In this report, we mostly report on notifications received and managed by Ahpra and the National Boards. 

When we include data about matters received and managed by the HPCA in New South Wales and OHO in Queensland, they are either provided in separate columns or, if incorporated into Ahpra data, acknowledged in the table title. 

This year, we transitioned to a new case management system, which introduced a significant change in the way data are captured and stored. We have continued to refine our data collection and reporting throughout this process to allow for comparison, where possible, with previous annual reports.

This year, we received 13,327 notifications – an increase of 19.0% compared with last year. While we continue to see an increase in the number of notifications received, it is difficult to name a single cause for this. However, several trends can be identified: 

• About 50% of the notifications received were categorised as lower risk and managed by an early determination process – an increase from 34.5% last year. 
• While the nature of concerns raised this year was largely similar to the previous year, the number of notifications where the primary concern related to a practitioner’s behaviour increased to 6.9% this year, from 4.8% last year. 
• Notifications increased across all professions except midwifery and Aboriginal and Torres Strait Islander Health Practice. 

A proactive approach to media has further helped to build our public profile and raised awareness of the role we play in handling concerns about health practitioners and protecting public safety.

Most notifications (72.8%) were made by patients, their families or representatives, or other members of the public. This was consistent with last year (70.9%).

A further 17% were from health practitioners and employers, followed by police, government or co-regulators (4%). This year, 1.5% of notifications were initiated by a National Board or their delegate, and the remaining 4.6% were raised by other sources, including education providers, self-notifications and anonymous notifiers.

This year we received 146 (1.0%) anonymous notifications (where the notifier does not disclose any identifying information to us).

Improvements 

Across the year, we improved several of our processes, including the following: 

• Improved our ‘Raise a concern’ form to better capture concerns raised by notifiers and their reasons. This has allowed us to progress these concerns faster and support notifiers in having their concerns considered by the most appropriate organisation. This new form was viewed over 59,000 times, 47.4% more than last year. 
• Continued to improve engagement with notifiers through a dedicated intake team to receive all new notifications. This team handled more than 8,000 phone calls. 
• Worked with National Boards to streamline decision making for our lowest-risk concerns, reducing the time to complete these matters by more than 30 days. 
• Improved our framework for identifying and managing vexatious notifications, and our processes for assessing and managing these notifications and unreasonable notifier behaviour. This year, 125 notifications were assessed for vexatiousness and 53 notifications were determined to be vexatious by a National Board, an increase from 21 last year. 

Experience 

Where possible, we seek direct feedback from notifiers and practitioners who engage with our regulatory processes. We are developing updates to these feedback mechanisms in our new case management system, which was launched in March. 

We continued work to create a culturally safe notifications process for notifiers, practitioners and witnesses who identify as Aboriginal and/or Torres Strait Islander. A cultural safety advisory team was established to provide guidance and oversight of this area. This team includes specially appointed Aboriginal and Torres Strait Islander cultural safety advisors, and decisions are made through the medical and nursing and midwifery Indigenous National Special Issues Committees. 

We also continued our work on improving the experience of notifiers, including the development of a navigator service to ensure notifiers are directed to the right agency for their concerns. 

Managing concerns 

There are three types of allegations we can manage. They are that: 

• a practitioner is practising their profession in an unsafe manner 
• a practitioner’s behaviour is placing the public at risk 
• a practitioner’s ability to make safe judgements about their patients might be impaired because of their health. 

The most common type of concern relates to the way a practitioner is practising their profession, including concerns about the clinical care provided or the practitioner’s management of a patient’s medication (see Table 15). 

A notification can be about more than one concern and 58.9% of notifications we received contained multiple concerns. 

Not all concerns raised with us are about individuals we register or things that we can deal with. When concerns are not within our jurisdiction, we speak with the notifier about why we are not able to consider their concerns and, where appropriate, provide them with information on where they may be able to raise their concerns.

Our case-management approach 

Once we determine that a concern is within our jurisdiction to manage, we decide how it can best be managed by considering: 

• the nature of the concern 
• the powers or processes best suited to gathering the required information 
• the likelihood that regulatory action might be needed. 

