Failures of record keeping Victorian Ombudsman Reports

Public Record Office Victoria - Records Management Network Meeting Tuesday 29 May 2012 Presentation by John R Taylor, Deputy Ombudsman for Victoria. _________________________________________________________________ It is disappointing to find in a modern public service that very often Ombudsman investigations identify significant failures in record keeping. These failures include: Poor record keeping Inadequate storage The destruction of records Falsification of records Lack of records in key decision making.

What are records? Very often our investigations identify that only paper records are maintained. That is, copies and originals of correspondence to and from an agency. However, when we delve further into an investigation we identify key decision making is often recorded in email, faxes and notes not maintained on the departmental file. For example, in the Ombudsmans investigation into the probity of the Hotel Windsor redevelopment tabled in Parliament in February 20111, we identified that the department of Planning and Community Development together with Heritage Victoria failed to make and keep adequate records regarding the Hotel Windsor planning and heritage permit application. These failures were particularly important as there had been significant media attention surrounding the then Ministers media plan regarding the development which was inadvertently sent to an ABC journalist in February 2010. Subsequently, the Chairman of the Legislative Council Standing Committee on Finance and Public Administration requested that the Ombudsman investigate the probity of the Hotel Windsor redevelopment. You would think that when you are looking at a multi million dollar redevelopment that good record keeping would be an essential part of the decision making process by any government agency. However, our investigation found poor management practices, including the failure of officers to file documents accurately and to folio files.
Ombudsman Investigation into the Probity of the Hotel Windsor Redevelopment, February 2011
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You will see in our report that we identify numerous occasions where significant meetings took place for which there was inadequate or no records made. When it came to testing what had taken place it was very hard to establish the sequence of events. The Ombudsman noted that he was concerned that several witnesses also said that the failure of the department and Heritage Victoria to maintain adequate records was not restricted to the Hotel Windsor planning and heritage permit applications. Emails are also a great source of information when determining what took place in relation to decision making. Very often we find information that puts the lie to documented decision making or provides amplification as to what took place. Very often copies of these emails are not filed on the departmental file. Poor record keeping Perhaps the most significant failure which we consistently identify is poor record keeping. A good example, of this is the investigation into record keeping failures by WorkSafe agents tabled in Parliament in May 2011.2 That investigation identified poor record keeping at WorkSafe agents, of which there were six at the time. These are agents paid for a range of benefits provided to injured workers including weekly payments, medical treatment, ambulance transport, and personal and household help. In 2009-10, WorkSafe paid its agents fees of over $200 million to manage over 56,000 claims by injured workers in Victoria. The investigation identified poor record keeping at the agents, which had the following consequences: Manipulation of the WorkSafe incentive scheme for agents Delays in payment Poor and delayed decision making and the reduced effectiveness of the scheme Breaches of privacy.

Poor recording keeping at the agents was as a result of inadequate file maintenance; inadequate understanding of statutory obligations; and out dated information technology systems.

Investigation into Record Keeping Failures by WorkSafe agents, May 2011

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Photographs 1, 2 and 3 are examples of the poor file maintenance and storage systems at a number of the WorkSafe agents. You can see that, by their very nature, the files and their condition contributed to incorrect information being sent to individuals, medical records being lost or misplaced, and delayed decision making. Contraband is often seized within prisons and detention centres. It is then the responsibility of Victoria Police to take appropriate action.

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Photograph 4 is a seizure or exhibit located during an inspection at the Juvenile Justice Detention Centre. It contained contraband which was found on detainees during a search. There were no names, dates or identifying details in relation to the seizure. Inadequate storage Our investigation into the storage and management of ward records by the Department of Human Services tabled in Parliament in March 2012, exemplifies the problems that can occur when agencies fail to adequately record and store departmental records.

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Photographs 5, 6 and 7 illustrate boxes of records held by the department that are stored in approximately 80 linear kilometres of files on shelves. These historical records relate to former wards of the State of Victoria and are stored in boxes at numerous locations. The department has not inspected or indexed a considerable portion of these records. Accordingly, it cannot provide an accurate estimate of what portion of the total holding relates to wards of the State. Despite having had the majority of these records in its archives for over 15 years the department has only indexed and catalogue records relating to 26 of the 150 plus years worth of records relating to wards and institutions it holds. The majority of these records remain in large part uninspected, unindexed and unscanned. The department is paying near $1 million a year to rent a facility that has been identified as being inadequate to store records and has been subject to flooding and rat infestation. The departments efforts to come to grips with its vast archive of documents have been piecemeal and ultimately unsuccessful. Increasing numbers of former wards are seeking access to records relating to their time spent in care as a way to not only understand their past but also to seek and identify siblings and relatives. An internal departmental report noted that in the three years prior to May 2011 approximately 21 per cent of all searches for records relating to freedom of information requests for former ward and adoption records resulted in no documents being located. Prisoner health records Under the Health Records Act 2001 medical information must be stored confidentially to protect the privacy of individuals.
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All prisoner medical records at the Melbourne Assessment Prison are held on site. Although these records are monitored by medical staff, one of their physical locations is in a thoroughfare and is accessible to all staff. Photograph 8

