Commission of Inquiry Recommendations

1. The Tasmanian Government should increase funding for specialist trauma therapy services for children in care to ensure their needs are met.
2. The Tasmanian Government should ensure the Child and Adolescent Mental Health Service’s new specialist mental health service for children in out-of-home care is resourced to meet demand.

Accountability

Health Executive Lead: Deputy Secretary, Community Mental Health and Wellbeing 

Timeframe

By 1 July 2026

Status

In progress

The Tasmanian Government should ensure: 

a. there are appropriate mechanisms and pathways for children in contact with the criminal justice system to be diverted to the mental health system for assessment and treatment
b. the proposed Youth Forensic Mental Health Service provides timely referral and access to mental health treatment, care and support for children and young people when appropriate, whether they are under community-based supervision, in detention or not yet sentenced (including on remand)
c. children and young people in detention have daily access to an onsite child and adolescent psychologist and fortnightly access to an onsite child and adolescent psychiatrist
d. the proposed mental health inpatient unit for children and adolescents in Hobart provides for children and young people in detention.

Accountability

Health Executive Lead: Deputy Secretary, Community Mental Health and Wellbeing

Timeframe

By 1 July 2026

Agency variation: Long-term priority (by 1 July 2029)

Reason: Context readiness and complexity due to infrastructure planning and build

Status

In progress

The Tasmanian Government should ensure children and young people in detention (including on remand):

a. receive a mental and physical health assessment on admission to the detention facility, and when needed while in detention
b. have access to 24/7 medical care
c. have a say in their mental and physical health care.

Accountability

Health Executive Lead: Deputy Secretary, Community Mental Health and Wellbeing 

Timeframe

By 1 July 2024

Agency variation: by 1 July 2025

Reason: Context readiness in regard to expanding the service model and recruiting staff. The process will be commenced in 2024, with expected completion by 1 July 2025.

Status

In progress

The Department of Health should develop and communicate a policy framework and implementation plan for reforms to improve responses to child sexual abuse in health services. The policy and implementation plan should: 

a. set out the purpose and need for the reforms
b. set out the role, responsibilities, and interactions of bodies the Department has set up as part of the reforms
c. explain how reforms, including departmental reforms and those recommended by the Child Safe Governance Review, Community Recovery Initiative and this Commission of Inquiry, will work together to respond to child sexual abuse in health services
d. outline how the reforms are being prioritised for implementation and who is responsible for their implementation
e. set out the expected timeframes for implementation
f. be published on the Department’s website.

Accountability

Health Executive Lead: Chief Risk Officer

Timeframe

By July 2024

Status

Completed 

1. The Tasmanian Government and Department of Health should continue to implement the National Principles for Child Safe Organisations across all health services.
2. The Tasmanian Government should advocate at a national level for compliance with the National Principles for Child Safe Organisations to be a mandatory requirement for accrediting health services against the National Safety and Quality Health Service Standards under the Australian Health Service Safety and Quality Accreditation Scheme.

Accountability

Health Executive Lead:

1. Chief Risk Officer
2. Deputy Secretary, Policy, Purchasing, Performance and Reform

Timeframe

By 1 July 2026

Status

In progress

The Department of Health should ensure its cultural improvement program embeds a safety culture in health services by:

a. requiring clear organisational values be observed across all levels of health services, including in relation to staff conduct
b. establishing strong governance arrangements to address staff practices that place children at risk of abuse, and complementing established patient safety governance structures
c. ensuring all levels of management demonstrate a commitment to a safety culture, including by addressing poor staff conduct
d. clarifying roles and responsibilities among staff when there is a suspicion that child sexual abuse has occurred or that safety policies are not observed
e. ensuring there are processes that hold senior managers and executives accountable to respond appropriately to the conduct of their staff, including through performance agreements and role descriptions
f. establishing measures of a strong organisational culture that indicate an organisation:
   i.   welcomes concerns about staff and sees them as an opportunity to improve safety for staff and patients
   ii.  empowers staff to feel safe and supported to raise concerns about colleagues with their leaders and gives them confidence in the ability of leaders to respond to concerns and take disciplinary actions (including termination) where appropriate
   iii. ensures staff are clear about the process for raising concerns, how these concerns will be addressed and what feedback they can expect to receive.
g. providing progress reports to the Child Sexual Abuse Reform Implementation Monitor to demonstrate how these principles have been translated into policy and practice (Recommendation 22.1).

