Table of implementation of recommendations

1

DETIR should apologise to [NS's parents] for the poor standard of its investigation.

Apology letter sent

2

DETIR should enter into meaningful negotiations with [NS's parents] to financially compensate them (a 50% contribution) for their legal expenses in having to arrange representation at the inquest.

Negotiations undertaken –compensation paid

3

A comprehensive management and strategic review of WH& S should be undertaken as soon as possible by a suitably qualified independent reviewer selected in consultation with myself. The review should address:

WHS and ESO Review undertaken by J. Crittall –recommendations implemented

3.1

the structure of WH& S, including the delegation and allocation of responsibility and the appropriateness of the current classifications of positions;

As above

3.2

the adequacy of staff and other resources within WH& S to enforce the WH& S Act and Regulations, including whether, specifically, matters developed and earmarked for prosecution have been or are being dropped because of resourcing difficulties;

As above

3.3

current investigation methodologies and processes, including the giving of warnings in relation to workplace audits;

As above

3.4

formal and informal staff training and guidance;

As above

3.5

management systems and processes used by WH& S, including internal and external performance indicators to monitor efficiency and effectiveness and internal communication and sharing of information on operations and performance, especially as between the audit and investigative teams;

As above

3.6

the competency of existing staff employed in compliance / enforcement roles within WH& S, so as to determine whether all such officers possess the appropriate skills, knowledge and training to undertake investigations, with any identified deficiencies being addressed by specific training and professional development;

As above

3.7

the lack of awareness of the quality system and the appropriate intervals at which compliance with it should be audited; and

As above

3.8

any other matters which impact on the economy, efficiency and effectiveness of investigations, prosecutions and audits.

As above

4

In the interim, a memorandum of understanding should be developed (if not already in place) between the ESO, WH& S and the Queensland Police Service concerning the conduct of investigations into electrical fatalities in the workplace that address the investigative duplication and overlap identified in this Report.

MOU developed, agreed and operationalised

5

The concept of a single agency responsible for the investigation of electrical accidents in Queensland should be considered. This concept will need to be assessed within the context of the ongoing legislative review presently underway.

ESO was transferred to the Department of Industrial Relations as a result of a Machinery of Government changes in March 2001

6

The giving of advance warnings of workplace audits should cease immediately in relation to all but essential cases.

The department has both an education and compliance role – where industry sectors have been subject to an education and compliance program future audits are actioned in accordance with the Ombudsman’s recommendation

7

Specialised training should be provided for investigative staff within WH& S as to how best to deal with the grieving family, friends and associates of persons who have died or been seriously injured in the workplace.

Policy / procedure - Contact with Relatives and Friends during Investigations developed and included in inspector training

1

DME should apologise to [NS's parents] in relation to the ESO's failure to adequately investigate this matter.

Apology letter sent

2

DME should enter into meaningful negotiations with [NS's parents] to financially compensate them (a 50% contribution) for their legal expenses in having to arrange representation at the inquest.

Negotiations undertaken – compensation paid

3

A comprehensive management and strategic review of the ESO should be undertaken contemporaneously by the same reviewer referred to in [WH& S]

Recommendation 3. The review should address:

WHS and ESO Review undertaken by J. Crittall – recommendations implemented

3.1

the structure of the ESO, including the delegation and allocation of responsibility and the appropriateness of current classification of positions;

As above

3.2

whether adequate staff and resources exist within the ESO to enforce the Electricity Act and Regulations;

As above

3.3

current investigation methodologies and processes;

As above

3.4

formal and informal staff training and guidance;

As above

3.5

management systems and processes used by the ESO, including internal and external performance indicators to monitor the efficiency and effectiveness of the ESO and internal communication and sharing of information on operations and performance;

As above

3.6

the competency of existing staff employed in compliance / enforcement roles within the ESO be assessed to determine whether all officers possess the appropriate skills, knowledge and abilities to perform electrical investigations and any identified deficiencies should be addressed by training and professional development; and

As above

3.7

any other matters that impact on the economy, efficiency and effectiveness of investigations, prosecutions and audits.

