Casebook July 2026: Investigations and complaint-handling case studies
Casebook July 2026 Investigations and complaint handling case studies
PDF - 1MB
Casebook July 2026 Investigations and complaint handling case studies
PDF - 1MB
Casebook July 2026: Investigations and complaint-handling case studies highlights a selection of the 8,913 actionable complaints received and 6 maladministration investigations finalised between 1 January and 30 June 2026. It demonstrates how independent oversight leads to fairer outcomes for the people of New South Wales.
The NSW Ombudsman is an independent integrity agency that pursues fairness for the people of NSW. We strive to ensure that those entrusted with public power and resources fulfil their responsibilities and treat everyone fairly.
One of our central functions is to receive and respond to complaints from the public about NSW public authorities, local councils and community service providers funded by the NSW Government.
Anyone can contact us to complain if they believe they have been treated unfairly by any of the bodies we can handle complaints about, or to report concerns about possible maladministration.
Our services are free to the public. We are fully independent, and we act impartially in the public interest. People who complain to us are protected by law if anyone tries to retaliate against them. Additional protections apply for public official whistleblowers who report serious wrongdoing to us under the Public Interest Disclosures Act 2022 (PID Act).
Under the Ombudsman Act 1974 (Ombudsman Act) the Ombudsman may conduct an investigation into the conduct of a public authority[1] or a community service provider[2] if it appears to the Ombudsman that the conduct, or any part of it, may be:
In the case of complaints about community service providers, in addition to the above, the Ombudsman may also investigate a complaint if it appears to the Ombudsman that it raises a significant issue of public safety or public interest, or a significant question as to the appropriate care or treatment of a person by a service provider.[4]
Investigations can be commenced whether or not anyone has complained to the Ombudsman about the conduct in question.
Most complaints we receive do not result in a formal investigation. This is because we generally aim to resolve complaints at the earliest stage possible. If a satisfactory outcome can be achieved through inquiries or conciliatory engagement with the agency and the complainant, we will take that action.
Our office has a range of other statutory functions in addition to complaint-handling and investigation, including monitoring and reviewing government programs and services. We also provide guidance and training for agencies in complaints management. See our website and annual reports for more information.
This report contains a range of case studies to promote shared learning about how to improve decision making and administrative processes for those we oversight. Additionally, the case studies inform Parliament and the public about the work of the Ombudsman by demonstrating ways in which we have held agencies to account and how we have reached positive outcomes for the people of NSW.
The report comprises 2 parts:
A summary of the 6 principles for effective complaint management is appended to the report. These principles are a guide for all public sector agencies on the essential requirements for effective complaint management.
If, following investigation, wrong conduct is found to have occurred, the Ombudsman must produce an investigation report. That report must be provided to the relevant public authority and to the relevant minister. The Ombudsman may also report the outcomes of the investigation to the complainant.
The investigation report is not otherwise made public by the Ombudsman, unless the Ombudsman decides to table a special report to Parliament.
Any request for a copy of an investigation report would need to be made to the relevant public authority or the relevant minister, who would need to consider any public interest considerations for and against disclosure. The investigation report is ‘excluded information’ under the Government Information (Public Access) Act 2009 (GIPA Act) and an application cannot be made to the Ombudsman for it under the GIPA Act.
The Ombudsman may, however, make a special report to Parliament at any time on any matter arising in connection with the discharge of the Ombudsman’s functions. Following the completion of an investigation, the Ombudsman may consider tabling a separate, special report concerning the investigation. That is typically done where the investigation (or a series of investigations) raises particularly significant issues of broader public interest.
The biannual casebook reports include a summary of some of the investigations concluded in the relevant 6-month period, regardless of whether a special report has also been tabled in respect of the investigation.
We do not use real names of complainants and otherwise seek as far as possible to omit other identifying information in this report. Agencies that are identified have been given an opportunity to comment on the factual accuracy of any case studies concerning their actions.
This part provides a summary of formal investigations finalised between 1 January and 30 June 2026.
Investigations are an essential tool for holding agencies to account. We can start an investigation of our own motion, or following complaints and public interest disclosures that indicate serious maladministration by an agency may have occurred. Maladministration is a term used to describe administrative conduct that is unlawful, unjust, unreasonable, improperly discriminatory or otherwise wrong. Our investigations examine the conduct of agencies (and in some cases individuals) and enable us to make findings where we believe the evidence is sufficient to show that wrong conduct has occurred.
Investigations can be resource-intensive, both for our office and for the agency under scrutiny. Generally, we give priority to investigating only the most serious matters. When we undertake an investigation, we have similar powers to a royal commission. For example, we can require an agency to provide us with a statement of information or documents relating to the conduct we are investigating. We can also undertake inspections and conduct hearings under oath.
When we finish an investigation, we will report what we found and what we consider should happen next. Any agency or individual subject of proposed findings by us are given an opportunity to respond before we make a final report.
Examples of recommendations we may make include that an agency or service provider:
Monitoring agency progress against our recommendations is a key step in holding agencies to account and ensuring that our work leads to tangible and positive change.
In most instances, when agencies accept our recommendations, they undertake to act on them over time. We monitor their progress by seeking regular updates.
In total, we made 42 recommendations in respect of the investigations reported in this casebook. Of these, 13 have been fully accepted, 1 accepted in principle and we are waiting for agency responses on 28 recommendations.
Our recommendations are not legally binding on agencies. However, in accordance with s 27(1) of the Ombudsman Act, the Ombudsman may decide to make a report to Parliament in the event he or she is not satisfied that sufficient steps have been taken by an agency in response to a recommendation. We made 1 report of this nature during the reporting period. On 2 March 2026, we tabled a report titled, The progress of NSW’s inmate discipline system reform[5] where we raised concerns that insufficient action had been taken to reform the inmate discipline system in response to our 2024 investigation.[6]
In addition, where a recommendation is made in an investigation of a community service provider, administrative review proceedings can be brought in the NSW Civil and Administrative Tribunal to review the service provider’s decision to not implement, or to not implement fully, the recommendation.[7]
Six investigations finalised in the above 6-month period have been included in this casebook.
The investigations examined how public authorities discharged their statutory role across a diverse spectrum of services and responsibilities in areas with significant impacts on individuals and the NSW community.
The summaries include investigations about the handling of reports concerning children at risk of significant harm; a local council’s lack of enforcement of fire safety obligations at a residential building; audit processes and debt recovery of government grants; delays in adjusting workers compensation premiums; the treatment of a public housing tenant’s personal property, and inmates in protective custody not having access to daily exercise.
While each investigation focused on a different area of public administration, all identified shortcomings relating to delay, inaction and poor communication with affected people – often exacerbating harm or distress. Another theme across many of the matters was failures in governance, including inconsistent application of policy, gaps in policy and lack of guidance for staff, which undermine the fair and effective performance of statutory functions.
All 6 investigations resulted in findings of wrongdoing and several recommendations for improvements. Five of the investigations were tabled separately in Parliament as special reports under s 31 of the Ombudsman Act.