Accountability

Health Executive Lead: Chief Risk Officer

Timeframe

By 1 July 2024

Status

Completed

1. The Department of Health should consider integrating features of the St Vincent’s Health Australia’s Ethos Program into its cultural improvement program.
2. The Department of Health should ensure, in adopting its cultural improvement program, professional boundary breaches by staff towards a child are always formally reported, responded to and recorded in centralised records for future reference.

Accountability

Health Executive Lead: Chief Risk Officer

Timeframe

By 1 July 2026

Agency variation: Short-term priority by 1 July 2024

Reason: This work is already in progress and will be delivered before 1 July 2024. Gap analysis between the One Health Culture Program and St Vincent’s Health Australia Ethos Program will commence in February 2024

Status

Completed

The Department of Health should make health leadership accountable for embedding child safety as a priority, including by: 

a. ensuring that all relevant health leaders have an obligation to act consistently with the National Principles for Child Safe Organisations (reflected in Tasmania’s Child and Youth Safe Standards) in their role descriptions and performance agreements, with compliance with this obligation to be reviewed annually
b. ensuring that the role descriptions and performance agreements of all staff providing services to children require them to protect child safety, with compliance with this obligation to be considered as part of annual performance reviews.

Accountability

Health Executive Lead: Chief Risk Officer 

Timeframe

By 1 July 2024

Status

Completed

The Department of Health, to support health services become child safe organisations, should ensure: 

a. child safety, including safety from abuse in health services, is overseen by the governance and leadership structures established through the cultural improvement program
b. child safety is built into the safety and quality systems of health services
c. staff responsible for providing care to children have the knowledge and skills to respond to child safety concerns in line with the expectations of a child safe organisation and relevant health service policies, including being equipped to identify and respond to indicators of child sexual abuse
d. staff act consistently with the National Principles for Child Safe Organisations (reflected in Tasmania’s Child and Youth Safe Standards) when performing their work, including in discussions between health practitioners, health workers and children about care planning and treatment.

Accountability

Health Executive Lead: Chief Risk Officer 

Timeframe

By 1 July 2026

Status

In progress

1. The Department of Health should establish a health services young people’s advisory group. The advisory group should: 
   1. have a clear purpose and objectives
   2. be guided by clear terms of reference developed in consultation with children and young people
   3. comprise young people with significant lived experience of health services, including young people of different ages, from diverse backgrounds and with different care needs
   4. enable young people to contribute to decision making in a safe and meaningful way about issues that affect them
   5. allow young people to have a say in departmental strategies, policies, procedures and protocols that affect them
   6. be adequately funded and resourced.
2. Summaries of the health services young people’s advisory group meetings should be prepared and distributed to all senior executive teams in the Department.
3. The Department should report on the activities of the health services young people’s advisory group and on other engagement with children and young people through its annual report.
4. The Department should undertake other age-appropriate engagement with children to ensure as many children and young people as possible can take part in shaping health services.

Accountability

Health Executive Lead: Chief Risk Officer 

Timeframe

By 1 July 2024

Status

Completed

1. The Department of Health should ensure consistent information is provided to patients, including suitable age-appropriate resources for children and young people and their families and carers, across its health services. These resources should include information on: 
   1. requirements and expectations of a child safe organisation
   2. patient rights when receiving health care, including the rights of children and young people
   3. expected standards of behaviour for health service staff
   4. processes for raising concerns and making complaints internally and externally
   5. roles of health regulatory bodies in receiving complaints.
2. This information should be provided in formats that meet community needs, especially for those with less capacity to comprehend complex written text.

