Bermuda Ombudsman - Annual Report 2024 (Final)
Bermuda Ombudsman - Annual Report 2024 (Final)
We’re proud to say we focus not only on policy and procedure, but also the
human aspect of our work. We are reminded that behind every case file
and procedure is a real person seeking understanding and fairness. The
Bermudiana reminds us that true service lies not merely in the decisions
we reach, but in how we honour each person’s story along the way.
When someone feels truly heard and understood, when their concerns
are met with authentic human care rather than bureaucratic distance, we
create the conditions where fairness can flourish.
I have the honour of presenting my Annual Report which covers the period 1st January to 31st
December 2024.
This Report is submitted in accordance with section 24(1) and (3) of the Ombudsman Act 2004
which provides:
24 (1) The Ombudsman shall, as soon as practicable and in any case within six
months after the end of each year, prepare a report on the performance of his
function under the Act during that year.
24 (3) The Ombudsman shall address and deliver his annual report and any special
report made under this section to the Speaker of the House of Assembly, and
send a copy of the report to the Governor and the President of the Senate.
Sincerely,
Michael A. DeSilva
Ombudsman for Bermuda
1
CONTENTS
Ombudsman’s Message 5
Farewells 7
Overview 9
Our Work 11
Casework in Context 14
Outstanding Cases 15
International Collaboration 22
Affiliations 24
Complaint Stages 37
Complaint Dispositions 38
A
s I reflect on 2024, my thoughts turn not to
statistics and case closures, but to the human
stories that shape our work at the Office of the
Ombudsman. Behind every complaint that crosses
our desks is a person – often frustrated, sometimes angry,
frequently feeling unheard – who has turned to us as their last
hope. It is this deeply personal dimension of our mandate that
continues to humble and motivate me, even after three years in
the role.
meetings to explain our processes, discuss systemic issues, and This aspect of the work has reinforced my appreciation for our
work collaboratively toward solutions. exceptional team. Day after day, they demonstrate patience with
the impatient, empathy with the frustrated, and professionalism
These meetings have yielded unexpected results. When with the occasionally unreasonable. They understand that
authority representatives understand our recommendations behind every complaint is a person who often feels powerless
and the reasoning behind them, they are more likely to embrace within ‘the system’ and they approach each case with the dignity
meaningful change. When we can discuss a complainant’s and attention it deserves. Their dedication to fairness, their
situation in human terms rather than merely procedural ones, commitment to thorough investigation, and their genuine care for
we often find common ground that seemed impossible on paper. the people we serve make me proud to work alongside them.
This investment of time – and it is a significant investment – has
proven worthwhile in terms of both case outcomes and fostering While I salute the strength of our current team, I would be remiss
professional relationships with staff at the authorities. not to acknowledge two valued colleagues who moved on to new
opportunities during 2024. Shaun Dill, our Manager of Finance
Speaking of time, this year has provided sobering lessons about and Administration, departed after five years of exceptional
the reality of thorough case work. Complex complaints simply service. Finance, I must admit, is decidedly not my forte –
cannot be rushed. Each case requires careful investigation, perhaps another case of the old dog struggling with new tricks.
thoughtful analysis, and often extensive consultation with Shaun’s capable and competent guidance was invaluable to our
multiple parties. Our casework takes time to do properly, and operations. His financial stewardship allowed me to focus on our
‘time’ continues to be a relentless force on our capabilities. In casework with confidence that our administrative foundation was
our Annual Report for 2023, I discussed the competing demands solid.
that face our office of only six: small cases; big cases; systemic
investigations; public outreach; authority engagement; and Gainelle Simons, our Executive Assistant for two years, brought a
administrative work. With an annual caseload of around 300, lively personality and creative flair to the office. Her enthusiasm
our team does its best to juggle their duties across a wide array added a vibrancy to our office culture that was refreshing and
of tasks. But, as I wrote last year, “Backlogs are inevitable under energising. Both Shaun and Gainelle contributed significantly to
these circumstances. Sooner or later, we will need to increase our the effectiveness of our Office, and I genuinely enjoyed working
investigative capacity if we are expected to continue to make a with them. While we miss their presence, we celebrate their
meaningful public impact”. advancement to bigger and better things, and we wish them
continued success in their new endeavours.
We submitted a business case to the Ministry of Finance in
September and requested funding to support two additional
posts – one for investigations and casework, and the other for
outreach and administrative support. Regrettably, the request
was not approved. We will, therefore, continue to do our best with
what we have. But with our commitment to quality over quantity,
it means that we have to be strategic about which matters
require our full investigative attention and which can be resolved
informally or by referral. It also means being transparent with Michael A. DeSilva
complainants about realistic timelines – conversations that are Ombudsman for Bermuda
sometimes uncomfortable to have.
FAREWELLS
Special Thanks to:
Gainelle Simons
Former Executive Assistant
Shaun Dill
Former Manager – Finance
/ Administration
VALUES
MOTTO
“For the Good of the Public, and Those Who Serve the Public.”
