that is minor in nature and does not require action by us 
• is the result of a misunderstanding or miscommunication that does not compromise safety 
• does not indicate that a practitioner’s standard of practice is unsafe. 

These types of concerns accounted for 29.6% of our decisions to close cases early following an initial assessment. 

We may also close a notification more quickly if it is clear that the practitioner or the place where they work has acted on the subject matter of the concern. We call this collaborative regulation. Practitioners and workplaces may work together to resolve many of the concerns that are shared with us. 

• Where a practitioner addressed the issues that were raised about them (we call this good individual risk controls), 6.4% of our decisions resulted in earlier case closure (645 cases). 
• Where the practitioner’s workplace or employer addressed the issues that were raised (we call this good organisational risk controls), 4.0% of our decisions resulted in earlier case closure (402). 

No further action 

We referred more notifications to health complaints entities (HCEs) this year and as a result, our proportion of matters with no further action decreased (61.1%, compared with 71.1% in 2020/21). That means that, instead of closing the matter after an initial assessment, we referred it to an HCE, where appropriate. This is part of our commitment to help notifiers be at the right place – to ensure their matter is dealt with by the appropriate agency based on the concerns they raised and the outcomes they seek. To achieve this, we moved to a national approach for consultations with HCEs, improved the way we record outcomes and collaborated effectively with HCEs.

Investigating more serious cases 

Some issues can be more serious and we have options to help us better understand and address the issues raised. We can gather more information about the practitioner or an incident that has been raised with us informally or through an investigation. 

We prefer to use collaborative approaches to gather information. This includes engaging with notifiers, practitioners, workplaces and employers if they will cooperate with our enquiries. For many notifications, less formal engagement with practitioners is enough to ensure we play our role in public protection.

We can ask other practitioners who are registered in the same profession as the practitioner to speak with and observe them in practice (a performance assessment). 

We can also ask a psychiatrist, occupational physician, addiction medicine specialist or psychologist to review the practitioner and assess whether they have an impairment that poses a substantial risk to the public (a health assessment). 

We understand the impact that a formal investigation can have on the person being investigated – being the subject of an investigation is often stressful. We strive to find alternative ways of managing notifications that avoid the stress of an investigation, and try to limit investigations to cases when there is a potential risk to the public and we lack sufficient information to make a properly informed decision. 

Sometimes the seriousness of an individual notification or pattern of notifications by a practitioner means an investigation is necessary. 

• 2,519 notifications about 1,749 practitioners were referred for investigation. 
• 22.6% of all notifications were referred for investigation (down from 27.4% in 2020/21 and 26.2% in 2019/20). 

It was much more likely this year that an investigation involved more than one notification about the same practitioner – 46.0% of the practitioners who had an investigation start this year were the subject of more than one notification, up from 35.5% in 2020/21. One-off concerns were more readily able to be resolved without a formal investigation.

Strengthening practice 

We take our role of protecting the public seriously. We work with practitioners who are the subject of a notification to strengthen their practice whenever possible. Stronger, safer practice can be achieved when a practitioner: 

• understands what led to the notification 
• reflects on the causes of the notification 
• takes accountability for managing the causes of the concern or notification 
• demonstrates to us that they are taking appropriate actions about the cause of the notification. 

This can be supported by: 

• workplaces that seek to continually improve policies or practices that might have room for improvement 
• action taken by employers to ensure their employees understand the risks and consequences of unsafe practice 
• other regulators sharing investigations or outcomes with us that indicate a concern has been addressed with the practitioner 
• action by us to caution a practitioner for the thing that they did that contributed to a safety or professionalism concern 
• additional action by us that is published on the national Register of practitioners as a condition or undertaking. 

Our role is not to punish a practitioner, even though at times our response is a penalty. We only impose a regulatory outcome if this action is necessary to ensure the practitioner practises safely and professionally. 