Accountability

Health Executive Lead: Deputy Secretary, Hospitals and Primary Care

Timeframe

By 1 July 2024

Status

Completed

The Department of Health should require its health services to undertake regular and ongoing monitoring of children and young people’s sense of safety in health services to inform continuous improvements to child safety, including in the safety of the physical environment.

Accountability

Health Executive Lead: Chief Risk Officer 

Timeframe

By 1 July 2029

Status

In progress

The Department of Health should work with relevant stakeholders to consider the needs and backgrounds of children and young people using health services, including Aboriginal children, children from culturally diverse backgrounds, children with disability, children with mental illness and children who identify as LGBTQIA+. The Department should consult with Aboriginal communities on how it can provide culturally safe spaces for Aboriginal children across its health services.

Accountability

Health Executive Lead: 

Timeframe

By 1 July 2026

Status

Completed

1. The Department of Health should review and consolidate its policies, procedures and protocols. This review should prioritise identifying gaps in relation to safeguarding children and should inform the development and implementation of consistent statewide policies, procedures and protocols on child safety.
2. The Department’s safeguarding policies should include implementing the National Principles for Child Safe Organisations and other recommended policy changes (namely, policies on reporting obligations, professional conduct and providing a chaperone (Recommendations 15.12, 15.13 and 15.14)).
3. The Department should undertake regular scheduled reviews of its policies, procedures and protocols for child safety to ensure they continue to reflect best practice and organisational changes.
4. The Department should publish its policies, procedures and protocols for child safety on its website to promote transparency and ensure accessibility to staff, patients and their families.

Accountability

Health Executive Lead: Chief Risk Officer 

Timeframe

By 1 July 2024

Status

Completed

1. The Department of Health should ensure there are up-to-date policies on mandatory and voluntary reporting obligations, including for concerns about staff conduct, and that these are effectively communicated to staff. These policies must not require that reporting be formally authorised.
2. The Department’s review of the Tasmanian Health Service Protocol – Complaint or Concern about Health Professional Conduct and associated documents should include:
   1. a description of external reporting requirements in relation to child safety, including voluntary reporting pathways, and reporting to Tasmania Police, Child Safety Services, the Registrar of the Registration to Work with Vulnerable People Scheme, the Independent Regulator under the Child and Youth Safe Organisations Act 2023 and the Australian Health Practitioner Regulation Agency
   2. guidance on when it is appropriate to acquit mandatory reporting obligations by reporting concerns to a superior (for example, to avoid multiple notifications). This should make clear that a person is always entitled to make a notification to an external agency if they wish to do so.
   3. a list of internal contacts for staff who have questions about child safety concerns and their reporting obligations.

Accountability

Health Executive Lead:

1. Director, Office of the Secretary
2. Deputy Secretary, Clinical Quality Regulation and Accreditation

Timeframe

By 1 July 2024

Status

Completed

1. The Department of Health, in developing a professional conduct policy (Recommendation 20.2), should ensure: 
   1. there is a separate professional conduct policy for staff who have contact with children and young people in health services
   2. the professional conduct policy for health services, in addition to the matters set out in Recommendation 20.2
      1. specifies expectations outlined in other relevant Department of Health policies and procedures
      2. refers to other professional obligations of registered health practitioners, including those developed by the Australian Health Practitioner Regulation Agency and the National Boards
      3. reflects the specific risks that arise in health services, particularly the sometimes intimate and invasive nature of health services, and the significant trust and power afforded by patients and the broader community to those providing health services
   3. the professional conduct policy for health services spells out expected standards of behaviour for volunteers, contractors and sub-contractors
   4. the Department uses appropriate mechanisms to ensure compliance by volunteers, contractors and sub-contractors with the professional conduct policy for health services.
2. The professional conduct policy for health services should be reinforced through professional development requirements (Recommendation 15.15).

