Notifications

We received most notifications (71.0%) from patients, their families and friends, and other members of the public; this is similar to last year (71.1%). We received some notifications (18.5%) from health practitioners and employers.

In previous reports, we have shown notifications referred to us from health complaints entities as a separate category. However, as these complaints are typically made by patients, we have revised the categories in this overview to remove health complaints entities as a source of notifications.

We received 1,808 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.

A notification can be about more than one concern. During the year, 66.3% of notifications we received were about a single concern, 24.1% were about two concerns, and 9.6% were about three or more concerns.

Clinical care was the most common type of concern received, specifically inadequate or inappropriate treatment.

The National Law sets out specific grounds on which a notification can be made. Notifications can be made where:

• a practitioner’s behaviour is placing the public at risk
• a practitioner is practising their profession in an unsafe way
• a practitioner’s ability to make safe judgements about their patients might be impaired because of their health.

Not all concerns raised with us are about individuals we register or about things that can be dealt with by a National Board. When concerns are raised with us that we can’t help with, we direct the notifier to alternative sources of support where appropriate.

A case-management approach

The way we manage concerns once we accept them continues to evolve. This year, we made some significant changes to improve our processes.
Instead of having one team assess each notification and hand it to another team to investigate, our revised approach is to allocate a single case manager to each notification for its whole life cycle.

To accomplish these changes, we looked closely at the sorts of notifications that we receive and how they could best be dealt with. We allocate notifications based on a combination of:

• risk assessment
• which powers or processes might be best suited to gathering the required information
• the likelihood that regulatory action might be needed.

Case study: Not a ground for a notification

A notifier reported that they were contracted by a company, the director of which was a psychologist.

The notifier claimed to be out of pocket for a tender that they provided to the company. The company did not accept the tender but instead accepted a cheaper proposal from another tenderer.

We considered that the issue was a commercial dispute between the notifier and the company. Although the notifier identified the psychologist as a director of the company, it was the corporate entity that the notifier had been dealing with.

We determined the complaint was not about a person registered in the scheme and was therefore not a ground for a notification.

We directed the notifier to a complaints resolution body that may be able to assist with their concern.

Early determination

An early determination team manages the notifications that we judge to be low risk to the public, based on the notification and on an overall risk assessment of the practitioner. Where appropriate, we consider making a decision to take no action in response to the notification.

For notifications that are raised by consumers, we consider whether it is appropriate to refer the notification to a health complaints entity (HCE). There are HCEs in every state and territory of Australia.

They are vital partners in ensuring that consumer complaints about health services are resolved.

HCEs share every complaint they receive about a registered health practitioner with Ahpra. Ahpra shares any complaint that could also have an aspect that Ahpra can’t address, such as helping the consumer get an apology or a refund. For every complaint that is shared, Ahpra and the HCE decide which is the most appropriate body to deal with the complaint.

A total of 2,395 concerns were retained by, or referred to, an HCE during the year. This represents 22.5% of all the notifications we completed. It is slightly fewer than were retained by or referred to an HCE in the previous year.

Case study: Referral to an HCE

A patient had a filling placed by a dentist but a few weeks later the filling fell out. The patient paid to have the filling replaced by another dentist.

The patient complained to us that the original filling had failed, that they needed an appointment with another dentist, and that they were out of pocket.

The original dentist had been practising as a dentist for more than 20 years without being the subject of any previous notifications. They worked in a medium-size suburban dental practice with other dentists.

No concerns were raised by the second practitioner, or by our clinical advisor, that the work performed by the first dentist was inappropriate. There is an inherent risk of fillings falling out, fracturing, or failing in some other way. This risk may vary depending on the material used, where it is placed, the condition of the tooth beforehand or several other factors that may not relate to the knowledge, skill or competency of the practitioner.

The patient had been invited by the original dentist to return to the practice if there were any issues with the filling, which they decided not to do. We referred the complaint to the health complaints entity in the state where the care was provided. They secured a refund and an explanation for the patient.