Public authority: | Department of Communities and Justice |
Responsible minister: | Minister for Families and Communities |
Investigation report issued: | 6 February 2026 |
Findings: | Conduct that was unreasonable (including by reason of being inconsistent with statutory responsibilities) |
Recommendations: | Policy review and reform; legislative review; staff training. 4 recommendations were made, all 4 recommendations were accepted by DCJ. |
A full report of this investigation was tabled as a special report to Parliament in February 2026. A copy of that report is available here. | |
We commenced an own motion investigation into the Department of Communities and Justice’s (DCJ’s) practice of closing a large proportion of reports it receives about risks of significant harm (ROSH) to children and young persons without a face-to-face assessment, and without being assured that the child is not at ROSH.
In 2024-25, DCJ received 244,710 ROSH reports. Based on a stated reason of lack of capacity or competing priorities, DCJ closed 64% of these reports without allocating them to a caseworker for further assessment.
We made findings of maladministration and made recommendations that include legislative and policy review, as well as immediate improvements to practices while a longer-term reform is finalised.
Determining whether a child or a young person is at risk of significant harm is typically the first step in considering any child protection intervention in respect of that child. It is one of DCJ’s core responsibilities under the Children and Young Persons (Care and Protection) Act 1998 (the Care Act). Our investigation sought to examine DCJ’s practices involved in triaging and assessing the ROSH reports it receives and assess whether they are aligned with the requirements of the Care Act.
We made comprehensive observations and findings in our report tabled in Parliament.
We found that:
We also made additional observations and findings about DCJ’s over-reliance on, and failure to review, its structured decision-making tools.
We recommended that:
All recommendations were accepted by DCJ, with an action plan developed to address each of the recommendations. Implementation of the action plan is underway and we will continue to monitor DCJ’s progress.
Public authority: | Lane Cove Council |
Responsible minister: | Minister for Local Government |
Investigation report issued: | 25 May 2026 |
Findings: | Conduct that was unreasonable and contrary to law |
Recommendations: | Apology; confirmation of actions to rectify outstanding fire safety issues; provide annual fire safety statements; provide progress update of implementation of recommendations from external auditors; audit the fire safety register and advise us of outcome of audit. There were 6 recommendations made, all 6 were accepted by Lane Cove Council. 2 have been fully implemented and the remaining in progress. |
A full report of this investigation was tabled as a special report to Parliament in May 2026. A copy of that report is available here. | |
We investigated Lane Cove Council’s (Council) actions in regulating and enforcing fire safety requirements at a mixed-use strata premises in Lane Cove following a complaint from the chair of the owner’s corporation for the residential part of the building. Council had developed (and continues to partially own) the premises.
Council failed to rectify known fire safety defects, including at a multi-storey residential building on the premises. Council failed to comply with applicable legislation by failing to obtain annual fire safety statements for the premises. It took no enforcement action for continued non-compliance against the building owners, including Council itself as a part-owner of the premises.
Council also had inadequate systems to manage the inherent conflicts of interest that may arise when councils hold multiple potentially conflicting roles, such as when they are the landowner, developer, and regulator for the same development.
We made several recommendations to ensure that compliance is achieved, and Council improves its processes for managing conflicts and complying with fire safety requirements.
Council had developed one of its existing sites in Lane Cove to provide additional parking and a connection to other facilities. Part of the development included the construction of a multi-storey residential building on top of Council’s car park and commercial office spaces.
Following subdivision, Council had retained ownership of 5 lots. The newly constructed residential building, consisting of approximately 107 apartments, became lot 6.
Now, a number of years later, the chair of the owners corporation for the residential building complained to us that Council had not taken appropriate action to fix multiple defects in the building, including fire safety issues, and had failed to enforce regulations requiring building owners to provide annual fire safety statements. A separate investigation by the NSW Building Commissioner confirmed there were serious fire safety defects in the building.
We found that Council’s conduct was unreasonable because it:
Council also acted contrary to law. As the owner of 5 lots, it was required to provide annual fire safety statements for the buildings it owned. As the majority owner and a member of the building management committee, it should have taken the lead role in arranging annual fire safety statements for the entire premises, but it failed to do so for 7 years.
We recommended that Council:
Lane Cove Council accepted all recommendations. Apologies and written confirmation of actions to address fire safety issues have been sent to the owners. We will continue to monitor implementation of the remaining recommendations.
Public authorities: | Service NSW and Revenue NSW |
Responsible ministers: | Minister for Customer Service and Digital Government and Minister for Finance |
Investigation report issued: | 28 April 2026 |
Findings: | Conduct that was wrong |
Recommendations: | Improvements to grant audit processes and policy documents; provide better information to grant applicants; conduct a review of auditees found ineligible at audit, to see if their debt should be refunded. There were 7 recommendations made, all are awaiting response by Service NSW and Revenue NSW. |
A full report of this investigation was tabled as a special report to Parliament in April 2026. A copy of that report is available here. | |
We investigated how Service NSW and Revenue NSW audited certain businesses that had received grants during the COVID-19 pandemic following a series of complaints from affected businesses. We also looked at how any debts raised following audits were recovered.
We found that the audit program was not supported by a consistent framework. The approaches taken by both Service NSW and Revenue NSW changed over time, resulting in inconsistent treatment of applicants and in some cases leading to financial stress.
To prevent similar issues arising in future, we recommended that both agencies make improvements to their grant audit processes and supporting policy documents. We recommended that clear information should be provided to applicants for any future grants about the nature and extent of automated approvals. We also recommended that certain groups of audited applicants should be reviewed to confirm whether their debts should be refunded.
During the COVID-19 pandemic, part of the NSW Government’s response included financial support to businesses. This included 3 grants: the Business Grant (a one-off cash payment to businesses), the JobSaver Payment (fortnightly cash payments to help businesses maintain employee headcount) and the Micro-Business Grant (weekly cash payments to small businesses). The 3 grants were open between July and October 2021 and cost a combined total of $10.7 billion. They provided payments to almost 300,000 businesses in New South Wales.
In many cases an automated system was used to process the grant applications. Rather than evaluating applications against the eligibility criteria, it relied on applicant’s self-declaration of their eligibility. Not all applications were reviewed by staff from Service NSW or Revenue NSW to confirm eligibility. This meant that some businesses that did not meet eligibility criteria were approved by the automated system and received grant payments to which they were not entitled.
After the audit program began in late 2021, we began receiving complaints from affected businesses that claimed they applied for grants in good faith, honestly believing they were eligible. Some even told us they received advice from agency staff that had encouraged them to apply as they appeared to meet the criteria. Many reported experiencing financial and psychological stress.
The audits were implemented as essentially an ‘after-the-fact’ eligibility assessment by the agencies.
The errors made during the application period – including system errors and incorrect advice given by staff on eligibility criteria – were not consistently taken into account when deciding whether to take steps to recover a debt or otherwise exclude a grant recipient from the debt recovery process.
Some applicants were exempted from audits due to system errors, while others were not. Policies on exemptions, hardship, and alternatives to enforcement were introduced iteratively and late in the compliance program. While basic procedures and work instructions existed, the lack of a comprehensive audit framework from the outset of the audits meant similar cases were treated differently, leading to inequitable outcomes.
Discretionary measures – including allowing applicants an ‘offset’ if they were assessed to be ineligible for the grant they received but would have been eligible for a different, lesser grant, had they applied for it – were also inconsistently applied.
Audited applicants were sometimes assessed against interpretations of guidelines that had not been communicated at the time they applied. The imposition of the debts following the audits led to financial stress for many small businesses, something the Covid-19 grants had been intended to prevent.