Accountability

Health Executive Lead: Chief Risk Officer

Timeframe

By 1 July 2024

Status

Completed

The Department of Health’s chaperone (or Accompanying Person/Observer) policy should be updated to require the presence of an extra staff member during examinations or episodes of care where no family member or carer can be present.

Accountability

Health Executive Lead: Deputy Secretary Hospitals and Primary Care

Timeframe

By 1 July 2024

Status

Completed

1. The Department of Health should identify minimum requirements for professional development on child safety for different levels of staff, including staff, volunteers and contractors, as well as leadership. Professional development should cover, at a minimum:
   1. understanding child sexual abuse (including grooming and boundary breaches)
   2. the requirements and expectations of a child safe organisation
   3. mandatory and voluntary reporting obligations, including the role and function of Tasmania Police, Child Safety Services, the Registrar of the Registration to Work with Vulnerable People Scheme, the Independent Regulator under the Child and Youth Safe Organisations Act 2023 and the Australian Health Practitioner Regulation Agency
   4. relevant child safeguarding policies and procedures.
2. The Department should have appropriate processes in place to ensure leaders have the knowledge, skills, aptitude and core capability requirements to effectively manage people and to lead a child safe organisation.
3. The Department should develop outcomes-based measures of the effectiveness of child safety professional development initiatives for all categories of staff, volunteers, and contractors, including management, leadership, human resources, and professional and non-professional staff.
4. These outcomes-based measures should be reviewed annually, and the results used to inform further professional development initiatives and leadership selection.

Accountability

Health Executive Lead: Chief Risk Officer

Timeframe

By 1 July 2026

Status

In progress

1. The Department of Health should have a specific policy on responding to complaints and concerns about staff conduct. The policy should establish a complaints escalation, management and investigation process that is informed by the following principles: 
   1. Complaints processes should be well-understood, trusted and accessible to staff, patients and others. 
   2. Complaints processes should have clear escalation processes, internal and external reporting requirements within specific timeframes, and address immediate risks to children’s safety.
   3. There should be appropriate scrutiny and oversight of how complaints about child safety are escalated to senior staff, managed and recorded.
   4. Complaints about child safety should be recorded comprehensively and stored securely in incident management (such as the Safety Reporting and Learning System) and human resources systems.
   5. Complaints about unprofessional conduct and boundary breaches with child patients should be recognised as indicating a patient safety issue and treated as serious.
   6. Complaints data should support decision making and inform system improvements.
   7. There should be appropriate communication and supports provided to those making complaints or affected by the alleged conduct, including through open disclosure processes (Recommendation 15.18).
2. The policy should include a diagram showing the complaints escalation, management and investigation pathways for child safety concerns and associated governance and review arrangements. It should also outline the roles and responsibilities of the various bodies involved in responding to child safety concerns.
3. This policy and diagram should be available to health service users and the public.

Accountability

Health Executive Lead: Director, Office of the Secretary 

Timeframe

By 1 July 2024

Status

Completed

1. If the Department establishes a new Health Services Child-Related Incident The Department of Health should establish a separate Health Services Child Related Incident Management Directorate or partner with the Child-Related Incident Management Directorate (Recommendation 6.6) to respond to allegations of child sexual abuse and related conduct by staff, breaches of the State Service Code of Conduct and professional conduct policies, and reportable conduct (as defined by the Child and Youth Safe Organisations Act 2023) in health services. 
2. If the Department partners with the Child-Related Incident Management Directorate, it should ensure the directorate has access to specialised advice to inform investigations against health services staff, particularly where allegations have arisen in the context of provision of health care.
3. Management Directorate, it should mirror the functions and manner of operation reflected in the Child-Related Incident Management Directorate, including having three distinct roles and skill sets covering incident response management, investigations, and misconduct and disciplinary advice.

