Improving policy, procedure or service - Casebook 2022 examples

22 Nov 2022 Improving policy and procedure, Case studies

Our recently released Learning from experience report notes that 69% of our reports over the past 20 years identified an issue about policies and procedures as a factor for the problem under investigation.
These Casebook 2022 examples show how to improve policy, procedure or service:


Using mediation to help solve problems (p.10)

Jerry’s residential property shared a border with a commercial facility. There was a long history of disagreements between the operators of the facility and Jerry and the previous owners of his residential property. The disagreements related to interpretation of historic rezoning and building approvals.

Jerry complained to the council about the use of a building on the shared boundary, and potential replacement of the boundary fence. Council responded with its understanding of his concerns, outlining steps to take regarding sharing costs between Jerry and the facility for replacing the fence. Jerry was dissatisfied with this response as he felt that council had not satisfactorily addressed all of his concerns. He then complained to this Office.

The result
This Office outlined a range of factors which council could consider as a basis for facilitating further discussions.

Council agreed to convene a meeting of the parties (that is, council, Jerry and facility management), as well as an independent mediator to try and resolve the concerns.
The points for discussion included the use of the land and building, proximity of activity to the boundary, noise reduction options and cost considerations.
Resolution of the matter was possible outside of finalisation of the investigation by this Office as council:

  • agreed to conduct the meeting
  • had a list of discussion topics relevant to all parties, including as posed by this Office
  • organised to have it facilitated by an independent professional mediator with planning and legal experience.

The mediator facilitated a written agreement between all the parties.

Ombudsman insight 
Used appropriately, mediation and other alternative dispute resolution processes can be cost effective ways for agencies to resolve complaints. 


Providing an internal review observes natural justice for complainant (p.11)

Emily was under 18 years old and had previously been identified as a child in need of protection by the Department of Child Safety, Youth and Women. There were barriers and a range of complexities to Emily living with either her father and mother who were separated, however she wished to reside with her mother. The department had no current intervention with the family and the family was receiving a number of community-based supports. Emily sought help to reunite with her estranged mother. Emily said that the department had previously advised her that it would provide support to her family to help this happen. When Emily made the request, the department provided her with a list of services to enable her to live independently. 

Emily was dissatisfied with the department’s response and complained to this Office. This Office referred her back to the department for an internal review as she had not yet used that right. 

The department assessed her request was out of scope of the department’s Complaints Management Policy and Procedure for a complaint process to occur as there was no ongoing or active intervention for her and her family. Emily complained again to this Office, specifically that the department did not conduct the internal review. 

The result 
The Office’s investigation made further enquiries with the department. These enquiries established that the department had not exhausted all avenues of their complaint management system and the Office referred the matter back to the department for investigation. 

The department undertook an internal review and found that the department’s decision not to progress Emily’s complaint on the basis that it was outside of the scope of the department’s policy was incorrect. 

In response to this Office’s Management of child safety complaints – second report, the department established an internal review process that complies with the Australian/New Zealand Standard. The department took the opportunity provided by Emily’s complaint to remind its staff about internal reviews, and specifically about why an internal review in this case was appropriate and it should have been undertaken. 

The department’s original decision was replaced with a decision that Emily’s concerns were within scope of the policy. A complaints management process was then conducted to address Emily’s request for help her reside with her mother. Emily was satisfied with the outcome of her complaint.

Ombudsman’s insight 
Complaints are useful sources of information for agencies about how to improve their services. Learnings from complaints can be used to communicate areas for improvement to staff. 


Council agreed to review dog attack procedures after inadequate investigation (p.12)

Kevin took his ageing beagle, Sparky, for a walk on a lead. Another dog, Rex, ‘raced out’ of an open gate and attacked them as they walked past the house where Rex lived. Kevin tried to protect Sparky and received puncture wounds that required hospital treatment. Sparky received minor injuries. 

Kevin complained to the council. An Animal Management Inspector (AMI) was assigned to assess the matter. The AMI’s report declared that Rex’s owner would be fined, but there would be no prosecution as: 

  • Sparky had minor injuries 
  • Kevin was injured as a result of protecting his dog and not from Rex biting him 
  • Rex escaped the property as a third party had left the gate open 
  • it was the first time that Rex had escaped since being declared a dangerous dog seven years prior. 

Kevin was dissatisfied with the report, and requested a review. Council’s review upheld the original decision. Kevin then complained to this Office. 

The result 
This Office’s investigation identified inadequacies with council’s internal processes in dealing with the dog attack. These included: 

  • lack of sufficient, quality evidence collected in council’s investigation 
  • no evaluation of Rex’s history as a declared dangerous dog 
  • compliance-related issues concerning Rex’s enclosure 
  • council’s lack of consideration of the relevant provisions of the Animal Management Act (Cats and Dogs) 2008 
  • council’s policy and procedure in dealing with dog attacks. 

Council agreed to conduct a new investigation and make a fresh decision about the dog attack. Council also agreed to update its dog attack procedures, including reviewing a checklist for inspection of enclosures of declared dangerous dogs.

Ombudsman insight 
A decision-maker should gather all relevant information to enable them to make an informed decision. Gathering relevant information should focus on the factual matters to be proved and considered. 

Last updated: Wednesday, 5 April 2023 10:22:05 AM