Photograph 8 shows medical records stored on open shelves at the Melbourne Assessment Prison. This situation was identified in our investigation into prisoner access to health care in a report tabled in parliament in August 2011. As a result of bringing this issue to the attention of Justice Health the then Director advised that Justice Health was in the process of designing the refurbishment of office space and storage and that lockable cupboards were now in place for the storage of medical records in the centre. Destruction of records It is not uncommon to find departmental records missing during an investigation. This is particularly the case where misconduct is involved as was identified in our investigation into procurement3, where in a number of instances officers obtained a benefit from a supplier of toner cartridges and the invoices had been destroyed. In one case involving a project officer from Arts Victoria the invoices which listed gifts that the officer had received were missing. When questioned about this, the project officer said I generally did not keep copies of the invoices. In this particular case we were able to establish from invoices obtained from the company that in 2009-10, the project officer received $8,300 in Coles-Myer vouchers and prepaid visa cards from the company.

Corrupt Conduct by Pubic Officers in Procurement, June 2011

In another case in 2009 involving a building inspector at a council, the councils hard copy building file for a property involved in an unorthodox transaction, could not be located. When questioned the building inspector acknowledged that a hard copy file for the 2008 building inspections had existed but denied destroying it, despite having told his manager that he had done so.4 Falsification of records Departmental records, by their very nature, are required to represent the history of a case, transaction or business event. However, at times we have identified instances where records have been falsified to cover up improper conduct. In an investigation involving the allegation of mistreatment of a male resident of a supported residential service managed by the Department of Human Services5, we identified that two documents allegedly created in response to the incident were fabricated by a senior staff member to give the false impression that the department had investigated the matter. This of course amounts to serious misconduct and as a result discipline action was taken against the officer. Improper use of records There are times when departmental offices will improperly use information for their own purposes. In one case, an employee of the Victorian Institute of Forensic Medicine6 took home autopsy information concerning deceased persons for their own prurient interest. When we obtained access to his computer and records at his home we located 49 hard copy autopsy reports and over 1,200 work related photographs on a CD and hard drive of his computer. In addition we identified that this person had been circulating photographs of inquest material to friends for their enjoyment. The officer resigned during the investigation.

Whistleblowers Protection Act 2001, Conflict of Interest and Abuse of Power by the building inspector of the Brimbank City Council, June 2009 5 Ombudsman Investigation, Assault of a Disability Service Client by Department of Human Services Staff, March 2011 6 Investigation into the Improper Release of Autopsy Information by a Victorian Institute of Forensic Medicine employee, May 2011

Lack of records in key decision making Good public administration requires that key decision making be adequately documented. This is particularly important where significant government expenditure is involved. It is concerning when our enquiries identify that decision making in relation to major public expenditure is either not documented or poorly documented. Photograph 9

One example as illustrated in photograph 9 was that the only document located which established the expenditure of over $27 million in relation to funding for a major IT project within Victoria Police, was a one page document with hand written annotations. This document was illustrative of a poorly run area within a major organisation where numerous documents were located in unregistered and informal files. Interviewees also said that files they knew had been raised could not be located. Further enquiries identified that a number of decisions taken at a committee level were not documented in signed records.7 More recently in our investigation into the Food Bowl Modernisation Project the investigation identified that the decision to commit significant funding in relation to the Food Bowl Modernisation Project was based on oral discussions and earlier projects with virtually no documentation to support the decision making. The background report which had been commissioned by a private organisation and provided to the then Treasurer could not be located.

Own Motion Investigation into the Tendering and Contracting of Information Technology Services within Victoria Police, November 2009

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Subsequently the government committed to $600 million without adequate planning or documentation.8 Conclusion The Ombudsmans statutory function is to investigation complaints about administrative actions. Inevitably our stories are about wrong doing, errors and mistakes. However the case studies are illustrative of where things go wrong and how such problems could be avoided by careful planning and management. Even the wrong doing identified for example in the toner affair could have been prevented by appropriate supervision and management of expenditure and records. We frequently ask the question Who is responsible?. It is easy to blame the individual who failed to keep the record or destroyed a document. However there is also a responsibility in terms of leadership within an organisation. The challenge for the public sector is to ensure that not only do managers lead by example but also to encourage staff to act appropriately in all circumstances. The Ombudsman has regularly reported on his concerns about the failure of leadership in the public sector. Many of the problems identified in our investigations are because of a lack of leadership and management. Good leadership in the public sector is important because it: Assists in developing a culture where administrative excellence and ethical conduct is encouraged Protects against improper conduct and can assist in its early detection Ensures adequate scrutiny is applied to areas such as expenditure of public funds Sets and achieves realistic and beneficial goals Establishes an operating norm of efficiency and diligence.

Despite progress made by some agencies, we continue to identify agencies that fail to learn from their mistakes and fail to fully implement revised policies and procedures that our enquiries and investigations have identified.

Investigation into the Food Bowl Modernisation Project and Related Matters, November 2011

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