Case study: No further regulatory action needed

A patient attended an appointment with a physiotherapist after suffering a fall and experiencing significant pain and swelling of their ankle.

At the initial examination, the physiotherapist recommended that the patient have their ankle X-rayed to rule out a bone fracture before undertaking any manual therapy. The physiotherapist suggested the patient return for treatment once a fracture was ruled out.

The patient made a notification after the X-ray confirmed no fracture, because they believe that the failure to provide treatment prolonged their pain.

The physiotherapist works at a group physiotherapy practice and had been registered for eight years without any previous notifications.

Our clinical advisors confirmed that it was reasonable for the physiotherapist to want to rule out a fracture before providing manual treatment, despite this prolonging the patient’s pain.

The Physiotherapy Board of Australia decided no regulatory action was required in response to the concerns.

Strengthening practice

A strengthening practice team manages notifications where we consider there to be some risk to the public based on the notification and following an overall risk assessment of the practitioner.

Around half of the notifications we accepted were referred to the strengthening practice team.

This team focuses on outcomes that result in a practitioner improving their practice. It ensures there are sufficient individual, organisational or regulatory risk controls in place to be confident the practitioner is acting safely and professionally.

When our assessment is that the risk is lower, we rely more heavily on protective factors that are implemented by a practitioner or their workplace.

As the risk level increases, the amount and type of information that we seek also increases, to ensure the right safeguards are in place for us to be confident that the practitioner is practising safely and professionally.

Case discussions

Our approach to strengthening practice champions non-adversarial, personal engagement between notification staff, our clinical advisors and the practitioners who are the subject of a notification.We use case discussions with greater frequency to prevent drawn-out written processes, which practitioners have reported were overly bureaucratic.

Case discussions give us, the practitioner and the practitioner’s advisors or supporters a chance to discuss the concerns in a reflective and open way. They are an opportunity to consider safety issues that arise from the concerns, and understand how they are being, or could be, addressed.

Case study: Strengthening practice approaches for moderate-risk concerns

A nurse unit manager of a busy emergency department made a mandatory notification about the performance of a registered nurse. The nurse unit manager reported that the nurse had failed to follow hospital protocol when triaging a patient. The patient’s health had deteriorated while they were waiting for care and should have been assessed as a more urgent case.

The nurse was a relatively junior member of the nursing team and had only worked at the hospital for a month before the incident.

The nurse had participated in a review of the case with the hospital, had undertaken further education about the hospital’s triage, assessment and escalation processes, and had accepted a warning from the owner of the hospital.

The nurse shared the information provided by the workplace along with details of continuing professional development they had undertaken to ensure safer practice in future. They also participated in a case discussion where they shared their reflections of the incident, and the impact it had had on their ongoing practice.

The Nursing and Midwifery Board of Australia was satisfied that the individual and workplace risk controls that had been implemented ensured the nurse’s practice would be stronger in future, and so they decided to take no further regulatory action.

Case study: Strengthening practice approaches for more serious concerns

We received a notification about a practitioner’s prescribing of opiates and benzodiazepines. The notifier, another regulator, identified multiple instances of prescribing that raised concerns about:

• managing requests for drugs of dependence from drug-dependent or dependence-developing patients
• maintaining appropriate boundaries and expectations when dealing with requests for drugs of dependence
• the adequacy of clinical records.

The medical practitioner had been the subject of three prior notifications made by relatives of patients concerned about prescribing.

Several patients had suffered harm from the prescribing and the Medical Board of Australia imposed immediate conditions on the practitioner’s registration preventing them from prescribing certain medication while further information was sought.

We sought information from relevant drug and poison regulators, the practitioner’s workplace, and the records for the patients identified in the notification.

We met with the medical practitioner for a case discussion.

During the case discussion, the medical practitioner acknowledged facing several problems in their work environment. They discussed steps taken, including:

• moving to a group practice, with greater administrative and collegial support
• completing education to improve their understanding of prescription monitoring, pain management and opioid dependency
• attending multidisciplinary meetings at a tertiary hospital where opportunities to discuss cases with colleagues were provided
• documenting referral pathways for patients with special needs to be jointly cared for by addiction medicine specialists.