Where possible, each notification is allocated to a single case manager from beginning to end. 

Early determination 

When a notification indicates no or low ongoing risk to patients, we consider whether it is appropriate to refer it to a health complaints organisation (HCO). 

There are HCOs in all states and territories. They are vital partners in ensuring that consumer complaints about health services are resolved. HCOs share the complaints they receive about registered health practitioners with Ahpra, and Ahpra shares relevant consumer complaints it receives with the HCOs. Together we decide which is the most appropriate body to deal with the complaint. 

This year, 3,353 notifications were retained by, or referred to, an HCO. This is 27.7% of all the notifications we completed, and is a 63% increase from the previous year. 

A further 2,379 (19.7%) notifications received did not require referral to an HCO and resulted in no further action being taken. These notifications were retained by Ahpra and closed through the early determination process. 

Legislative changes that came into effect in May 2023 mean that where a notification is better managed by another entity, such as an employer, we may refer the notification to that entity. This year, 128 notifications were referred to an external entity other than an HCO. 

Where low-risk concerns are managed by Ahpra, we seek to progress the notification as soon as possible. This year, we worked with the National Boards to introduce a new decision-making process that supports the timely review and completion of low-risk notifications. This process has reduced the timeframe to complete these matters by more than 30 days on average, with 204 matters closed within 30 days of receipt. 

Identifying at an early point which notifications can be dealt with through early determination has improved the time it takes to close notifications. 

Strengthening practice 

When a concern identifies some risk to the public, we engage with practitioners. 

Our specialist teams gather information from practitioners, employers and others about the way the practitioner practises and, where required, to understand what steps have already been taken to improve their practice. 

We do not need to take any regulatory action when this information indicates that we can rely on individual or organisational risk controls, or existing regulatory risk controls, to mitigate any ongoing risk to the public. 

Around 40% of notifications were managed through a strengthening practice approach, and 17% of these were closed without any regulatory action because the practitioner demonstrated the steps they had taken to reflect on and improve their practice.

Case studies 

Not a ground for a notification 

A patient raised a notification after they booked an appointment to see a dermatologist. After booking the appointment, the clinic informed the patient they were a paediatric clinic and were unable to treat the adult patient. The patient raised concerns about the clinic’s refusal to provide a service to them. 

The Medical Board of Australia reviewed the concerns and decided the concerns did not meet grounds for a notification. 

No response required 

A patient raised concerns about a medical practitioner who changed their prescribed medication and added a new medication in response to high blood pressure, which the notifier believed was caused by stress. 

The Medical Board of Australia noted that a change in prescribed medication is not, in and of itself, indicative of a performance concern and no response was required from the practitioner. The Board decided no regulatory action was required. 

Strengthening practice: Steps taken to address 

A patient raised concerns about complications following surgery on their leg. The patient required multiple follow-up surgeries and developed an infection requiring management and treatment. 
The surgeon had no previous notifications and had been practising for several years. The Medical Board of Australia sought information from the hospital, which confirmed the practitioner had made changes to his surgical approach because of the complication. 

The practitioner provided a response to the concerns raised, took responsibility for the surgical management and committed to change their practice to avoid complications in the future. 

The Board acknowledged the distress felt by the patient and their family but noted that the complication was a rare but recognised risk of the surgery. The Board noted the steps taken by the hospital and practitioner in response to the events and decided no further action was required. 

Strengthening practice: Regulatory action necessary 

A notification was received from a patient raising concerns that a physiotherapist forcefully cracked the patient’s back during a consultation despite the patient advising of a previous back injury.

As a result, the patient required hospitalisation and surgery. 

In response to the notification, the practitioner outlined the justification for the treatment provided, including a high velocity thrust to the patient’s spine, and reflected on their process for obtaining consent. 

The Physiotherapy Board of Australia determined that the practitioner’s choice of treatment was not appropriate in addressing the patient’s lower back pain. Additionally, the Board considered the practitioner’s consent process to be inadequate because informed consent should be discussed and obtained at every appointment. The Board required the practitioner to undertake education relating to clinical reasoning, treatment planning for lower back pain, communication and informed consent.