As above

4

In the interim, a protocol or memorandum of understanding should be developed (if not already in place) between the ESO, WH& S and the Queensland Police Service in relation to the conduct of the investigation of electrical fatalities in the workplace and elsewhere that address the investigative duplication and overlap identified in this report.

MOU developed, agreed and operationalised

5

The penalty provisions within the Electricity Act 1994 and Regulation should be reviewed to determine their appropriateness.

Stand alone electrical safety legislation developed – Electrical Safety Act incorporating revised and enhanced penalty provisions

6

Specialised training should be provided for investigation staff within the ESO on how to deal with the grieving family, friends and associates of electrocution victims.

Policy / procedure - Contact with Relatives and Friends during Investigations developed and included in inspector training

7

The concept of a single agency responsible for the investigation of electrical accidents in Queensland should be considered. This concept will need to be assessed within the context of the ongoing legislative review presently underway.

ESO was transferred to the Department of Industrial Relations as a result of a Machinery of Government changes in March 2001

Recommendations - Division of Workplace Health & Safety

1

DETIR should apologise to [AK's parents] for the poor standard of its investigation.

Apology letter sent

2

DETIR should enter into meaningful negotiations with [AK's parents] to financially compensate them (a 75% contribution) for their legal expenses in having to arrange representation at the inquest.

Negotiations undertaken – compensation paid

3

A comprehensive management and strategic review of WH& S should be undertaken as soon as possible by a suitably qualified independent reviewer. The review should address:

WHS and ESO Review undertaken by J. Crittall – recommendations implemented

3.1

the structure of WH& S, including the delegation and allocation of responsibility and the appropriateness of the current classifications of positions;

As above

3.2

the adequacy of staff and other resources within WH& S to enforce the WH& S Act and Regulations, including whether, specifically, matters developed and earmarked for prosecution have been or are being dropped because of resourcing difficulties;

As above

3.3

current investigation methodologies and processes;

As above

3.4

formal and informal staff training and guidance;

As above

3.5

management systems and processes used by WH& S, including internal and external performance indicators to monitor efficiency and effectiveness and internal communication and sharing of information on operations and performance, especially as between the audit and investigative teams;

As above

3.6

the competency of existing staff employed in compliance / enforcement roles within WH& S, so as to determine whether all such officers possess the appropriate skills, knowledge and training to undertake investigations, with any identified deficiencies being addressed by specific training and professional development;

As above

3.7

the lack of awareness of the quality system and the appropriate intervals at which compliance with it should be audited; and

As above

3.8

any other matters which impact on the economy, efficiency and effectiveness of investigations, prosecutions and audits.

As above

4

In the interim, a memorandum of understanding should be developed (if not already in place) between the ESO, WH& S and the Queensland Police Service concerning the conduct of investigations into electrical fatalities in the workplace that address the investigative duplication and overlap identified in this Report.

MOU developed, agreed and operationalised

5

The concept of a single agency responsible for the investigation of electrical accidents in Queensland should be considered.

ESO was transferred to the Department of Industrial Relations as a result of a Machinery of Government changes in March 2001

6

Specialised training should be provided for investigative staff within WH& S as to how best to deal with the grieving family, friends and associates of persons who have died or have been seriously injured in the workplace.

Policy / procedure - Contact with Relatives and Friends during Investigations developed and included in inspector training

7

Procedures should be developed to ensure verbal information gathered during the course of investigations is adequately recorded in writing.

Procedures developed and incorporated into inspector training

1

DME should apologise to [AK's parents] in relation to the ESO's failure to adequately investigate this matter.

Apology letter sent

2

DME should enter into meaningful negotiations with [AK's parents] to financially compensate them (a 25% contribution) for their legal expenses in having to arrange representation at the inquest.

