Avoiding, acknowledging and fixing mistakes: investigation of a complaint about the Australian Community Pharmacy Authority

This investigation into the approval process for pharmaceuticals produced findings with broader lessons for Commonwealth agencies about the importance of proper program design, sharing information necessary to ensure proper outcomes and about service recovery arrangements when things go wrong. Foreword This is a report on the Ombudsman’s investigation of a complaint from a pharmacist about the Department of Health (DoH) and the Department of Human Services (DHS). The complainant contacted our office because he believed that a neighbouring pharmacy had been incorrectly approved to dispense medications under the Pharmaceutical Benefits Scheme (PBS). He told us the neighbouring pharmacy had relocated from its original site to one closer to his pharmacy than the rules allowed and this affected the viability of his business. He had unsuccessfully attempted to find out from DoH and DHS how this had happened, and was frustrated in his attempts to obtain a resolution. The approval process, jointly administered by DoH and DHS, relies upon the pharmacist applying for approval to provide evidence of the distances between their new location, old location and any other nearby pharmacies. There was an error in the measurement of the distances between the pharmacies. This error had come to the attention of the DoH before the approval was finalised, but the information was not relayed to DHS, which granted the approval without knowing that the application did not meet the location requirements. We found problems in the design of the pharmacy approval program, which focussed primarily on the interests of the applicant pharmacist without considering how to protect the interests of other pharmacies in the area. The program was delivered by two separate agencies, without sufficient regard to the need to share information in a timely way to ensure the integrity of the scheme. When it became apparent to DoH that DHS had made a decision based on wrong information, it initially failed to consult with DHS about how to put things right. In our view, DoH responded to the mistake in an inappropriately defensive way. Finally, when someone affected by the error complained about it, they were met by an unwillingness to explain or admit fault, and told their only option was to go to court. We were unable to obtain a remedy for the complainant. However, DoH agreed that, if the complainant makes a claim for compensation including evidence of loss, it will refer that claim to its Minister for consideration. We note that DoH has already implemented changes to its administrative procedures to address some of the problems that this complaint revealed. At the conclusion of this report we make four recommendations that we believe will further strengthen those arrangements, and provide a more open and responsive complaint process. While this complaint is about a very particular set of factual circumstances, we believe it holds broader lessons for Commonwealth agencies about the importance of proper program design, sharing information necessary to ensure proper outcomes and about service recovery arrangements when things go wrong

Report into referred immigration cases: mental health and incapacity

In 2005 and 2006 the Australian government referred to the Commonwealth Ombudsman the cases of 247 persons who had been detained by the Department of Immigration and Multicultural Affairs (DIMA) and later released on the basis that they could not be detained any longer as an unlawful non-citizen. This office agreed to investigate and report to DIMA about each individual’s case under the Ombudsman’s power to conduct an own motion investigation, as provided for in s 5 of the Ombudsman Act 1976. This report deals with nine cases that raise mental health or incapacity issues, but have not yet been reported on publicly. Attachment B to this report contains eight case studies that provide a brief outline of each case. An individual analysis of each case has been provided by the Ombudsman’s office to DIMA, but these will not be published. The common issues about immigration administration identified in each individual investigation have instead been incorporated into this consolidated report

Report into referred immigation cases: Mr G

Mr G’s case is one of some 200 cases involving immigration detention matters previously referred to the Palmer Inquiry by the Minister for Immigration and Multicultural and Indigenous Affairs in May 2005. In July 2005, the federal government asked me to complete the investigation of these cases. I accepted the government’s request and advised that I would investigate these matters under the Ombudsman’s own motion provisions, as provided for in s 5 of the Ombudsman Act 1976. In all, 247 detention matters have been referred to this office for investigation. Mr G is of Timorese origin. Although he appears to have been healthy upon his arrival in Australia in September 1975, by the time he was detained on 28 August 2002 he was suffering from severe mental health problems and living on Fremantle streets. DIMA records indicated that he entered Australia lawfully in 1975, but the systems did not reveal any further information. In the absence of further records, it was assumed by the relevant DIMA officers that he became unlawful sometime after he entered Australia and had never regularised his immigration status. After 43 calendar days in detention, Mr G was released on 9 October 2002 after DIMA assessed him as meeting the criteria for an absorbed person visa. By operation of law, Mr G is deemed to have held this visa since 1994. His detention was occasioned by serious errors on the part of DIMA, especially in its use of the s 189 detention power, its assessment of the absorbed person visa criteria and failures to pursue relevant information. It should be noted at the outset that the investigation into this matter has revealed that many DIMA officers were aware of Mr G’s poor mental health and, in recognition of the complexity of his situation, management level officers intervened at a very early stage. They explored three options for Mr G’s release: removal from Australia to East Timor, a bridging visa in conjunction with an application for a protection visa, and an absorbed person visa. Given the difficult nature of Mr G’s case, this senior level intervention was warranted and appropriate. &nbsp

Immigration reports

The Ombudsman is investigating over 200 cases of suspected unwarranted detention under the Migration Act. These reports on sixteen of the cases were tabled in Parliament 21 March 2007; the government\u27s responses to the recommendations are also provided

Report into referred immigration cases: Children in detention

In 2005 and 2006 the Australian government referred to the Commonwealth Ombudsman the cases of 247 persons who had been detained by the Department of Immigration and Multicultural Affairs (DIMA) and later released on the basis that they could not be detained any longer as an unlawful non-citizen. This office agreed to investigate and report to DIMA about each individual’s case under the Ombudsman’s power to conduct an own motion investigation, as provided for in s 5 of the Ombudsman Act 1976. This report deals with 10 cases, which have not been publicly reported, where children were taken into immigration detention. The period in which these detentions occurred spanned the years 2002 to 2005. These cases are referred to by way of de-identified case studies throughout the body of this report. There is a brief summary of each case at the end of this report. An individual analysis of each case has been provided to DIMA by the Ombudsman’s office, but these will not be published. The issues relating to immigration administration identified in the individual cases have been incorporated into this consolidated report. The Ombudsman acknowledges that since these events occurred DIMA’s approach to the management of unlawful non-citizen children has changed so that children will only be detained within an immigration detention facility (IDF) as a measure of last resort