Early audit communications were perceived as harsh and threatening. Over time, the tone of communication improved, but issues remained, including unreasonably short and inconsistent timeframes for responding to audits, including requests for further information, and inadequate explanations for audit outcomes.
We made recommendations aimed at improving future compliance programs by:
We also recommended that outcomes for particular cohorts of grant auditees should be reviewed with a view to rectifying inequitable outcomes.
We are awaiting a response from Service NSW and Revenue NSW regarding our recommendations.
Public authority: | Insurance and Care NSW |
Responsible minister: | Minister for Industrial Relations and Minister for Work Health and Safety |
Investigation report issued: | 29 May 2026 |
Findings: | Conduct that was unreasonable |
Recommendations: | Apology; offer appropriate payment plans to complainants; provide a written report on the outcomes of a remediation plan. There were 4 recommendations made, all 4 were accepted by Icare, |
A full report of this investigation was tabled as a special report to Parliament in May 2026. A copy of that report is available here. | |
One of the functions of Insurance and Care NSW (icare) is to provide workers compensation insurance to employers in NSW and their employees.
We began an investigation after receiving complaints from 6 employers suggesting that icare had been significantly delayed in adjusting their workers compensation premiums based on the actual wages they paid to their employees, which they had declared to icare as required. We looked at the systems, processes and procedures icare uses in processing actual wage declarations and making the consequent premium adjustments, known as ‘hindsight adjustments’.
We found that icare’s conduct was unreasonable as, although it knew from 2017 that it had a substantial number of unprocessed hindsight adjustments and that there were problems with its software that impacted on timely processing, it did not fix the issues until 2025. The delays impacted individual employers and also risked undermining the integrity of the workers compensation scheme.
We recommended that icare formally apologise to the complainants and negotiate appropriate payment plans relative to their financial circumstances. We also asked icare to provide us with a written report about the outcome of its remediation plan.
The purpose of a hindsight adjustment to a workers compensation premium is to ensure that an employer pays a fair, accurate, and transparent premium that reflects the wages they actually paid, rather than the wages they estimated they would pay at the start of the insurance year (and on which their premium is originally calculated). Hindsight adjustment is an important mechanism that ensures that employers maintain appropriate levels of workers compensation insurance and allows icare to maintain the financial viability of the workers compensation scheme.
The 6 insured employers who complained to us told us that delays in adjusting their premiums resulted in substantial unexpected invoices and caused them financial hardship.
In each case, the employers had lodged their actual wage declarations with icare in accordance with the legislative timeframe – that is, within 4 months following the close of the insurance year. The employers received invoices for hindsight adjustments much later than this, ranging between 12 months and 3 years later. Two employers received substantial invoices for multiple years, with only 3 months given to pay the debts.
Between 2017 and 2023 there were systemic failures that caused unreasonable delays in processing hindsight adjustments.
In 2017, icare inherited a backlog of 55,000 unprocessed hindsight adjustments when it took over policy and billing functions from scheme agents across the workers compensation scheme. Although the legislation does not impose processing timeframes on icare, as a general principle all statutory functions must be exercised reasonably – including in respect of timeframes.
icare’s software was not adequately configured to process hindsight adjustments automatically until 2023. Administrative oversights – including the erroneous closure of files – further worsened delays. icare only implemented internal timeliness metrics for processing hindsight adjustments in 2023.
icare implemented a remediation plan in 2025 and has now identified and processed all outstanding actual wage declarations for active policies it received between 2019 and 2024.
We made findings of unreasonable conduct because of icare’s failure to:
We recommended that icare:
icare accepted all recommendations and has apologised to the affected employees and negotiated payment plans. We will monitor icare’s implementation of the outstanding recommendations.
We investigated Homes NSW’s conduct in disposing of an elderly tenant’s household contents after several sewage leaks at her unit, which contaminated and damaged her property. We also looked at how Homes NSW communicated with the tenant and her advocates, and how it handled her subsequent insurance claim, which was rejected.
We found that Homes NSW’s conduct was unreasonable, and that the disposal of the tenant’s property happened without her consent and contrary to what she was initially told. The insurance company handling the claim was not provided with full and accurate information about the claim.
To remedy the impact on the tenant, we recommended that Homes NSW apologise to her and pay full compensation for the value of her destroyed property, including for the distress she suffered in pursuing her complaint over 5 years. In addition, we recommended development of property disposal procedures and a review of how insurance claims are handled.
An elderly woman who lived in a public housing unit for over 15 years complained to us that 3 successive sewage overflows had occurred at her unit within 3 months, resulting in raw sewage entering her unit. After the last and worst sewage overflow, the tenant was relocated but her property remained at the contaminated unit for a further 2 months until it was boxed up and moved into a vacant unit. The property – which included furniture, household items, an extensive book collection and family heirlooms – was not cleaned.
Homes NSW told the tenant that she would have an opportunity to go through her belongings with Homes NSW and contractors and decide which items could be cleaned and returned to her. Any items deemed non-salvageable were to be disposed of, and the tenant compensated after lodging an insurance claim. Homes NSW staff assured her that she would be actively involved in the decision to keep or dispose of any items.
Despite these assurances, the contractor engaged by Homes NSW disposed of all of the tenant’s contaminated property without her consent. The tenant was then assured that she would be adequately compensated through an insurance claim. However, Homes NSW failed to provide full and accurate information to the insurer. When the tenant submitted the claim, Homes NSW’s insurer denied liability and offered her a small amount of the value claimed as a ‘goodwill’ gesture.
Homes NSW’s conduct was unreasonable because it:
Homes NSW also failed to provide full and accurate information to the insurer to inform its decision on whether to accept liability. It did not inform the insurer that the disposal of the tenant’s property was not in accordance with any agreement, documented procedure or the tenant’s consent.
We recommended that Homes NSW:
Homes NSW has accepted all the recommendations and advised that the tenant will receive an apology and will be fully compensated for the disposal of her property by the end of August 2026.
Public authority: | Corrective Services NSW |
Responsible minister: | Minister for Corrections |
Investigation report issued: | 16 June 2026 |
Findings: | Conduct that was oppressive, unlawful, and wrong |
Recommendations: | Conduct review of policies and procedures, provide training and ensure compliance with relevant legislation. There were 16 recommendations, all which are awaiting an agency response from South Coast Corrective Services. |
A full report of this investigation was tabled as a special report to Parliament in May 2026. A copy of that report is available here. | |
The investigation examined the treatment of inmates held in protective custody at South Coast Correctional Centre (South Coast CC) and several other centres following a number of complaints from inmates. It found that inmates were effectively locked in their cells 24 hours 7 days a week without access to daily outdoor exercise and no access to contact visits or other meaningful human contact. The conditions they were held in resembled solitary confinement, which in some cases extended over a period of weeks.
We recommended Corrective Service NSW (CSNSW) conduct regular reviews of inmates in protective custody, reinstate the ability of those inmates to associate with one another where appropriate, review its protective custody procedures and provide training to staff on recordkeeping. We further recommended that correctional centres should notify assistant commissioners whenever any inmates were unable to access their daily exercise entitlements for 3 continuous days or more.