Negotiations undertaken – compensation paid

3

A comprehensive management and strategic review of the ESO should be undertaken contemporaneously by the same reviewer referred to in [WH& S]

Recommendation 3. The review should address:

WHS and ESO Review undertaken by J. Crittall – recommendations implemented

3.1

the structure of the ESO, including the delegation and allocation of responsibility and the appropriateness of current classification of positions;

As above

3.2

whether adequate staff and resources exist within the ESO to enforce the Electricity Act and Regulations;

As above

3.3

current investigation methodologies and processes, including the present reliance placed upon " authorised persons" ;

As above

3.4

formal and informal staff training and guidance;

As above

3.5

management systems and processes used by the ESO, including internal and external performance indicators to monitor the efficiency and effectiveness of the ESO and internal communication and sharing of information on operations and performance;

As above

3.6

the competency of existing staff employed in compliance / enforcement roles within the ESO be assessed to determine whether all officers possess the appropriate skills, knowledge and abilities to perform electrical investigations and any identified deficiencies should be addressed by training and professional development; and

As above

3.7

any other matters that impact on the economy, efficiency and effectiveness of investigations, prosecutions and audits.

As above

4

In the interim, a protocol or memorandum of understanding should be developed (if not already in place) between the ESO, WH& S and the Queensland Police Service in relation to the conduct of the investigation of electrical fatalities in the workplace and elsewhere that address the investigative duplication and overlap identified in this report.

MOU developed, agreed and operationalised

5

The penalty provisions within the Electricity Act 1994 and Reg should be reviewed to determine their appropriateness.

Stand alone electrical safety legislation developed – Electrical Safety Act incorporating revised and enhanced penalty provisions

6

Specialised training should be provided for investigation staff within the ESO on how to deal with the grieving family, friends and associates of electrocution victims.

Policy / procedure - Contact with Relatives and Friends during Investigations developed and included in inspector training

7

The concept of a single agency responsible for the investigation of electrical accidents in Queensland should be considered.

ESO was transferred to the Department of Industrial Relations as a result of a Machinery of Government changes in March 2001

8

The role of " authorised persons" should be referred to the Joint Ministerial Taskforce and the reviewer referred to in [WH& S] Recommendation 3 for further analysis.

Issued referred to WHS and ESO Review undertaken by J. Crittall – recommendations implemented

9

The Director-General of DME should issue an immediate directive to the [position title deleted] indicating that it is inappropriate for the ESO to rely solely on internal investigations undertaken by an electricity entity when an electrical accident involving that same electricity entity occurs.

Instructions issued

10

The Director-General of DME should issue an immediate directive to the [position title deleted] indicating that the ESO must conduct independent investigations into all electrical fatalities, including examining and reporting on all electrical articles and equipment involved in any such incident.

Instructions issued

1.1

the ESO obtain a written legal opinion from either senior counsel or an academic with an acknowledged expertise in statutory interpretation, in respect of the meaning of " electrical work" to ensure that the term, as defined in the proposed new electrical safety legislation, covers the situations and addresses the problems highlighted in this Report; and

Opinion of Senior Counsel obtained - definition of electrical work incorporated in Electrical Safety Act 2002

1.2

this Office be consulted in relation to the briefing of such person and be provided with a copy of the opinion. The cost of obtaining such opinion is to be borne by the ESO.

Ombudsman consulted

2

WH& S unconditionally apologise to [TM's parents] for the inadequacy of the initial stage of the investigation.

Apology letter sent

3

WH& S unconditionally apologise to [TM's parents] for the premature and inappropriate release to the media of unsustainable conclusions concerning their son's death.

Apology letter sent

4

WHS's current media policy and procedures be replaced with a media policy that addresses each of the issues raised in this Report, with this Office to be consulted on the contents of the new policy before it is published.

Media policy revised to incorporate issues raised

5

WH& S immediately enter into meaningful discussions with [TM's parents] with a view to making an ex-gratis payment to assist them to meet their ongoing out of pocket medical and counselling expenses. A lump sum should be negotiated. This Office is prepared to provide guidance as to the terms and conditions of such settlement should [TM's parents] and DIR be unable to reach an agreement.

Discussions entered into

6

In future, all priority 1 files and at least 50% of priority 2 files marked for " no further action" should be reviewed by a senior manager (either a Regional Investigations Manager or a Regional Manager, depending on the priority of the matter) before any decision is made to cease investigative activity in relation to the subject matter of the file.

