The Health Ombudsman commenced a systemic investigation into a health service after a review of documents provided for individual practitioner notifications at the health service identified several possible systemic concerns that may have been impacting on the provision of safe and effective care.

Wider Learnings and Recommendations for service improvements

The investigation highlights the opportunity for health services to:

• continuously review, improve and embed changes within their governance systems, maintain oversight of the impact of the changes on service provision and patient outcomes through robust auditing and feedback schedules;
• explore and implement processes and methods to ensure transparent and meaningful feedback of quality and safety data to patients and staff at all clinical levels; and
• review processes related to Enduring Power Of Attorney to ensure easy identification and documentation of alternative decision makers