All staff play an important role in contributing to a positive workplace culture by working in a professional and productive manner. When issues arise, policies and guidance are available to help staff through appropriate resolutions.

NSW Health has a policy framework for managing complaints, depending on the nature and circumstances of the matter. More than one policy may apply to a particular complaint and all complaints are required to be managed in accordance with the relevant legislation and Policy Directive.

Last updated: 29 September 2023

Effective complaint handling is underpinned by the following principles:

  • Respectful treatment
  • Information and accessibility
  • Good communication
  • Taking ownership
  • Timeliness
  • Transparency

Managers have a responsibility to create a positive culture within their teams, and to identify, respond to and promptly address issues when they arise.

Staff are encouraged to raise any concerns with their manager where it is practical to do so, or through key personnel within their organisation, such as through human resources, internal audit, or executive management.

Policy directives

The following NSW Health Policy Directives outline the minimum standards in making and responding to concerns raised by NSW Health staff, in particular areas and contexts.

Workplace grievances

A workplace grievance means a problem, concern, issue or incident raised by a staff member who believes he / she is the subject of unreasonable treatment from the organisation or another person(s) in the workplace.

For workplace grievances between staff members, the NSW Health Policy Directive Resolving Workplace Grievances (PD2016_046) should be followed.

Workplace bullying

For bullying allegations, the NSW Health Policy Directive Prevention and Management of Bullying (PD2021_030) must be followed in conjunction with the Managing Misconduct Policy Directive.

For complaints about bullying and unacceptable behaviour arising from the junior medical workforce, the NSW Health Policy Directive Prevention and Management of unacceptable workplace behaviours – JMO module (PD2021_031) should be consulted.

Complaints or concerns about a clinician

In relation to a complaint or concerns about a clinician, the NSW Health Policy Directive Managing complaint or concern about a clinician (PD2018_032) must be followed.

This Policy applies to the management of serious complaints or concerns about a specific clinician or clinicians that indicate a potential risk to patient safety and, if found to be substantiated, could result in disciplinary and/or remedial action and/or a notification to the Australian Health Practitioner Regulation Agency (AHPRA) and/or to the relevant NSW Health Professional Council.

This includes complaints and concerns involving alleged or suspected serious performance-related issues.

Alleged abuse of an older person

For complaints involving alleged abuse of an older person, the NSW Health Policy Directive Identifying and responding to abuse of older people (PD2020_001) may apply.

Corporate and clinical incidents

For corporate or clinical incidents, the NSW Health Policy Directive Incident Management (PD2020_047) must be followed – including where the organisation becomes aware of the incident as a result of a complaint.

For incidents involving patients (including where a complaint provides information indicating that an incident has occurred), the NSW Health Policy Directive Open Disclosure (PD2014_028) must be followed.

Misconduct by a staff member

For managing a complaint involving alleged misconduct by a staff member, the NSW Health Policy Directive Managing Misconduct (PD2018_031) must be followed, including:

This includes making a report to the Child Protection Helpline where there are concerns that a child or young person or a class of children is at risk of significant harm.

Research misconduct

Where a complaint alleges misconduct relating to research, the NSW Health Guideline Research Governance in NSW Public Health Organisations (GL2011_001) should be consulted.

Complaints about a recruitment process within NSW Health

For complaints about a recruitment process within NSW Health, the NSW Health Policy Directive Recruitment and selection of staff to the NSW Health Service ( PD2017_040) applies.

Serious wrongdoing by public officials 

For complaints about serious wrongdoing by public officials the NSW Health Policy Directive Public Interest Disclosures(PD2023_026) may apply.

Where a complaint indicates that corrupt conduct has, or may have occurred, the NSW Health Policy Directive Reporting corrupt conduct to ICAC (PD2016_029) must be followed.

Privacy concerns

For complaints about privacy issues, the NSW Health Guideline NSW Health Privacy Internal Review Guidelines (GL2019_015) and the Privacy Manual for Health Information must be followed.

Additional support

NSW Ministry of Health

In certain circumstances, it may be appropriate for staff members to contact the Ministry of Health if they are unable to raise concerns locally, or have already escalated concerns through local channels and there has been no outcome.