Procedure incorporated into Investigations and Prosecutions protocol.

7

A senior officer or officers from WH& S State Office, chosen in consultation with this Office:

• immediately undertake a comprehensive audit of investigation reports relating to all Priority 1 and Priority 2 files in the Cairns office of WH& S that have been marked for " no further action" and that relate to events that occurred between 1 July 2000 and the date of this Report;
• report on the validity of such " NFA" recommendations; and
• provide a copy of the report to me within 28 days of the finalisation of that audit

Comprehensive audit undertaken

8

DIR consider taking appropriate disciplinary action, pursuant to the provisions of Part 6 of the Public Service Act 1996, against:

Disciplinary action initiated

8.1

the [position title deleted], in respect of [the] handling of the initial stage of the [TM] investigation; and

As above

8.2

the [position title deleted], in respect of [the] management of the initial stage of the [TM] investigation.

As above

9

DIR address the problems identified in this Report in relation to the regional model.

Incorporated into WHS and ESO Review undertaken by J. Crittall – recommendations implemented

10

There should be a separate Electrical Safety Act to regulate safety matters pertaining to the electrical industry.

Electrical Safety Act 2002 developed

11

An independent safety regulator be established.

Established under the Electrical Safety Act 2002

12

A single agency be responsible for the investigation of electrical accidents in Queensland.

Achieved with the transfer of ESO to the Department of Industrial Relations ( Machinery of Government changes in March 2001)

13

There should be consistency in the amount of the penalties that may be imposed under the WH& S Act and the Electricity Act for like offences.

Consistency achieved with the introduction of the Electrical Safety Act 2002

1

WH& S legal/prosecution unit prepare and maintain a central register of all internal persons with a level of technical knowledge that qualifies them to give expert evidence in a particular field. The register should also record similar details of any experts external to WH& S that have been used in any proceedings.

WH& S legal/prosecution unit developed a central register of experts

2

All persons employed by DIR who may be called upon to provide expert advice or opinion be trained in the drafting of statements for court purposes and the presentation of evidence in court.

Training undertaken

3

WH& S develop a policy/procedure in relation to the use of experts. The policy should require officers to formulate a list of specific questions to be put to experts where their advice is sought. It should also require the experts to describe their specific qualifications and/or experience in the field to which the questions relate.

WHS Legal and Prosecution Services have a procedure in place and approve the use of all experts

4

DIR should address the administrative deficiencies identified in Part 6.5 of this report [that is, the investigation report on Case 4] including by providing inspectors with further training in good investigative practice. It may be that they can be addressed by the Ministerial Review implementation.

Two week investigation course developed and delivered to all inspectors. In addition, each region has a number of specialist investigators

5

In consultation with the Ombudsman’s Office, DIR establish an effective internal review process to deal with complaints that cannot be dealt with under Part 11 of the Workplace Health & Safety Act 1995, including complaints about the quality of WH& S investigations.

DIR developed and implemented a complaints management policy and procedures

6

Where a complaint relates to a decision by DIR not to commence a prosecution following a WH& S investigation, the internal review process require that advice be given to the complainant, in reasonable detail, of the critical factors taken into account by DIR in reaching the decision not to prosecute, subject to the complainant having a sufficient direct interest in the matter.

Incorporated into Policy / procedure - Contact with Relatives and Friends during Investigations

7

DIR formally apologise to the [AM's parents] for the decision of the ESO not to conduct an investigation into whether [AM]'s death involved any breaches of the Electricity Act and Electricity Reg by SEQEB.

Apology letter sent

8

Training be provided to DIR investigative staff on the scope and purpose of the Coroners Act 1958 and the compilation and presentation of evidence in Coronial Inquests.

Incorporated into the advanced investigation course

9

DIR should enter into meaningful negotiations with [AM's parents] with a view to compensating them for the out of pocket legal expenses incurred by them in obtaining legal representation at the Coronial Inquest.

Negotiations entered

1

That WH& S and the QPS develop a Memorandum of Understanding (MOU) about their respective investigative responsibilities in relation to incidents involving potential breaches of WH& S legislation and potential offences under the criminal law.

