Investigation reports

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, as well as on other matters as determined by the Health Ombudsman.

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. Health services are also provided the opportunity to comment on service improvement recommendations that are made from an investigation.

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 ‘snapshot’ reports of investigations which focus on sharing the key issues, outcomes and wider learnings from investigations. The Health Ombudsman is bound by strict confidentiality provisions of the Health Ombudsman Act 2013 which limits the circumstances in which it is appropriate to publish reports with identifying details.

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

Where the Health Ombudsman has made specific recommendations for change and improvement, we may monitor the health service provider on the implementation of these recommendations and seek evidence from the health service provider that they have implemented and are compliant with the recommendations, and may also seek information from other parties to support/confirm the evidence provided. When broader service improvement recommendations are made, we will seek updates from the health service provider on these service improvement activities as part of our regular engagement with services.