The likelihood that we will need to take regulatory action to ensure safe professional practice increases according to the: 

• level of risk that the lapse in safety or professionalism led to 
• level of insight into a problem that a practitioner demonstrates and the extent to which they and their workplace have responded to it 
• number of times that a person has been reported to us for safety or professionalism issues 
• nature of care that the person provides 
• nature of the setting in which they deliver care 
  • if there are not strong organisational supports evident, it is more likely that we will need to consider a regulatory control 
• level of oversight that might already be in place to ensure the practitioner practises safely and professionally.

• 35 notifications were made to Ahpra about students; this is down from 42 last year 
• 2 notifications resulted in conditions or undertakings affecting a student’s registration, compared to 7 last year 

There are limited grounds for making notifications about students compared to registered health practitioners. A voluntary notification can be made about a student's criminal history, impairment or if they have not complied with a restriction on their registration as a student. 

There is only one ground for a mandatory notification – an education provider needs to tell us when they have formed a reasonable belief that a student has an impairment that may place a patient at substantial risk of harm when the student is doing clinical training.

Where applicable, practitioners and employers must tell us if they think another practitioner’s conduct, health impairment or performance places their patients at risk.

Mandatory notifications made up 9.6% of notifications received. 

• We received 1,033 mandatory notifications; 18.4% fewer than in 2020/21. 
• 43.7% were about nurses (451). 
• 33% were about medical practitioners (339). 
• The number of mandatory notifications about impairment (407) reduced from 453 in 2020/21. 
• Immediate action arising from mandatory notifications was considered on 378 occasions and taken 215 times.

The often more serious nature of mandatory notifications is reflected in the outcomes. 

• 29.8% of completed mandatory notifications resulted in regulatory action being taken (compared to 13.4% for all notification categories). 

Regulatory action taken in response to mandatory notifications was down from 31.3% in 2020/21.

When we are worried that there is a serious risk to public safety, or it is otherwise in the public interest, we can take immediate action while we make further enquiries. 

Immediate action was taken: 

• 685 times – 14.7% (88) more than in 2020/21 
• on 6.3% of notifications received. 

A slightly higher proportion of immediate action was taken as a percentage of notifications received this year than in previous years (6.3% in 2021/22, 5.9% in 2020/21, 5.7% in 2019/20 and 4.1% in 2018/19). 

Being the subject of an immediate action by a Board can be extremely daunting. We will only use our immediate action powers when: 

• there is a serious risk to the public 
• we believe a practitioner’s registration has been improperly obtained, because they have provided misleading information when applying for registration 
• the practitioner holds registration outside Australia, and that registration has been suspended or cancelled by another regulator 
• there is a clear and compelling reason to suspend the practitioner’s registration, based on public interest reasons (including, for example, that a practitioner has been charged with or convicted of serious criminal behaviour). 

When a practitioner’s behaviour is significantly below a reasonable standard of practice, when a practitioner engages in multiple instances of poor performance, or when a practitioner behaves in a way that the public would view as untrustworthy, we refer the practitioner to a responsible tribunal. 

A National Board must refer a practitioner whose behaviour is considered to be professional misconduct to a responsible tribunal. 

There was a 91.1% increase in the number of notifications referred to a responsible tribunal by a National Board. The most common referrals were for concerns about boundary violations (30.8%).

There must be proper boundaries in a practitioner–patient relationship.

We received 925 notifications involving a possible failure to maintain appropriate professional boundaries. These can include comments made by a practitioner to a patient during a consultation, or even online, that are deemed inappropriate when considered against the relevant Board’s code of conduct. Or they can involve inappropriate sexual relationships or even unlawful sexual acts. This was 63% more than we received last year (568).

• 81.4% were made about practitioners in three professions: 
  • medical practitioners 43% 
  • nurses 26% 
  • psychologists 13%. 