MOU reviewed, amended and operationalised

The MOU should recognise the statutory limitation for the commencement of prosecutions under the WH& S legislation and provide, in appropriate circumstances, for offences under that legislation to be commenced and, at the request of QPS, adjourned until the QPS investigation has been finalised.

As above

2

That the MOU be communicated to all relevant persons within DIR and QPS.

MOU communicated to all relevant staff

3

In [Case 4 of the WEP] I recommended that DIR establish a formal and credible internal review process that seriously considers complaints by members of the public about the quality of its investigations. I would add to that recommendation the specific points that all persons performing such review functions should be:

of at least the same seniority as the original inspector/decision maker; and

have had no substantial involvement in the investigation subject to review.

DIR developed and implemented a complaints management policy and procedures consistent with the Ombudsman’s guidelines

4

That the Director of DIR Investigations and Prosecutions Unit conduct the further internal inquiries into the WH& S investigation into the death of [DD] that I have detailed above, with a view to providing relevant evidence to the Coroner. A report on the results of those further inquiries should be provided to my Office as soon as they have been completed.

Review undertaken, report prepared and forwarded to the Coroner

5

If [former caravan park owner] again seeks to be licensed as an electrical fitter, DIR conduct inquiries into whether he is a suitable person to hold a licence under the Electricity Act.

Licensing systems and files duly noted

6

DIR assess the competence of staff within the ESO to conduct and/or manage future show cause investigations into licence holders under the electrical legislation and provide training as appropriate.

Assessment of staff completed in February 2003

7

That the Director of DIR Investigations and Prosecutions Unit conduct the further internal inquiries into the ESO investigation into the death of [DD] that I have detailed above with a view to providing relevant evidence to the Coroner. A report on the results of those further inquiries should be provided to my Office as soon as they have been completed.

Review undertaken, report prepared and forwarded to the Coroner

8

DIR should write to [DD's father] and apologise for wrongly attributing these comments to him.

Apology letter sent

9

DIR should formally apologise to [DD's father] for the failure of both WH& S and the ESO to competently perform their statutory duties in relation to the investigation of the incident on 13 January 1997 that claimed the life of his son.

Apology letter sent

1

The Commissioner for Electrical Safety consider the safety issues raised in Part 6 of this report with a view to recommending to the Minister that measures be prescribed to address those issues in relevant Codes of Practice under the Electrical Safety Act 2002.

Long-term projects – a number of aspects completed with on-going activity in terms of awareness campaign and crane electrical safety; Interim reports submitted to the Ombudsman

1

DIR should undertake relevant independent research into the various types of splice joins used by electricity supply entities with a view to determining whether any of those joins are unsuitable to bear the static and dynamic loadings likely to be encountered in the geographic region in which any such entity operates.

A suitably qualified and independent consultant was engaged to undertake this research – recommendations actioned

2

DIR write to PC's parents] and apologise for the deficiencies in the WH& S and the ESO investigative processes and explain the reforms that have been implemented to address these inadequacies.

Apology letter sent

3

DIR write to the coordinator of GRAVES, and acknowledge that the former Minister was provided with misleading advice in a briefing prepared by the [position title deleted] in relation to [the coordinator of GRAVES] complaint about the level and quality of the WH& S investigation into the incident. DIR should also apologise to [the coordinator of GRAVES] for the provision of the misleading advice. A copy of this correspondence should be sent to PC's parents] and the present Minister responsible for DIR, the Honourable Gordon Nuttall MP. DIR should also advise the former Minister, Mr Paul Braddy, of the circumstances relating to the provision of the misleading advice.

Letter and apology sent to coordinator of GRAVES (August 2003)

4

DIR should enter into meaningful negotiations with JC's parents] with a view to compensating them for the out of pocket legal expenses incurred by them in obtaining legal representation at the Coronial Inquest.

Negotiations completed – compensation paid

1

DIR should undertake relevant independent research into the vegetation management policies and practices of the electricity supply entities and determine whether these are appropriate.