We started the investigation after receiving complaints in April 2025 from a number of inmates who were held in protective custody at South Coast CC. Inmates in protective custody are kept separated from the mainstream population because of a threat to their safety, rather than as a punishment. The inmates told us that they had been locked in their cells for 24 hours a day for periods ranging from 2 weeks to 3 months.
The law requires that all inmates be offered access to daily exercise in the open air for a minimum of 2 hours.[9] Inmates who are in protective custody retain the same legal entitlements as inmates in the general population.
Prolonged confinement to a cell without access to exercise can lead to significant physical deterioration and psychological harm and can compound the challenges inmates face when reintegrating into society upon release.
Since 2020, inmates who needed protection were either held in isolation from all other inmates under ‘protective custody orders’ or under another mechanism known as ‘s 78A orders’, which allowed them limited association with other similar inmates.
In July 2024, CSNSW received legal advice that s 78A orders did not provide a separate head of power to separate inmates from the general prison population. Six months after receiving that advice, all centres were directed to cease using s 78A orders. Inmates who were separated under such orders were to be transitioned to another placement or order. This resulted in a large increase in the number of inmates being placed on protective custody orders. Inmates moved from a situation where they were being held together as a cohort, to one where they were required to be fully isolated from every other inmate.
The sudden increase in protective custody inmates quickly exhausted the facilities that are available at centres for such inmates. The ‘overflows’ of protective custody inmates were placed in other areas within centres, where providing access to yards (in isolation from all other inmates) was more challenging. Staffing shortages exacerbated the problems, particularly given that more protective custody inmates require increased staffing to facilitate and supervise time out of cells.
At South Coast CC, overflow inmates were placed in a reception area (with no dedicated yards attached) intended to house inmates only for a short period of time pending their transition to the general prison population. The inmates were effectively confined to their individual cells and denied access to exercise in the open air for prolonged periods. They were also restricted to non-contact visits with family or friends.
The increase of protective custody inmates following receipt of the legal advice and the directive to centres to cease using s 78A orders to separate inmates were clearly foreseeable and should have been planned for. In the six months between the legal advice and the directive no action was taken to prepare for the influx.
We found that CSNSW failed to identify and manage foreseeable risks that came from the change.
We also made findings that keeping protective custody inmates, both at South Coast CC and other centres, for prolonged periods of time without access to daily open-air exercise unlawful and oppressive.
The denial of contact visits for inmates at South Coast CC was also unlawful. The housing of those inmates was also not properly authorised or recorded, and was unlawful and otherwise wrong as a breach of policy.
We made 13 recommendations, including that CSNSW:
We are awaiting a response from Corrective Services NSW regarding our recommendations.
This part provides summaries of some complaints we finalised during the period 1 January to 30 June 2026.
The NSW Ombudsman manages complaints relating to unfair treatment by most NSW Government agencies, local councils, or NSW Government funded community service providers. We receive complaints over the phone, in person or in writing, including through our online complaint portal. Any person can complain to us about:
Between January 2026 and June 2026, we received 8913 ‘actionable complaints’ – that is, complaints about a public authority or community service provider that we are authorised to deal with.
We have a range of ways that we manage and resolve complaints outside of conducting a formal investigation. This part of the report demonstrates the kinds of outcomes the Ombudsman can achieve through the different means available to us.
Our aim is to resolve complaints as early and efficiently as possible. Many complaints are finalised by our staff providing information and advice to complainants – for example, guidance on how to navigate an agency’s complaint-handling process. With some larger agencies, complaints can be directly referred to them with the complainant’s consent, allowing the agency a chance to resolve the matter without the need for our office to intervene.
We can make preliminary inquiries under s 13AA of the Ombudsman Act for the purpose of deciding whether the conduct of an agency should be the subject of an investigation. Most complaints that result in preliminary inquiries are finalised without proceeding to an investigation. Inquiries can provide information that assists in resolving the complaint – sometimes the information suggests that no further action is warranted, and we are in a better position to explain to the complainant why this is the case.
In other cases, our inquiries prompt agencies to take corrective action to resolve the complaint (for example, by reviewing a decision, providing an apology, taking action where there has been unwarranted delay, or undertaking some other action), or to provide the complainant with (clearer) reasons or further information that addresses their concerns.
In the process of resolving a complaint we may make formal comments or suggestions to an agency under s 31AC of the Ombudsman Act. These comments are generally aimed at assisting an agency to improve its service delivery or its own complaint-handling practices.
We can and do also make comments to suggest an agency take steps to address a complainant’s particular concerns, such as issuing an apology or taking some other action to resolve the situation.
Alternatively, we can manage a complaint under s 12A of the Ombudsman Act, which enables us to refer the complaint to a public authority for it to conduct an investigation. In those cases, the public authority is required to report back to us on the outcome. Using similar powers under CS CRAMA, we can also refer a community services complaint to the relevant department or a provider to resolve a complaint at a local level and report back to us on the outcome.
Finally, we can conciliate a matter either under s 13A of the Ombudsman Act or under s 74 of the
Public Interest Disclosures Act 2022. Conciliation is held on a voluntary basis and can be most helpful where there is an ongoing relationship between the complainant and the agency that needs to be repaired or restored.
The case studies below provide a range of examples of how we use these powers.
When we finalise a complaint, there are almost always lessons to be learned. The case studies in this report include key learnings that could apply to any public authority or service provider. They are provided here to support continuous improvement in public administration including complaint-handling.
This report also provides transparency around the work we do and illustrates how our services make a difference for the people of NSW.
The case studies illustrate the various ways we can resolve complaints using early resolution powers, including conciliation, preliminary inquiries, direct referrals, liaison with agencies and issuing suggestions and comments under s 31AC of the Ombudsman Act.
There are several recurring themes in this casebook:
A family member complained that the NSW Trustee and Guardian (NSWTG) took 6 years to finalise a deceased estate and distribute funds to the beneficiaries. They also complained about unclear communication regarding the NSWTG’s procedures for withholding funds in reserve for tax, and the distribution of the deceased’s personal items to the beneficiaries of the estate.
We made inquiries with the NSWTG.
We found that the NSWTG could have communicated with the beneficiaries more effectively, including providing advice regarding tax reserve and the distribution of the deceased’s personal possessions. We found there was an opportunity for the NSWTG to apologise to the beneficiaries and refund any estate management fees that could have been avoided. We also identified that the NSWTG’s Easy to Read Guide for Beneficiaries and the general Guide to Beneficiaries, available on its website, did not clearly outline some procedures regarding a deceased estate.
We made 6 suggestions under s 31AC of the Ombudsman Act with a focus on improving service delivery and communication with the beneficiaries of an estate.
The NSWTG accepted all 6 of our suggestions, including apologising in writing to the complainant for its unclear communication and to all of the beneficiaries for the delays in finalising the estate. NSWTG also updated information in its Easy to Read Guide for Beneficiaries regarding reserve tax and the distribution of personal possessions. NSWTG collaborated with the Council for Intellectual Disability to update the Easy to Read Guide for Beneficiaries and the general Guide to Beneficiaries, which are both now available on its website, with printed copies available in its Parramatta, Broken Hill and Newcastle offices.
Clear, timely communication is particularly important when administering complex and sensitive services, including around deceased estates.
Delays may sometimes be unavoidable, but those affected should be kept informed about the reasons for those delays. Clear information – supported by accurate and accessible guidance materials – can reduce confusion and help maintain confidence in the process.