Accountability

Health Executive Lead: Director, Office of the Secretary 

Timeframe

By 1 July 2026

Status

In progress

The Department of Health should ensure open disclosure processes for patients who experience child sexual abuse in health services and their families and carers that: 

a. create a safe, trauma-informed pathway for victim-survivors, or others affected by an event, to receive clear and personalised information in response to their questions or concerns
b. facilitate appropriate notifications including to Tasmania Police, Child Safety Services, the Registrar of the Registration to Work with Vulnerable People Scheme, the Independent Regulator under the Child and Youth Safe Organisations Act 2023 and the Australian Health Practitioner Regulation Agenc
c. make appropriate supports available to affected people, including victim-survivors, their immediate family and carers, where abuse is connected to the Department’s health services, including warm referrals, with the person’s consent, to trained and experienced child sexual abuse counsellors.

Accountability

Health Executive Lead: Deputy Secretary, Hospitals and Primary Care

Timeframe

By 1 July 2024

Status

Completed

The Department of Health should develop and implement a critical incident response plan for human-caused traumatic events where numerous staff and patients are affected, including serious child-related incidents. The response plan should: 

a. identify who is responsible for leading the response to a critical incident and set out the applicable reporting arrangements
b. identify the steps to responding to a human-caused traumatic event (including incidents relating to child safety)
c. provide for external assistance from experts with training and expertise in crisis management
d. be based on best practice responses to traumatic events
e. provide for early communication of information about the event
f. provide psychological first aid to affected people
g. provide extra support from skilled psychologists on an ‘as needed’ basis to affected people
h. provide for information about other support services that can assist affected people
i. facilitate communication and support among affected people as a means of social support
j. provide for critical incident debriefing run by a neutral and trained expert where appropriate
k. provide for a review of the Department’s response to the critical incident
l. provide for an evaluation of any actions to be implemented as part of the Department’s response to the critical incident
m. provide for any lessons from a review or an evaluation of the Department’s response to the critical incident, to be shared with the Secretaries Board to further inform responses to critical incidents across the whole of government.

Accountability

Health Executive Lead: Chief People Officer 

Timeframe

By 1 July 2026

Status

In progress

1. The Department of Health, Launceston General Hospital and Tasmania Police should make clear that they will continue to assist, on an ongoing basis, known and as yet unknown victim-survivors of child sexual abuse by James Griffin related to the hospital and should nominate a contact person for people who have enquiries.
2. Assistance should include:
   1. outlining what is known about Mr Griffin’s offending at the hospital 
   2. taking steps to ascertain whether a person is or may be a victim-survivor of Mr Griffin’s offending or clearly explaining why this cannot be done. 
3. The Department and Launceston General Hospital’s communications with known and as yet unknown victim-survivors of Mr Griffin and their families and carers and the broader community should be informed by the principles of open disclosure. 
4. Launceston General Hospital should ensure victim-survivors and their families and carers who do not receive individual open disclosure (Recommendation 15.18) still receive a warm referral to trained child sexual abuse counsellors if desired.

Accountability

Health Executive Lead: Chief Executive Hospitals North 

Timeframe

By 1 July 2024

Status

Completed

1. The Department of Health should increase the availability of forensic medical examination services for child victim-survivors of sexual abuse to ensure all child victim-survivors can access an examination with minimal delay. To achieve this, the Department should:
   1. train existing adult sexual assault forensic medical examination services to examine child victim-survivors
   2. ensure, in areas of Tasmania where no sexual assault forensic medical examination services exist, suitably qualified local health professionals are trained and supported to conduct forensic medical examinations for child sexual abuse.
2. At a minimum, the training should include:
   1. an external, recognised qualification in forensic medical examinations
   2. external recognised training in sexual abuse care for children.

Accountability

Health Executive Lead: Deputy Secretary, Hospitals and Primary Care 

Timeframe

By 1 July 2026

Status

In progress