A suitably qualified and independent consultant was engaged to undertake this research – recommendations actioned

2

DIR review action taken by the ESO in response to the Coroner's eight riders. If appropriate action has not been taken in respect of any issue, DIR should address any rider not actioned.

All coronial riders actioned by April 2003

3

DIR write to [JS's father-in-law] and apologise for the deficiencies in the WH& S and ESO investigative processes and explain the reforms that have been implemented to address these inadequacies.

Apology letter sent

4

DIR should enter into meaningful negotiations with the families of the deceased with a view to compensating them for the out of pocket legal expenses incurred by them in obtaining legal representation at the Coronial Inquest.

Negotiations undertaken – compensation paid to one family

5

DIR should consider whether electricity supply entities should be required as a matter of law to immediately de-energise supply upon receiving notification of a fallen power line so that a specific safety procedure is followed before the electricity supply can be re-energised to ensure the risk to health and safety has been completely removed.

Legal advice on this issue received – it is considered that the obligations of entities are clear and do not require amendment

6

DIR:

undertake independent research into the regulatory approaches of other State and (relevant) international jurisdictions to LV fault protection; and

consult widely with relevant academic and industry bodies on any existing, new or emerging technology that would enable the risks presented by fallen LV power lines to be removed or minimised.

Research undertaken – draft “National Low Voltage Electricity Network Electrical Protection Guideline" developed and being further reviewed.

1

DIR investigate why the Crown Law legal opinions were not disclosed to my Office, the Coroner and the complainant and advise me of the results of its investigation.

Investigation undertaken and Ombudsman advised of results

2

DIR immediately provide copies of the three Crown Law opinions to:

• the complainant; and
• the Coroner, by providing them to the QPS officer assisting the Coroner.

Copies of opinions provided

3

DIR review the investigations of the incident conducted by WH& S and the ESO and form an opinion as to whether the findings made were correct.

Investigation undertaken by a suitably qualified and experienced investigator and Ombudsman advised of results

4

In conducting the review, DIR have regard to the opinions I have expressed and the issues for investigation I have identified in this Report.

As above

5

DIR advise me of the outcome of its review and provide reasons.

As above

6

DIR concludes from the review that the original findings were not soundly based, DIR advise the complainant and the Coroner (by providing a copy to the CPS officer assisting the Coroner) and provide reasons.

Copies of investigation report provided to the Coroner and complainant

7

DIR establish procedures to ensure officers involved in investigations do not have potential or actual conflicts of interest in matters being investigated.

Investigations Manual for WHS and ESO reviewed and amended to include procedure

8

DIR request the Commissioner for Electrical Safety to review:

Commisioner of Electrical Safety requested to review – his is a significant project with substantial progress to ate – Ombudsman has been provided with interim reports on progress

8.1

whether the issues of concern expressed in the Electrical Safety Alert relating to the design and operation of EWPs and their suitability for undertaking work in proximity to overhead electric lines are still valid and, if so, what action should be taken to ensure the health and safety of electrical workers using EWPs for overhead line work;

As above

8.2

the adequacy of current training programs for electrical workers in the operation of EWPs;

As above

8.3

any inconsistencies, ambiguities and duplication in the various Guidelines and Manuals discussed in this Report; and

As above

8.4

whether the Electrical Safety Act, the Electrical Safety Reg or any of the Codes of Practice issued under the Electrical Safety Act require amendment in light of the opinions I have expressed and the issues for investigation I have identified in this report.

As above

9

DIR assess and if necessary investigate, the matters raised by the complainant in his letter of 21 November 1999 relating specifically to the incident and provide a written response to the complainant.

Investigation undertaken and advice provided to complainant in February 2005

10

DIR investigate how incorrect information about the use of insulating mats contained in a memorandum dated 6 August 1999 was provided to both the Director-General of DETIR and the Minister for DETIR and advise me of the outcome of the investigation.

Investigation undertaken by a suitably qualified and experienced investigator and Ombudsman advised of results

11

DIR seek legal advice from the Solicitor-General: about the issues I have raised in Part 7.5.6 of this report; and liaise with my Office in relation to the preparation of the brief.

Legal advice sought and provided to Ombudsman