We received a complaint from a parent of a young person about poor communication by a service provider responsible for the case management of their child who was in out-of-home care. The parent felt the service provider had not appropriately recognised their disability and mental health circumstances, and that this had impacted on their understanding of what was happening with their child. They told us this had affected their sense of self-respect.
Our inquiries found that final orders had been made by the Children’s Court and case management had recently been transferred, which had led to a reduction in family time.
We made a referral for local resolution[10] under s 25 of the Community Services (Complaints, Monitoring and Reviews) Act 1993. We asked that the service provider meet with the parent to better understand her experience and explore ways to improve communication.
The service provider met with the parent and their support workers and listened to the parent’s experience, including the parent’s own time living in out-of-home care. The service provider heard that the parent had felt discriminated against, and that this had triggered a trauma-related response that in turn led to a further deterioration of the relationship.
The service provider acknowledged the parent’s experience and apologised. It acknowledged that a large volume of documentation contained inconsistent information about the complainant’s disability, and that this had since been updated.
The parent and the service provider agreed that improvements to communication were necessary. The service provider scheduled regular updates with more detailed and appropriate information. In addition, they agreed that future family time visits would be held in environments that would better meet the family’s needs. The service provider also proposed a clinical consultation to support the parent’s ongoing relationship with the service provider to assist the complainant’s understanding of their child’s needs.
This complaint highlights the importance of recognising a person’s individual circumstances, including their disability and mental health circumstances and responding in a trauma-informed way. Agencies should listen to people’s experiences and adapt their communication and service delivery wherever possible to meet individual needs, particularly where the relationship is ongoing and where – as in this case – doing so supports a child’s ongoing care.
A young person complained to us about the Department of Communities and Justice’s (DCJ’s) decision to place them and their siblings to live with a family member. They told us that DCJ had already placed some of their younger siblings with the family member, and the plan was for the complainant to be moved there later.
The young person felt that they weren’t being heard by DCJ. They raised concerns about the family member’s behaviour, which they thought might destabilise their siblings. They were particularly concerned for the mental health of one of their siblings. DCJ’s decisions had left them feeling very upset and confused. They described feeling alone, disempowered and let down by the system.
We made a referral for local resolution[11] under s 25 of the Community Services (Complaints, Monitoring and Reviews) Act 1993. We summarised the complainant’s concerns as part of our referral, including those relating to how decisions were made and how concerns could be raised.
DCJ met with the complainant and agreed that the placement decision was made without proper consultation with the young person. They provided an apology and expedited a plan for the young person to reside with their siblings. DCJ acknowledged the young person’s experience, and a communication strategy was agreed upon.
While they had raised the issues with DCJ before, the structured local resolution meeting empowered the young person to discuss their concerns directly, allowing them to articulate their concerns and work towards a resolution. It also gave the agency an opportunity to understand the experience of the young person.
The young person later confirmed they had moved to live with the family member and siblings. They told us that they felt supported by DCJ and that the situation had ‘improved a lot’.
It is important that agencies meaningfully consult with children and young people about decisions that affect them and provide opportunities for them to explain their concerns and properly understand decisions that are made. Agencies should then listen carefully to those concerns and respond appropriately.
An inmate told us that strip searches of maximum-security inmates following visits were being conducted in a common area in the presence of other inmates and officers. The inmate also told us that there were no cubicles or privacy screens available, contrary to relevant policies.
We made inquiries with the Governor, who confirmed that strip searches were being conducted in a common space without cubicles or partitions available for the privacy of inmates.
Corrective Services NSW advised that partitions had been ordered and have since been installed in the maximum-security visits area to provide a suitable level of privacy for inmates undergoing a strip search.
The Custodial Operations Policy and Procedures states that strip searches are to be conducted with due regard to inmate dignity, privacy and respect. Additionally, the Inspector of Custodial Services had previously observed the lack of privacy screens on a visit to the centre in May 2024, and raised the issue in her report in December 2025.
The Governor advised that the local policy relating to the visits process was under review to incorporate more efficient visitor processing and inmate searching procedures.
This case highlights how strip search processes can impact the dignity and privacy of inmates in custody, and how complaints can result in practical improvements and policy changes that promote more respectful treatment and protect dignity.
A complainant was unhappy with City of Coffs Harbour Council’s (Council) handling of their complaint. They had complained to Council that in responding to concerns about proposed construction occurring at a local beach park, it had incorrectly referred to the land as ‘Crown land’. Council’s response appeared to conflict with public planning information that indicated that the land was part of Coffs Coast Regional Park.
Crown land is managed under the Crown Lands Management Act 2016, and regional parks are managed under the National Parks and Wildlife Act 1974. Both Acts can allow a local council to be appointed as a land manager to make decisions or undertake work on the land. However, each Act confers different obligations and processes for land management.
The complainant was concerned that Council was acting based on a mistake, meaning that its decisions in the management of the park were not following the processes required by the relevant law.
We made preliminary inquiries with Council, requesting information on its understanding of the status of the park land in question.
Council acknowledged that its previous responses to the complainant had incorrectly characterised the land in question as Crown land when it was in fact a regional park. Consultation with NSW National Parks and Wildlife Service confirmed that Council’s proposed actions for the land were within its lawful authority to both propose and carry out.
In response to our feedback, Council was able to improve its complaint handling processes. It changed its processes to ensure information provided to complainants is verified and that complaints are triaged correctly – so it can seek information from the relevant subject matter experts before responding.
Agencies should verify accuracy of information they provide in response to complaints, particularly in circumstances where a complainant has raised concerns about the reliability of information given.
In February 2026, while on a visit to a youth justice centre, a young person told us he was no longer allowed access to photographs taken of him within the centre.
He said a sporting team had recently visited the centre, and several young people had photographs taken with the players. He was told by staff that he was not allowed to have the photos in his room, nor would they be placed in his personal property for when he exited detention.
We made preliminary inquiries with the youth justice centre.
The youth justice centre advised that, while photographs could no longer be displayed around the centre due to privacy concerns, young people could have access to their individual photographs with invited guests (including the sporting team) and the photographs could also be placed in their property as long as the photo did not contain any other young person.
The Centre Manager acknowledged that there appeared to be a miscommunication with staff about the issue, after a recent internal communication had been sent out to staff providing guidelines about the taking and sharing of photographs of young people.
Following our inquiries, the centre also sought clarification through Youth Justice NSW to confirm that photographs taken with external facilitators and the young person could be kept if consent was obtained and no security features were visible.
The centre advised that all individual photos of young people taken with the sporting team had been given to the young people.
Agencies should ensure staff receive clear guidance on operational policies and understand how to apply them correctly. When policies are misunderstood, people in custody (including young people) may be unnecessarily denied possessions or opportunities – in this case, photographs of a significant and potentially rehabilitative moment in their lives.
A grandparent told us that the Department of Communities and Justice (DCJ) had removed their grandchild from their care and placed them with foster carers. The grandparent told us that they did not understand the reasoning for this decision, as case workers had previously told them that they were doing well in supporting the child in their care. They told us that they wanted their grandchild returned to their care and not ‘placed with strangers.’
We made inquiries of DCJ to understand the circumstances of this complaint, including the processes that were followed and relied on, in deciding to relocate the child.