Health management 

When a practitioner has a health impairment that affects their ability to practise safely, we have a role to ensure public safety. 

In 2022 we established a specialist team to manage concerns related to a practitioner’s health. The establishment of this team resulted in improved processes for managing these notifications, specifically a reduction in timeframes to complete concerns related to a practitioner’s health. This year, 39.2% of notifications managed by the health management team were completed within three months. This is in line with the previous two years, but considerably higher than before the specialist health team was established. We continue to implement changes to minimise distress for practitioners involved in our regulatory processes.

Professional standards 

Ahpra and the National Boards investigate behaviour by a practitioner that is substantially below the standard expected by the public or their peers, or inconsistent with the requirement to be a fit and proper person to hold registration. If a Board forms the view there was professional misconduct, the concerns may be referred to a responsible tribunal. This year, 192 practitioners were referred to a tribunal. This is an 18.3% decrease from last year. 

The Boards have limited discretion to decide not to refer professional misconduct matters to a tribunal. This year, a Board decided not to refer four notifications relating to one practitioner as there was no public interest in their notifications being heard by a tribunal. The practitioner no longer held registration and did not intend to return to practice due to their age.

Case studies 

A health concern 

A notifier who is also a practitioner raised concerns with Ahpra about the ability of their colleague to perform surgery due to a physical health impairment affecting the movement in their hands and legs. 

The Notifications health management team contacted the practitioner to discuss the notification and obtain further information about their scope of practice. The practitioner advised that over time, and in line with their current abilities, they had made adjustments to their practice and made referrals to colleagues as required. 

The practitioner provided evidence of their ongoing treatment and treating team, as well as reports from their employer confirming their work performance. 

The Medical Board of Australia considered the matter within 30 days of receipt by Ahpra and decided the steps taken by the practitioner to self-manage their health were suitable and that no regulatory action was required. 

Serious conduct concerns 

A notification was received from a government department raising concerns about a pharmacist unlawfully dispensing medication and falsifying dispensing records. The notification indicated the pharmacist had dispensed prescription-only medications to their family members and themself, and falsely recorded other practitioner names as the prescribing practitioner. 
Information obtained during the investigation indicated that the unlawful dispensing had occurred on a large number of occasions to family members and to the practitioner themself, and the practitioner had provided false and misleading information to the Pharmacy Board of Australia. The practitioner admitted to the unlawful dispensing and falsification of clinical records. 

The Board determined that the practitioner’s poor judgement, fraudulent behaviour and unethical decision making had placed their family members and their own health at risk and formed the reasonable belief that the practitioner’s conduct amounted to professional misconduct. The Board referred the practitioner to the responsible tribunal.

Boundary violations 

Table 16 shows that we received 1,991 notifications about boundary violations, which include complaints about sexual misconduct. This category of complaints continues to increase across all professions, alongside growing social awareness of, and lack of tolerance for, sexual misconduct. 

We continued to implement reforms as part of an action plan we published in 2023 to better protect patients from boundary violations. We held a second public consultation to inform the review of the National Boards’ Criminal history registration standard. We also published our evaluation of the Notifier Support Service to better understand experiences with the service and improve support provided to victim-survivors who make complaints about sexual misconduct by health practitioners. 

We are also supporting National Law amendments to permanently publish information on the Register of practitioners when a tribunal finds a practitioner engaged in professional misconduct involving sexual misconduct. 

Mandatory notifications 

In certain circumstances, practitioners and employers must tell us if they think a practitioner’s conduct, performance or health places their patients at risk. Education providers may also be required to advise about the health or conduct of students. 

• Mandatory notifications made up 11.6% of notifications received. Table 17 shows that we received 1,542 mandatory notifications, 32% more than last year. 
• 40% (617) were about nurses. 
• 32.6% (503) were about medical practitioners. 

Most mandatory notifications related to a departure from professional standards (61%), followed by a practitioner suffering from a possible impairment (23.9%), sexual misconduct (9.7%) and practising while intoxicated (5.4%).