The Ministry will conduct an initial assessment of the matter and, depending on the nature of the concern, clarity of information provided and the complexity of the matter, may:

  • Contact the staff member for more information
  • Provide advice or guidance (which may include linking with the Employee Assistance Program)
  • Direct the matter back to the health organisation for assessment, review, or investigation (internal or outsourced) or other action/advice as appropriate
  • Conduct or oversee a review or investigation
  • Refer the matter to an external agency
  • Take another appropriate course of action
  • A combination of some, or all, of the above.
  • The Ministry will refer the matter back to the health organisation if its initial assessment identifies that the health organisation has not had a reasonable opportunity to consider or take action in response to the complaint and it is otherwise appropriate to do so.

If the initial assessment identifies that the health organisation has already appropriately dealt with the matter, the Ministry may not take any further action.

Staff can raise a concern by contacting the ‘Author Branch’ listed on the front page of the relevant policy document listed above for which your concern relates, or make a submission via the NSW Health website.

Health Care Complaints Commission

The HCCC deals with complaints about all health services and providers in NSW including public and private hospitals, and registered and non-registered health practitioners. They do not deal with matters that are not directly related to health service provision or providers.

All mandatory reports and other notifications to AHPRA concerning NSW registered health practitioners regarding clinical care, performance and conduct are forwarded to the Commission for management. Complaints may also be made directly to the Commission.

They also have the capacity to investigate matters where there are allegations of cover up of clinical issues, improper falsification of clinical documentation, or systemic issues posing a risk to public health and safety.

The HCCC prosecutes registered health practitioners for serious breaches of professional and safety standards in the NSW Civil and Administrative Tribunal (NCAT).

Possible outcomes from a complaint made to the HCCC include:

  • Investigate the complaint
  • Refer to relevant Health Professional Council (for registered practitioners)
  • Conciliation
  • Refer for assisted resolution
  • Refer for local resolution
  • Refer to another body
  • Discontinue the complaint or discontinue with comments.

To find out more about the Health Care Complaints Commission, visit Health Care Complaints Commission.

You can also raise a concern via the HCCC’s Complaints Portalor by calling 1800 043 159.

NSW Ombudsman

The NSW Ombudsman's Office is an independent and impartial integrity agency. The Ombudsman’s Office (the Ombudsman) watches over most NSW public sector agencies and some community service providers. They help to ensure these organisations and their staff do their jobs properly and meet their responsibilities to the community.

The role of the NSW Ombudsman in relation to complaints and disclosures includes:

  • Receiving and handling complaints about the conduct of a ‘public authority’ (including the Ministry of Health and Local Health Districts), relating to a matter of administration. The Ombudsman can also make inquiries about conduct in the absence of a complaint.
  • Taking action where a complaint raises concerns about maladministration or other wrong conduct by an agency. This includes making preliminary inquiries; conciliating a complaint; referring a matter to the agency for investigation and monitoring that investigation; or where concerns are particularly serious, drawing on formal investigation powers.1
    (Note: the Ombudsman does not deal with matters affecting a person as an employee, unless the conduct arises from the making of a Public Interest Disclosure)
  • Oversight of the Public Interest Disclosures Act. This includes promoting public awareness of the Act; providing advice, assistance and training to public authorities and public officials; issuing guidelines; monitoring compliance with the PID act and auditing public authorities. The Ombudsman is also an investigating authority under the Act.
  • Reviewing the complaint handling system of a public authority.
  • Provide education and guidance to the NSW Public Sector on good administration and practice in complaints

Any person can make a complaint to the Ombudsman. Before the Ombudsman considers any action on a complaint, you will usually need to contact the agency first and make a complaint directly to them. However, the Ombudsman can be contacted for advice in this regard for both complaints and Public Interest Disclosures.

To find out more about how to make a complaint to the NSW Ombudsman, visit NSW Ombudsman - Make a complaint online.

1 s26 of the Ombudsman Act 1974 sets out conduct that may be investigated, including conduct that is or may be contrary to law; unreasonable, unjust, oppressive or improperly discriminatory; based wholly or partly on improper motives, irrelevant grounds or irrelevant consideration, or on a mistake of fact or law, or is otherwise wrong.
Current as at: Friday 29 September 2023
Contact page owner: NSW Health