The increase in the number of boundary violation matters can be attributed to the inclusion of new concern types, which are consistent with Ahpra and the National Boards’ condemnation of sexism, sexual harassment or gendered violence in healthcare and expectations of practitioners to maintain respectful, professional practice (see the position statement No place for sexism, sexual harassment or violence in healthcare). 

The concerns raised by notifiers include: 

• inappropriate or sexualised remarks, comments or electronic exchanges 
• touching of a patient in a place the patient thinks is intimate, when the patient did not believe that consent had been provided 
• other forms of physical contact that a notifier believes were not appropriate 
• sexual offending, of any kind, by a practitioner 
• rough or painful examination or treatment 
• sexism, aggressive behaviour or violence, or harassment of peers, patients or others.

The serious nature of these notifications is reflected in the outcomes. Action was taken more often about boundary notifications than about other notifications: 

• 6.2% boundary notifications resulted in a caution or reprimand (compared to 4.8% for all notifications) 
• 10.6% boundary notifications resulted in conditions being imposed on a practitioner’s registration (compared to 6.8% for all) 
• 4.3% boundary notifications resulted in a practitioner’s registration being surrendered, suspended or cancelled (compared to 1.1% for all). 

The higher risk profile of boundary matters is also reflected in the stage of closure: 

• 50.3% were closed following an investigation (compared to 21.4% for all notifications) 
• 41.8% were closed at assessment (compared to 74.9% for all notifications) 
• 6.5% were closed after referral to a tribunal (compared to 1.8% for all notifications). 

Boundary notifications had a higher proportion of suspensions through immediate action (29.0%) compared to all notifications (24.0%). 

In 17.2% of cases, Boards imposed conditions. 

In 6.3% of cases, Boards accepted an undertaking. 

In 47.5% of cases, after consideration, Boards decided not to take immediate action. 

The Notifier Support Service started in August. The service is part of Ahpra and the National Boards’ ongoing work to improve the experience of notifiers in matters involving sexual boundary breaches and misconduct. Notifiers help us to keep the community safe by raising serious concerns about practitioners. The service is only offered to notifiers who have been personally affected by the concerns raised. 

The notification process is often emotionally challenging and complex to navigate, and a range of factors may affect a person’s participation. Notifiers are referred to the service by notifications and legal staff and they then opt in if they would like to receive support. Referral guidance has been developed to help staff identify who may benefit from the service. For example, factors such as experiences of trauma, mental health, cultural safety, diversity needs and access to support can affect the notifier experience. 

Two qualified social workers provide emotional support and help explain how our processes work. Through providing procedural information they prepare notifiers/witnesses about what to expect and help guide them through the experience with us. The social workers do not provide therapeutic counselling or advocacy for the notifier but can suggest services that may be helpful and offer other targeted support. 

Using a trauma-informed approach, our social workers work in partnership with regulatory and legal advisors to help respond to the emotional impact experienced by notifiers. The social workers may also become a consistent point of contact once matters are referred to a tribunal. 

By providing this support, we aim to reduce the re-traumatisation that may occur and help notifiers engage and participate throughout all stages of the process. 

Since the service began, 149 referrals have been made by notifications and legal staff. About half of these matters have been or are currently in investigation, with the rest at tribunal or subject to immediate action. 

Initial feedback from notifiers/witnesses accepting the service has been extremely positive. It has also been welcomed and overwhelmingly endorsed by National Boards and Ahpra as addressing an unmet need. 

The service is currently in its pilot phase and will be evaluated in 2022/23. 

‘I started the process before the Notifier Support Service was available and had to spend time trying to navigate the situation by myself. The difference once I was hooked into a support person was remarkable. It made me feel like I wasn’t going through it alone. I had someone to talk to that understood the processes and what was happening.’ 
Notifier

‘I felt supported by the Notifier Support Service who recently helped me to engage with a notifier. There were sensitive issues involved, and their empathetic and relationship-based approach improved the experience for both the notifier and me.’ 
Regulatory advisor