Immediate action 

When information available to us indicates that there is a serious risk to public safety, or it is otherwise in the public interest, we can take immediate action while we make further enquiries. 

Table 18 shows that Ahpra took immediate action in 554 cases relating to 315 practitioners. This is up 34.1% from last year, largely due to the increase in notifications received. Of the notifications where immediate action was taken, 10.1% were related to concerns about a professional boundary violation. 

Being the subject of an immediate action by a Board can be extremely daunting. We only use our immediate action powers when: 

• there is a serious risk to the public 
• we believe a practitioner’s registration has been improperly obtained because they have provided misleading information when applying for registration 
• the practitioner holds registration outside Australia and that registration has been suspended or cancelled by another regulator 
• there is a clear and compelling reason to restrict or suspend the practitioner’s registration based on public interest (including, for example, that a practitioner has been charged with, or convicted of, serious criminal behaviour). 

We have improved our process for reviewing practitioners who are subject to immediate action. All practitioners with immediate action will have their restrictions reviewed at least once every 90 days and, where required, a recommendation can be made to a National Board to amend the immediate action restrictions. Since January, 65 practitioners had their immediate action restrictions amended or removed following a review by a Board.

Students 

We look into concerns raised about students who are studying to become registered health practitioners. 

There are limited grounds for making notifications about students: a notification can be made about their criminal history, an impairment, or if they have not complied with a restriction on their registration. 

There is only one ground for a mandatory notification – an education provider needs to tell us when they have formed a reasonable belief that a student has an impairment that may place a patient at substantial risk of harm when the student is doing clinical training. Students are also required to advise us if they are charged or convicted of an offence punishable by 12 months in prison. 

There were 18 notifications made to Ahpra about students; this is down from 20 last year. This year, there were no notifications that resulted in restrictions affecting a student’s registration, compared to one last year.

Timeframes 

We continue to close more notifications sooner: this year, 81.1% of all notifications were closed within six months of receipt. Overall, we completed 8.3% more notifications than the previous year, and the average time to complete a notification is the lowest recorded since the start of the scheme. 

The number of notifications open for 12 months or more increased (Table 19), partly due to the overall increase in the number of notifications received. These matters account for 20.0% of all open notifications. This is a slight increase from the previous year, when notifications aged 12 months or more accounted for 16.9% of all open notifications. 

Many of these aged notifications involve complex and long-running investigations and often have related external legal or investigative processes such as police investigations or coronial inquiries. Once a matter has been referred to a panel or tribunal (Table 20), we rely in part on the timeliness of external parties, such as the tribunal itself or the practitioner’s representatives. 

We are taking steps to improve our management of complex investigations and our timeframes for completion. We have established a Case Strategy Review Committee to provide advice on the management of our complex investigations and confirm the strategy for completion in collaboration with our National Legal Practice. Since the committee began in 2024, it has reviewed 236 notifications and 25.8% (61) of these notifications have been finalised. We are also piloting a team-based case management approach for our most complex investigations.

Outcomes 

There are several possible outcomes for notifications (see Tables 21, 22 and 23).

Restrictions on the practice of a health practitioner can only be imposed if they are necessary to ensure that health services are safe and of an appropriate quality. Actions taken by practitioners, workplaces, and other regulators or entities can contribute to an outcome of ‘no further regulatory action’. 

Of the notifications closed this year, just 1.4% resulted in the practitioner losing their registration or being disqualified from applying for registration.

The Office of the Health Ombudsman (OHO) receives notifications about registered and unregistered practitioners in Queensland. Ahpra and OHO work together to manage Queensland notifications. Together we responded to 3,975 notifications, and 33.3% were referred to Ahpra and the National Boards to manage (Table 24).

OHO closed 1,936 notifications about registered health practitioners following joint consideration, after agreeing with Ahpra that they did not require regulatory action. A further 714 notifications were retained by OHO for further action (for example, investigation or other complaints-resolution processes). The average time to complete the joint consideration process was 7.2 days from the date Ahpra received the concerns to the decision. This is consistent with the timeframes for last year.