Because of the seriousness and repetitive nature of the unsafe prescribing that was observed, the Board accepted an undertaking from the practitioner for ongoing mentoring, peer support and education. It also imposed a condition requiring quarterly auditing of prescribing practices over a 12-month period to ensure ongoing safety.

With an undertaking and condition in place, the Board then removed the restrictions on prescribing.

Health management

If a practitioner has a health issue that does not adversely affect their ability to practise their profession, then a concern raised about their health can be closed quickly, with no need for action.

When the health issue could adversely affect a practitioner’s ability to practise safely, we have a role. A health management team manages these concerns.

We adopt the following principles when we respond to concerns about a health impairment:

• We provide continuity of case management in a timely and efficient manner, and we keep the practitioner experience at the centre of our case management.
• Where possible we individualise our case management to the circumstances of the practitioner.
• We endeavour to keep the practitioner engaged in practice, at the level they choose, as long as it is safe to do so.
• We ensure that regulatory action recommendations are proportionate to the risk posed, aligned with the regulatory principles that underpin the work of the National Boards, and provide consistency in decision-making.

We publish information about the changes we have made when dealing with impaired practitioners on our website.

We continued to implement changes consistent with recommendations made by the Expert Advisory Group (EAG) on minimising practitioner distress for practitioners involved in our regulatory processes.

Practitioners with impairments can be some of the most vulnerable individuals we engage with. A lengthy investigation is generally not required where an impaired practitioner has shown good insight into their impairment. Where there is evidence of an impairment, and it is well managed by a practitioner and their treating team, National Boards generally do not need to act.

We reviewed the use of immediate action powers in response to impairment. Instead, we prioritise actions like greater use of undertakings and supportive conditions on registration. Undertakings and conditions are actively monitored.

The improvements we are making have had a significant impact on timeframes for health cases. For example, during the year, 50% of high-risk health concerns were completed within three months, compared to 11% before the introduction of our dedicated health team.

Case study: Managing a practitioner with a health concern

A doctor working in an acute mental health facility made a notification advising that they were caring for a medical radiation practitioner. The medical radiation practitioner had a health condition, severe anxiety and depression, requiring hospital admission as a voluntary patient, and a sustained period of treatment, including electroconvulsive therapy.

When we spoke with the medical radiation practitioner, they acknowledged a treatment-resistant, long-standing depression.

The medical radiation practitioner advised they were on a period of extended leave from work and that their employer was aware of their admission to hospital. They gave consent for Ahpra to speak with the treating practitioners and their employers.

All treating practitioners reported that the practitioner displayed a strong willingness to seek help when their health deteriorated. They agreed there was no suggestion that the practitioner had practised with impaired judgement.

The practitioner’s employer provided reassurance that they were satisfied with the practitioner’s performance before this period of leave. They were supportive of a graduated return to practice.

They also advised that the practitioner worked within a group-practice setting, where there were considerable opportunities for health and wellbeing checks, as well as case reviews and sharing of patients.

The Medical Radiation Practice Board of Australia was satisfied that individual and organisational risk controls were sufficient to manage any future deterioration in the practitioner’s mental health.

The case was closed without any regulatory action by the Board.

Professional standards

When the behaviour of a practitioner may be substantially below the standard expected by the public or their peers, either because of a one-off incident or a pattern of incidents, National Boards investigate and refer the behaviour to responsible tribunals across the country. The professional standards team manages these notifications.

A National Board must refer a practitioner to a tribunal if they form a reasonable belief the practitioner has behaved in a way that constitutes professional misconduct.

Professional misconduct includes conduct that is substantially below the standard reasonably expected of the practitioner’s peers, and conduct that is inconsistent with the practitioner being a fit and proper person to hold registration.

This year, there was a 7.9% increase in the number of practitioners referred to a tribunal by a National Board.

