Public Reports and Case Studies

Public Reports

Investigation: Legal and rights issues and ECT in relation to a mental health inpatient admission

Final Investigation Report (de-identified) (PDF)

Investigation into the Prison Health Service at Darwin Correctional Centre

PHS Investigation Report (PDF)

Investigation into Claims Made in Brochures Produced by Mr Colin Thompson

Thompson Report (PDF)

Report of Investigation into the Care Provided to Ms N

Ms N was an Aboriginal woman with disabilities who lived in a remote NT community.  This investigation looked at the care provided to Ms N by a variety of health and disability service providers from 1993 to 2006.

Report of Investigation into the Care Provided to Ms N (PDF)

Investigation into Royal Darwin Hospital Security Arrangements for the Protection of Children and Infants

RDH Security Investigation Part 1 (PDF)


Case Studies


Community Conciliation (PDF) (Doc)

Complaint Not Resolved (PDF) (Doc)

Complaint Resolved in Assessment (PDF) (Doc)

Complaint Split Between the NT Nursing Board of Australia and the HCSCC (PDF) (Doc)

Complaints About Disability Services Referred to Early Conciliation (PDF) (Doc)

Explanation Resolves Complaint at Early Conciliation  (PDF) (Doc)

Investigation Women Prisoners’ Access to Health Services (PDF) (Doc)

Vaccination not Processed (PDF) (Doc)


Medical Board Referral of Systemic Issue (PDF) (Doc)

Multiple Issues in one Complaint (PDF) (Doc)

Restraint of Elderly Person in Hospital (PDF) (Doc)

Conciliation Conducted in the Prison (PDF) (Doc)

Service Improvement (PDF) (Doc)

Apology from Patient Resolves Dispute (PDF) (Doc)


Communication During Delivery (PDF) (Doc)

Incorrect Prescription (PDF) (Doc)

Timing of Diagnosis (PDF) (Doc)

Waiting Time for Child (PDF) (Doc)

The Real Issue was not the Complaint (PDF) (Doc)

Billing Awareness (PDF) (Doc)

Refund for Patient after Poor Treatment Coordination (PDF) (Doc)


Apology Resolves Complaint (PDF) (Doc)

Complain More Than Two Years Old (PDF) (Doc)

Failure to Take Reasonable Steps to Resolve (PDF) (Doc)

Immunisation Error Leads to Improved Practice (PDF) (Doc)

Explanation Resolves Complaint (PDF) (Doc)

Contracted Disability Service (PDF) (Doc)

Resolution Takes Many Forms (PDF) (Doc)