In response to our inquiries, the relevant DCJ district office referred the matter to the Office of the Senior Practitioner within DCJ for a review of the decision-making process for the relocation of the child and the supports that had been provided to the complainant as carer before the decision was made. The review also considered whether appropriate procedures had been followed, and if any further action was required.
The review found that the grandparent had not been afforded procedural fairness and had not been told that they had the right to request a review of the decision to relocate the child. The grandparent subsequently requested a review of the decision, which was assigned to another district office to complete.
This complaint highlights the importance of following process and procedural fairness in making decisions. The agency initially viewed the grandparent’s concerns as disagreement with the decision, however after our involvement the agency provided opportunity for a review, including consideration of support and planning for the child.
A parent complained that they had not seen their 2 children for almost 3 years, despite their attempts to contact the out-of-home care service provider. Both children are under care of the Minister of Department of Communities and Justice and reside in an out-of-home care setting.
The parent told us that they have disability and have difficulty advocating for themselves. They told us that communication had broken down with the service provider and that they felt unheard.
We made a referral for local resolution[12] under s 25 of the Community Services (Complaints, Monitoring and Reviews) Act 1993. We asked that the service provider to meet with the parent to discuss the concerns. When making the referral, we told the service provider that the parent wished to attend any meeting held with their NDIS Support Worker.
The service provider met with the parent and their NDIS Support Worker. To ensure the parent felt comfortable to discuss their concerns, the meeting was held at a location of their choosing. At the meeting, the service provider scheduled contact between the parent and their children and provided guidance and support to help them reconnect. They were able to pass on gifts and record a video message for their children. The meeting gave them the opportunity to establish communication and a working relationship with the service provider and begin rebuilding their relationship with their children.
The process helped the service provider learn about the parent’s experience and to engage more effectively with them, gaining a better understanding of their disability and communication support needs. It was agreed that future contact between the service provider and the parent would be supported by their NDIS Support Worker to ensure they are adequately supported during discussions about the children.
This case illustrates the importance of identifying and addressing barriers to participation and communication, and adapting engagement to meet a person’s individual needs. Practical adjustments – for example involving a support person or changing where meetings are conducted – can improve communication and relationships and can assist in resolving issues.
An inmate told us that he was found guilty of the correctional centre offence of ‘destruction and damage of property’ and ordered to pay $245 in compensation after he used a ripped blanket to attempt self-harm. He was being managed under the Risk Intervention Team at the time and had a significant history of mental health concerns.
We made inquiries with the Compensation Order Review Team at Corrective Services NSW (CSNSW). Information from CSNSW confirmed the circumstances and charge as described by the inmate. The information also suggested that the inmate may have been confined to his cell for more than 48 hours pending adjudication of the offence (although this could not be confirmed due to a lack of recordkeeping).
CSNSW policy states that when guilt is determined for a correctional centre offence, the adjudicating officer should consider a range of factors before imposing a penalty, including recent behaviour and any mitigating circumstances. It appeared that in this case, mitigating circumstances – namely, that the property damage occurred during a self-harming incident, and that the inmate was being managed for complex mental health needs – had not been considered.
We made suggestions to CSNSW under s 31AC of the Ombudsman Act that it review:
CSNSW accepted our suggestions and told us it was reviewing current policies and procedures. It also provided information indicating that the inmate’s charge and compensation order had been revoked and refunded shortly after we raised our concerns with the compensation order review team. [13]
Decision makers should consider an individual’s circumstances before imposing penalties for correctional centre offences and it is vital that clear, transparent records are kept. In particular, relevant mitigating circumstances should be identified and weighed to ensure decisions are fair and reasonable.
A TAFE NSW student enrolled in a course believing she would be able to complete it fee-free. She was allowed to continue studying without paying any fees but was then pursued by debt collectors for approximately 3 years of outstanding fees.
TAFE NSW had sent her the standard VET Student Loan Fee Notice – Statement of Covered Fees, which stated that her enrolment had been accepted on the basis that either: some or all of her fees would be covered by Vocational Education and Training (VET) Loan, or that she would pay with an upfront self payment.
Although she did not obtain a VET loan or pay upfront, no blocks were placed on her study, and she was allowed to attend classes and continue the course. The subsequent notices she received had indicated there were no fees owing.
We made inquiries with TAFE NSW.
TAFE NSW confirmed that the student was not eligible for a fee-free place, and should have been made aware of the fees owing and been blocked from study if she had not paid them. TAFE NSW acknowledged a number of errors in the enrolment process, including:
The error went undetected until an internal fee review, at which time the full fee was first applied. Prior to this, errors in the fee records resulted in the system generating and sending fee notices showing no fees owing, which meant no system blocks were triggered on her studies.
Ultimately TAFE NSW elected to waive the entire outstanding fee of $44,990 due to the administrative errors that occurred.
After the fee was waived, the student was sent her diploma.
This complaint highlights the importance of discretionary debt waiver processes in preventing unfair financial detriment that can arise from flawed administrative processes.
An inmate complained to us about the level of force used on him. He was being held in a clinic cell for management of his complex mental health needs when officers allegedly attended his cell, dragged him along the ground and physically assaulted him. He told us he had sustained visible injuries as a consequence of the force used.
We made inquiries with the Governor of the correctional centre to better understand what had occurred, including requesting a copy of the use of force package and any available video footage (correctional officers who use force on an inmate are legally required to immediately report the use of force incident to the Governor under cl 133 of the Crimes (Administration of Sentences) Regulation 2014.)
Although there was no record of the use of force, the Governor reviewed video footage and confirmed that an unreported use of force had in fact occurred.
The Governor identified that the force used was, in part, unnecessary and unreasonable and subsequently referred the matter to an internal integrity committee, and a formal investigation was commenced. The Governor also immediately referred the inmate to the health clinic for review.
This complaint highlights the value of secondary sources of evidence, such as CCTV, in ensuring fairness where recordkeeping systems fail. It also underscores the importance of both internal and external complaint systems in scrutinising the use of administrative power, including use of force, particularly in closed environments such as correctional centres.
A public housing applicant told us that when she contacted Homes NSW to update her housing application, she was told her name had been removed from the waitlist around 3 years ago.
She told us that Homes NSW had not previously told her that she had been removed, despite the fact she had been placed on the list 5 years ago. She appealed the decision, but Homes NSW declined her appeal request because she hadn’t lodged the appeal within 3 months of the decision to remove her from the list.
She asserted to Homes NSW that she would have met that 3 month timeframe if she had been informed of or received Homes NSW’s decision. However, Homes NSW upheld its decision not to accept her appeal request.
We made inquiries with Homes NSW.
Homes NSW reviewed the applicant’s eligibility and status on the NSW Housing Register and confirmed that it had incorrectly closed her application.
Homes NSW then reactivated her housing application with full retrospective effect and confirmed her and her daughter’s eligibility for a 2-bedroom property. It also apologised for its oversight.
Care should be taken, before rejecting an appeal on the basis of an exceeded time limit, to check that the person was properly informed of the decision they are seeking to appeal. It is generally unfair and unreasonable for an agency to rely on a time limit for appealing a decision if the agency’s own administrative failings meant that the person had not been made aware of that decision.