The changes we made to improve our approaches to notification management include a significant focus on cases that may involve professional misconduct by a practitioner. Changes that make the notification process less onerous for most notification types have enabled us to ensure:

• greater investment in managing the most serious concerns we receive
• lower caseloads for investigators managing potential misconduct
• better support for victims and witnesses of professional misconduct.

Over time, these commitments are intended to speed up investigation timeframes to ensure more timely referral of misconduct to tribunals as part of improved regulatory responsiveness to serious concerns.

Case study: Investigations into serious conduct concerns

A pharmacist raised concerns that a nurse had presented handwritten prescriptions for significant quantities of Schedule 8 medication. The pharmacist was worried that the prescriptions had not been written by the medical practitioner whose prescriber number was used.

We investigated and determined that the nurse had misappropriated prescriptions belonging to a medical practitioner at their place of work. They had presented several of the stolen scripts at pharmacies to obtain medication unlawfully.

In collaboration with the workplace, the police and medicine regulators in the state, we established that the nurse had been obtaining drugs of addiction for unlawful sale to others. They were subsequently charged by the police and medicines regulator with a range of offences.

The Nursing and Midwifery Board of Australia suspended the nurse and referred their behaviour to a tribunal, where it will allege their behaviour constitutes professional misconduct.

Improved sexual misconduct processes

In February, we launched a blueprint to strengthen public safety in healthcare, with a strong focus on improving our handling of sexual misconduct matters. This work aims to raise the bar for patient safety and increase transparency and support for victim/survivors.

The blueprint is in part a response to the growth in complaints about sexual misconduct and other boundary violations by health practitioners.

We received 841 complaints about boundary violations (relating to 728 registered health practitioners), which is almost twice as many as we received three years ago. The types of complaints include inappropriate or sexualised remarks, intimate touching of a patient without consent, personal relationships where there is an imbalance of power, and aggressive sexual offending, including criminal behaviour.

Highlights of our work on the blueprint included:

• starting a public review of the criminal history registration standard that applies to all health practitioners, particularly to examine how the standard is applied to sexual misconduct offences
• adding another 10 full-time staff to our specialist investigation team
• progressing our work to implement a culturally safe notifications program for Aboriginal and Torres Strait Islander Peoples
• making our social-worker-led Notifier Support Service permanent and increasing its staffing
• working towards a clear statement of commitments for those people who have been harmed by practitioners
• examining options to increase the voice of the community in decision-making about practitioner misconduct.

Importantly, we also asked health ministers to consider changes to the National Law on two matters of patient safety. The first would allow Ahpra and the National Boards to publish more information on the Register of practitioners about practitioners with a history of professional misconduct in sexual boundary cases. The second would require tribunals to decide (in an open hearing) if practitioners who have had their registration cancelled can apply for re-registration. These changes are under active consideration by health ministers.

Special Issues Committee

The Medical Board’s National Special Issues Committee (Sexual boundaries and family violence) is made up of practitioner and community members and chaired by community member Ms Christine Gee AM. The committee has been making decisions about sexual boundary cases since 2017, a period in which Ms Gee has seen changes in the way sexual misconduct is viewed.
‘It is so encouraging to see more patients reaching out each year to tell us about their experiences, as difficult as it is for them to share their stories. The committee has zero tolerance for sexual misconduct, and we will recommend immediate action to place strict conditions or temporarily suspend a practitioner if we’re concerned about risk to the public while we investigate.’

Case study: Managing sexual boundary concerns

We received concerns that a medical practitioner carried out inappropriate clinical examinations of patients. Specifically, examinations were undertaken on female anatomical regions not connected with the health issues patients were consulting the practitioner for. The practitioner was suspended under immediate action powers.

We worked closely to support the patients to ensure the Medical Board of Australia and state police could obtain evidence of the examinations.

We obtained expert advice that indicated there was no reasonable clinical justification for the examinations.

Although the police formed the opinion that there was insufficient evidence to prosecute the practitioner to a criminal standard, the Board referred the practitioner to a tribunal, where it will allege the practitioner’s behaviour constitutes professional misconduct.