OVERVIEW
The contents of our Annual Report are laid out to reflect each of Download a copy of
the four aims in our Strategic Plan 2023 – 2026 as follows: our Strategic Plan here
Our Office serves the public, and those who serve the public. It is
important to us that our work makes a real difference to individ-
uals and government departments. We aim to restore fairness
where unfairness has occurred. We provide complainants with an
avenue to seek redress, and where appropriate, we help to bring
about positive changes to public services.
Our casework encompasses both complaints and enquiries. The distinction between a complaint and an enquiry
is based on the complainant’s intention when contacting our Office. A complaint is a case where the complainant
requests that we pursue inquiries into the complaint. In contrast, an enquiry is a case where the complainant asks for
guidance or assistance in determining the best next step.
CASEWORK IN 2024
To summarise new cases opened in 2024: or concerns and they ask to remain anonymous, we
do not record the person’s name. This number does
• We received 223 new cases. 191 were complaints, and not include complaints and enquiries made by such
32 were enquiries (see Figure A). persons.
• Of the 191 complaints, 122 were in our jurisdiction, and
From 1st January to 31st December 2024, we worked to
69 were not.
address a total of 285 cases (see Figure C). This number
• We referred 30 of the complaints within our jurisdiction included:
to other authorities where there was a more suitable
remedy. • cases carried into 2024 from previous years - 62
• We disposed of 67 complaints: • cases received in 2024 - 223
• 7 complaints were abandoned or withdrawn by
To summarise cases worked on in 2024 (see Figure B):
the complainant.
• 8 complaints were resolved between the com- • Of the 285 cases worked on in 2024, 51 were in prog-
plainant and the authority with informal and ress as of 31st December 2024. 234 cases were
limited intervention by us. disposed of: 202 of these cases were complaints, 129
of which were within our jurisdiction and 73 of which
• 52 were closed after our Office made inquiries
were not.
into the complaint.
• 51 complaints remained open at the year’s end. • Of the 129 complaints within our jurisdiction: 10 were
‘Informally Resolved’; 15 were ‘Deemed Premature’; 18
• 17 people raised multiple complaints and enquiries
were ‘Referred’; 1 was ‘Settled’; 11 were ‘Withdrawn’ or
with our Office within the 2024 reporting year, ac-
‘Abandoned; 71 were Closed After Inquiries’; one was
counting for 38 cases—roughly 17% of cases received
Closed After Investigation (No Maladministration); one
in 2024. When people contact our Office by phone, if
was Closed After Investigation (Maladministration);
the initial phone call fully addresses their questions
and one was Closed after an Outcome Review (not
substantiated).
223
cases received For a full description of our complaint process and
dispositions, see pages 37 and 38.
in 2024
Figure C shows the total for new cases in 2024 by Figure D summarises the new cases received in 2024
each authority, excluding bodies that are not in the by the relevant Ministry according to the Government’s
Ombudsman’s jurisdiction (Not-In-Jurisdiction). These October 2024 organisational chart which was in effect
numbers represent complaints and enquiries made, at year-end (the Government has since made changes
not the Ombudsman’s findings concerning those cases. to the organisation of Ministries, departments and other
Counts also do not indicate whether the complaints were bodies under its responsibility.) The graph also includes
substantiated. three additional categories: ‘Non-Ministry’, which are
government-funded bodies that are not part of a Ministry,
Authorities with a higher volume of public interaction have ‘Non-Government but Authority’, which are authorities that
a higher volume of service users and, consequently, tend are not within the Government’s organisational structure,
to have a high volume of complaints and enquiries made and ‘Not-In-Jurisdiction’ which are bodies not subject to
to the Ombudsman. the Ombudsman Act.
In 2024, we successfully addressed and closed 35 We continue to work towards carrying over the
of the 62 cases that were opened in prior years. fewest number possible of complaints at the end of
Of these 35 closed cases, we resolved 54% after each calendar year. 51 complaints remained open
inquiries that we considered to have reasonably at the end of 2024, a significant reduction from the
satisfied the issues and 2 cases were closed after an previous year (see Figure F). We will continue to
investigation. 51 cases remained open at the close monitor and address the backlog with the intention
of 2024: 1 from 2017; 1 from 2018; 1 from 2019; 0 from of further decreasing this number in the next
2020; 5 from 2021; 5 from 2022; 13 from 2023; and 25 reporting year.
from 2024 (see Figure E).
Year Opened
Complaint Status as at 31-Dec-24 2017 2018 2019 2020 2021 2022 2023 2024 TOTAL
Intake 1 7 15 23
Preliminary Inquiry 1 3 5 5 14
Early Resolution* 1 1
Pre-investigation 1 4 5
Investigation 1 1 1 3 1 1 8
Post Investigation 0
Implementation Review* 0
Outcome Review 0
INTERVENTIONS
Our Office quickly engaged with the department,
benefiting from an established relationship with the
director who had previously provided us with her cell
phone number for direct communication.