A complainant told us that Waverley Council had revoked a fine and ‘menacing dog’ order, subject to several conditions. Conditions that were imposed related appropriately to the control of the dog – however the agreement also required the complainant to agree not to disparage Council in any way. When the complainant refused to sign the agreement, Council reinstated the fine and the order.
We made preliminary inquiries with Council and raised concerns about the appropriateness and fairness of the actions taken by Council staff.
What was the outcome?
Council reviewed the matter and agreed that the process did not appear to adhere to their established protocols.[14] Council apologised to the complainant and undertook to review and communicate their procedures to staff to avoid a recurrence of the issue.
Conditions attached to regulatory decisions should relate to the purpose of the decision itself. While enforcement action was appropriate in these circumstances, public authorities should not use their regulatory powers to restrain a person’s right to complain, disagree or express criticism.
A complainant contacted us after the Health Care Complaints Commission (HCCC) declined their request for a review of the outcome of their complaint. They believed their concerns had not been properly addressed and their disabilities had not been accommodated during the complaints process.
The complainant had multiple disabilities which affected their communication. They told us they understood that the HCCC required complaints to be in writing, so they had used AI to draft their concerns, disclosed their disabilities in the complaint form, and indicated they wanted to speak with someone about their complaint. As the HCCC did not contact them until after they had issued the complaint outcome in writing, the complainant did not feel they had the opportunity to fully explain their concerns.
They also said they never received correspondence explaining the HCCC’s decision to decline their review request. The request for review had been made within 28 days of the complainant receiving the outcome of their complaint, and the HCCC’s legislation requires them to undertake a review if it is requested in this timeframe.
We made inquiries with the HCCC about its handling of the matter.
The HCCC advised that as the written complaint was clearly articulated and complete – noting the form completed by the complainant indicated ‘full information’ was attached – no adjustments for verbal contact were identified as being necessary.
It acknowledged that contacting the complainant prior to sending the original outcome letter would likely have led to a better result for the complainant.
As a result of our inquiries, it undertook to carry out the review and contacted the complainant.
We noted that asking an individual if they require supports for their disability, rather than assuming they do not, is generally accepted as the best way to determine if support is required.
This complaint highlights the importance of communicating with complainants to ensure clear, mutual understanding of the issues, especially with the rise of AI-assisted communication. Agencies should be aware that AI generated language in complaints may mask accessibility needs, and make appropriate accommodations to ensure people with disability are heard and understood.
An inmate with partial paraplegia complained about being housed in a correctional centre that could not adequately accommodate his disability.
He said that, until recently, he had not been provided a shower chair to use and had been partially disassembling his wheelchair, removing its more absorbent elements, so that he could use it as a makeshift shower chair. He also complained that he was limited to the standard 6-minute shower time allotted to all inmates in the centre, which was not enough time for him to properly clean himself.
We made inquiries with the Governor of the centre to understand what had occurred, including asking whether the State-wide Disability Service (SDS) had been consulted regarding accommodations for the man.
Following our inquiries, we were advised that centre staff had not consulted with the SDS since the inmate’s reception to the centre. Staff subsequently increased his allotted shower time from 6 minutes to 15 minutes to provide him with sufficient time to clean himself. Staff also checked to see if any further accommodation assistance was required.
We reminded the centre that, in future, they should proactively engage with SDS upon reception of an inmate with disabilities. This is to ensure appropriate arrangements are made to accommodate incarcerated persons living with disabilities, prior to a person reaching the point of complaint.
This complaint highlights the need for agencies to proactively consider how they can accommodate individuals’ differing needs, particularly in situations of known disability. When warranted, agencies should seek specialist advice early in these cases – doing so can help identify appropriate supports before problems arise and ensure the safe and equitable treatment of people with disability.
A housing tenant complained about non-responsiveness and prolonged inaction by the Aboriginal Housing Office (AHO) relating to maintenance requests to address a severe mould outbreak and structural damage in the bathroom of their residence. The tenant had reported ongoing water leaks from the shower, which had caused increased water bills.
Before complaining to us, the tenant had raised multiple maintenance requests via the MyHousing app and by telephone to the Maintenance Response Centre over a 3-month period. They had also raised a number of additional concerns relating to the lack of a complaint response to complaints they had made relating to rental payments and health concerns related to mould exposure.
We made inquiries with the AHO.
The AHO conducted a full review of the complainant’s file and acknowledged that it had not acted adequately on the tenant’s maintenance requests at the time. It told us this was because the requests had been lodged via the app and via telephone in a way that did not convey the severity of the issues, and the supporting photos the tenant provided also did not adequately reflect the extent of the issues.
The AHO apologised to the tenant for the administrative oversight. It raised work orders to scope each of the reported repairs and completed a full bathroom renovation. The tenant and their family were placed in temporary accommodation while the repairs and renovation were being completed.
The AHO clarified its complaint handling actions and rental calculations, confirming that the complainant was not overcharged. It also reviewed the water charges, escalating them to Homes NSW’s water management unit for review. The AHO undertook to oversee this process and keep the complainant informed of the outcome.
Agencies should ensure their processes identify and escalate issues that remain unresolved over time, particularly where delays caused by administrative oversight can significantly impact the people involved – including, as in this case, a family’s financial and health circumstances.
A complainant told us a private certifier had failed to respond to their complaint and follow-up correspondence about the building design of a neighbouring development, which they believed affected the privacy of their property. The private certifier had not responded to the complainant because it believed that the issues raised were better addressed by the local council as the consent authority.
We made inquiries with the private certifier.[15]
Following our inquiries, the private certifier responded to the complainant to address their concerns. It explained the roles of the private certifier and council when it comes to development concerns, so they could direct their concerns to the appropriate authority.
To prevent the recurrence of similar communication failures, the private certifier reviewed its internal correspondence management procedures and strengthened its administrative processes supporting the timely allocation of (and response to) incoming communications – including adopting measures to monitor response timeframes.
It is important to respond to complaints – even when it appears they might be misdirected. Rather than ignoring the complaint, clarifying information can be provided to help the complainant to direct their concerns to the relevant authority.
This case also shows how complaints can provide an opportunity to review and improve complaint handling and communication processes.
The complainant was the executor of their father’s will and received a house following their father’s death. As the complainant was the Executor the title to the house was placed into their name. The house was eventually sold, and they distributed the funds as the Executor. A few years later, the complainant then bought their first property with their partner. Revenue NSW told the complainant they were not eligible for the First Home Buyers Assistance scheme because their name was previously on the land title for their father’s property. The complainant told us that they were required to pay a large sum of money under a notice of investigation relating to unpaid stamp duty, interest and a fine.
We made preliminary inquiries with Revenue NSW.
Revenue NSW told us that it had not (yet) demanded payment of unpaid stamp duty, but had issued a notice of investigation to the complainant requesting supporting documents be provided in respect to their being the Executor of their father’s estate. At the time the complaint was lodged with us, Revenue NSW was still in the process of reviewing the information provided in response to that notice, and had not yet made a determination.
After Revenue NSW reviewed all relevant records and documentation provided by the complainant, it determined that the complainant had met the eligibility criteria for the First Home Buyers Assistance Scheme. Revenue NSW confirmed this outcome in a finalisation letter to the complainant.