Notifier Support Service

Now in its second year, the Notifier Support Service works to support those who have experienced sexual misconduct by registered health practitioners to navigate the notifications process. Using a trauma-informed approach, our social workers work in partnership with our regulatory and legal advisors to help respond to the emotional impact experienced by notifiers.

The service received 129 referrals. The majority (72%) of victim/survivors who were referred accepted the offer of support. We increased the support for notifiers, including attendance at tribunal hearings when they are giving evidence. Evaluation of the service is progressing, and feedback received from participants continues to show that the support offered is appreciated.

Mandatory notifications

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

Mandatory notifications made up 10.4% of notifications received. We received 1,011 mandatory notifications, 2.1% fewer than last year.

• 50.6% (512) were about nurses.
• 30.2% (305) were about medical practitioners.

Most mandatory notifications related to impairment (46.8%), followed by departure from professional standards (34.9%), sexual misconduct (10.6%) and intoxication (7.7%).

Immediate action

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 335 times, down 51.1% from last year. This reduction is primarily due to the changes we have made when dealing with health matters, where closer and more collaborative engagement with practitioners, their employers and their treating teams has allowed us to determine more quickly whether a practitioner is safe to practise. This often avoids the need for immediate action.

Being the subject of an immediate action by a Board can be extremely daunting. We 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).

Students

We look into concerns raised about students who are studying to become registered health practitioners.

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

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.

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

Case study: A notification about a student

A member of the public raised a concern with us that a nursing student had cheated on a recent assessment by having a family member write an assignment.

We can only accept notifications about students if:

• they have an impairment, which would mean they posed a risk to the public during a period of clinical placement, or
• they have been charged with a serious criminal offence.

Although we don’t condone any form of academic misconduct, this is not a ground for a notification about a student. We advised the notifier that the educational institution may be better equipped to address their concern.

Timeframes

The changes we are making to the ways we manage concerns are enabling us to close more notifications sooner.

We reduced the number of open notifications, and closed substantially more notifications within three months of them being received. The number of notifications open for more than 12 months fell by 12.8% across the year, excluding those being managed through a panel or tribunal process.

While only 235 of the notifications closed during the year were referred to a tribunal or panel (this is 2.2% of all closed notifications), these matters were generally open for an extended time. The notifications that were referred to a tribunal or panel often involved complex and long-running investigations or were on hold for a considerable period due to an external investigation taking place (for example, a police investigation or coronial inquiry). Of all notifications that were closed in 2022/23, 2.4% had spent time on hold. The average time they spent on hold was 192 days.

Once a matter has been referred to a panel or tribunal, we rely in part on the timeliness of external parties, such as the tribunal itself or the practitioner’s representatives. This year we continued to see the effects of the COVID-19 pandemic on tribunals’ capacity to hear matters in a timely way. Once a matter was referred to a tribunal, it took on average 660 days for it to be finalised by the tribunal.

We are committed to continuing to improve timeliness.

Outcomes

There are several possible outcomes for notifications. The National Law requires that restrictions on the practice of a health practitioner are to be imposed only if it is necessary to ensure health services are provided safely and are of an appropriate quality. Actions taken by practitioners, workplaces and other regulators or entities can contribute to an outcome of ‘no further regulatory action’.

The Office of the Health Ombudsman (OHO) receives notifications about registered and unregistered practitioners in Queensland.

This year was the first full year of joint consideration between Ahpra and OHO, with our two organisations working together to manage Queensland notifications. Together we responded to 3,690 notifications, and just under half were referred to Ahpra and the National Boards to manage.

OHO closed 1,299 notifications about registered health practitioners following joint consideration, after agreeing with Ahpra that the concerns raised did not require regulatory action. A further 573 notifications were retained by OHO for further action; for example, investigation or other complaints-resolution processes.

The average time from OHO receiving the notification to the completion of the joint consideration process was 7.4 days, down from 12 days last year. 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.