Systemic investigation

The Health Ombudsman Act provides powers to conduct and support investigations, including powers to investigate systemic issues relating to the provision of a health service, including issues affecting the quality of health services

A systemic investigation may be based on a complaint, initiated by the Health Ombudsman based on information received, or directed by the Minister.

Systemic investigation reports may be released publicly to raise awareness within the health sector and general public of the identified issues and the recommendations made to improve patient safety, and health service quality and delivery in Queensland.

Where an investigation report is made public and contains adverse comments, the health service provider is provided a copy and given an opportunity to make a submission before it is published.

Our published reports are available below. Where appropriate, full reports are published in order to share the learnings from these investigations and promote broader service improvements. We may also publish ‘snap shot’ summary reports of systemic investigations which focus on sharing the key issues, outcomes and wider learnings from investigations when it is not appropriate to publish the full report.

When an investigation report is made public, the names and identifying factors of those involved have been removed, where required by the Health Ombudsman Act 2013.

Where the Health Ombudsman has made recommendations for change and improvement, we monitor the health service provider on the implementation of these recommendations.