The complaint information allowed our office to provide feedback to Revenue NSW prior to them issuing the finalisation letter. The case highlights that the complaint process can provide an opportunity for parties to exchange further information which can ultimately resolve the issues that are the subject of the complaint.
A complainant told us their vehicle had been damaged by a fallen tree whilst travelling on a highway. The complainant lodged a liability claim with Transport for NSW (TfNSW) for the damage caused to their vehicle. The claim was referred to TfNSW's insurer and the complainant received correspondence from the insurer that led the complainant to believe the claim would be settled. The claim was handed back to TfNSW for determination and next steps.
Once returned to TfNSW, the claim underwent further review. A decision was made after this review to deny the claim. The complainant followed up twice with TfNSW and it eventually confirmed by email that the claim had been denied.
We made preliminary inquiries with TfNSW to understand the history of the claim and the reasons for the decisions.
Following escalation through our office’s complaint process, TfNSW escalated the matter with its insurer for a further review. Transport’s insurer confirmed that, given the claimant was previously advised by the insurer that the claim would be paid, the insurer was prepared to honour that position. Accordingly, the insurer accepted liability for the claim and arranged payment. The complainant was advised of the outcome.
Agencies should communicate decisions clearly and consistently. Complaint processes provide an important opportunity to identify and correct unfair outcomes arising from administrative error or inconsistent communication, particularly when third parties, such as insurers, are involved.
After a fire destroyed their home, a complainant and their young family were facing homelessness when Homes NSW declined to extend their temporary accommodation.
On the day renewal was due, the complainant was intending to pay the renewal amount directly to the accommodation provider (on the misunderstanding that such payments were to be made to that provider, when in fact they should be made to Homes NSW). Before they made the payment (which was due by midnight), they received a message that afternoon from Homes NSW informing them that it had declined temporary accommodation due to unmet obligations.
The complainant attempted to contact Homes NSW staff unsuccessfully, before learning from temporary accommodation staff that the payment was now overdue and should have been made directly to Homes NSW. It appears the payment had not been due by midnight as the complainant had thought, but rather earlier that afternoon. They immediately made a payment to Homes NSW, and followed up with a request for a review of the decision and a copy of the receipt showing their payment had been made.
They continued their attempts to contact Homes NSW by phone and email multiple times, but several days passed without contact from the Homes NSW officer who was overseeing their case. Their eviction was imminent.
We made urgent inquiries with Homes NSW.
Homes NSW advised that there were some complicating factors, but there was ultimately nothing preventing the family from accessing temporary accommodation, and the application was sitting with the local office for assessment.
Homes NSW confirmed that the family’s temporary accommodation would be extended and that the administrative steps to facilitate this had now commenced.
This complaint shows how miscommunication and delays in the administration of assistance (including temporary accommodation) can have a direct bearing on the risk of homelessness, and highlights the importance of timely communication and prompt remedial action.
Last year we reported that Central Coast Council (Council) generated the highest number of local government complaints to our office.[16] We continued to receive a high volume of complaints, and noted that several matters raised concerns about Council’s inaction and lack of response to complaints made to it. This resulted in members of the public having to repeatedly escalate their concerns with Council.
We raised concerns with Council about the adequacy of its complaint management systems and resources.
Our office publishes a range of resources to support all agencies with effective complaint management.[17] We gave Council copies of our resources and made comments under s 31AC of the Ombudsman Act.
Our comments centred on improving the timeliness, effectiveness and transparency of Council’s complaint management, with the aim of improving outcomes for members of the public. We suggested that Council:
Council responded positively to our suggestions, implementing several initiatives focused on continuous improvement. The general manager convened a cross-functional workshop that set an expectation that complaints are to be addressed as quickly as possible by an appropriate staff member. Council is now providing complaint-handling training to multiple teams to support consistency. It is also reviewing the effectiveness of its internal complaint-handling guidance material.
We will continue to monitor Council’s progress over the coming months.
This matter highlights the importance of having an effective complaints management system, that is appropriately resourced and supported by qualified or trained staff, so it can be responsive to the needs and expectations of complainants. It also underscores the important role of agency heads and senior leaders in fostering a culture where complaints are welcomed and valued.
A complainant contacted us after not receiving a response to concerns they had raised with the Building Commission NSW (Commission) about a builder whose work had led to water leakage in their home.
We contacted the Commission to better understand its informal dispute resolution service and how it handled the matter in line with its complaint assessment framework.
The Commission acknowledged that it had not clearly explained the limits of its role in providing an informal dispute resolution service, and that it should have clarified this in response to the complainant’s multiple follow-up emails. It apologised for not doing so.
The Commission contacted both the complainant and the builder to remedy the confusion. Subsequently, rectification works commenced and a Building Commission NSW inspector was assigned to assess the works and any remaining defects to determine whether further regulatory action was warranted.
The Commission provided feedback and additional training to the officer involved to improve the clarity of future complaint finalisation notices.
Agencies should clearly explain the scope and limits of their role. This helps manage expectations around what the agency can do, where its involvement ends and what people can expect as a matter progresses.
[1] Under s 246 of the Crimes (Administration of Sentences) Act 1999, the Ombudsman Act also applies to the management company, governors and staff of privately-run correctional centres as if they were public authorities.
[2] Under s 24 of the Community Services (Complaints, Reviews and Monitoring) Act 1993 (CS CRAMA), the Ombudsman Act applies to complaints about community service providers as it does to complaints about public authorities.
[3] Section 26 Ombudsman Act.
[4] Section 27 CS CRAMA.
[5] Available at www.ombo.nsw.gov.au: The progress of NSW inmate discipline system reform.
[6] Available at www.ombo.nsw.gov.au: Investigation into inmate discipline in NSW correctional centres.
[7] Section 28 CS CRAMA.
[8] Homes NSW was established in February 2024 as a central unit within the Department of Communities and Justice that coordinates the tenancy, asset, and Aboriginal Housing functions. Many of the events in this investigation predate the establishment of Homes NSW.
[9] Clause 53, Crimes (Administration of Sentences) Regulation 2014 (the only exception is inmates being confined as a punishment, who are entitled to 1 hour).
[10] Local resolution is a process in which our office asks an agency to meet directly with the complainant to resolve the concerns raised, and report any outcomes back to us.
[11] Local resolution is a process in which our office asks an agency to meet directly with the complainant to resolve the concerns raised, and report any outcomes back to us.
[12] Local resolution is a process in which our office helps agencies and complainants resolve concerns directly, with the agency reporting outcomes back to us.
[13] In August 2024 we issued a special report, Investigation into inmate discipline in NSW correctional centres, which also included concerns about inappriopriate use of inmate discipline charges to respond to inmates with self-harming behaviours: see pp 25 – 26.
[14] It is also important to note that, in terms of dog behaviour, standards under the Companion Animals Act still needed to be met.
[15] A private certifier (registered certifier within the meaning of the Building and Development Certifiers Act 2018) included in the definition of a public authority under s 5(1) of the the Ombudsman Act 1974.
[16] NSW Ombudsman Annual Report 2024-25, p 38 (NSW Ombudsman Annual Report 2024-25)
[17] Available on our website www.ombo.nsw.gov.au
We acknowledge the traditional custodians of the land on which we work and pay our respects to all Elders past and present, and to the children of today who are the Elders of the future.
Artist: Jasmine Sarin, a proud Kamilaroi and Jerrinja woman.