The director’s initial response revealed that the Prison Emergency Notification Button
staff member handling the application no longer
Did You Know that inmates locked in their cells must
worked in the department. Following weeks without
have a way to communicate with prison officers at any
a successful meeting between the complainant
time? This requirement, established in Section 7 of the
and the director, our Office’s follow-up discovered
Prison Rules 1980, ensures safety and wellbeing through
the complainant was considering abandoning her
emergency notification systems.
application due to frustration.
Key benefits of emergency notification buttons include:
Further investigation revealed the director’s meeting
request email had failed to send due to connectivity • Immediate medical assistance during health
issues. The director immediately resent the email, emergencies like heart attacks or injuries
and our Office promptly informed the complainant, • Quick response to fires, flooding, or other cell hazards
who confirmed receipt and expressed appreciation • Protection from self-harm or suicide attempts through
for our involvement. rapid intervention
• Access to help during mental health crises
• Communication during facility emergencies like
INSIGHTS
power outages
Strong relationships with public authorities • Prevention of violence through early officer notification
significantly enhance our ability to resolve • Compliance with human rights standards for prisoner
complaints efficiently, as demonstrated by the direct safety
communication channel with the director. This case
revealed how technical issues in communication The system balances security requirements with the duty
systems can significantly impact public service of care to those in custody.
delivery and citizen trust, highlighting the need for
verification processes for critical communications.
The complainant’s near-abandonment of her
application illustrates how unresponsiveness
can erode public trust in government services, Managing Prison Renovations & Maintenance
emphasizing the importance of prompt intervention.
Did You Know that the Department of Public Land and
While maintaining our independence as an oversight Buildings (“PLB”) maintains Bermuda’s correctional
body, our Office’s role in bridging communication facilities? During meetings with PLB and Department of
gaps between authorities and members of the Corrections representatives, our Office examined prison
public helps fulfill our broader mandate of improving maintenance management procedures. At Westgate,
public service delivery. Regular follow-up with both inmates rotate between three housing units to enable
parties proved crucial in identifying and correcting extensive renovations in empty units. Selected skilled
oversight, ultimately preventing the escalation of a inmates assist with the work alongside contractors,
simple communication breakdown into a significant with PLB conducting inspections. These inmates receive
issue affecting public trust. payment for their labour.
One of our key strategic priorities is to engage with our stakeholders to foster good relations. Getting to know the
people who work in the authorities in our jurisdiction is an important part of relationship management. Much of our
work relies on mutual trust and respect to reach compromise, find solutions, and resolve complaints. Meeting with
authorities also gives our Office an opportunity to learn more about government services, policies and procedures. In
this way, we serve the public more effectively and efficiently.
Collaborating and communicating with other ombudsman offices across the world keeps us up to date with good
practices, investigation techniques, administration procedures, and news and developments across the industry of
ombuds practice.
Over the course of the year, we participated in several Our Office also:
virtual meetings with overseas agencies, including a
roundtable discussion with Dr. Victor Ayeni, Governance • Attended the AGM of the Ombudsman Association.
and Management Services International, UK. Dr. Ayeni is an • Attended the 12th Biennial Conference of the
accomplished scholar and practitioner with over 35 years’ Caribbean Ombudsman Association (“CAROA”).
experience at the senior-level in academics, international
• Participating member of the Ombudsman
development and the Commonwealth. He is a leading
Association’s Outreach Network.
authority in Governance and Public Sector Management,
and he has carried out teaching, research and policy • Participating member of the U.S. Ombudsman
advisory assignments in Africa, Asia, the Caribbean, Pacific Association’s Diversity, Equity and Inclusion
and South America. Committee.
Our strategic plan calls for our Office to have an internal learning culture that helps us to continuously improve our
work, develop our skills, and enhance our individual and collective training standards. Throughout the year, our staff
took part in several formal training courses and professional development sessions.
Certifications
Congratulations to Investigations Officer Aquilah
Ombudsman Michael DeSilva obtained a certificate from Fleming who celebrated her 10th work anniversary
Osgoode Professional Development, in partnership with with our Office on 3rd March 2024!
the Forum of Canadian Ombudsman (“FCO”) and York
University in Canada. Held in Toronto in September, the
Essentials for Ombuds Certificate Programme provided
practical tips and strategies on conducting investigations,
implementing resolution techniques, and addressing con-
temporary ombudsman issues.
Trainings
Professional Development
It is in your hands
to create a better
world for all who
live in it.
–Nelson Mandela
CAROA – Caribbean Ombudsman Association
caribbeanombudsman.com
Ombudsman Association
ombudsmanassociation.org
The services provided by our Office are free of charge, and they
are available to everyone. Complainants are not restricted to be
Bermudian, or even residents of Bermuda. Our team keeps diver-
sity, equity, and inclusion at the front of our minds when dealing
with all complainants. We are working to identify and remove any
barriers that may prevent specific groups or individuals from hav-
ing unrestricted access to our Office.
We have Portuguese translations for most of our information Figure G: How we received cases in 2024
brochures and complainant forms on our website, and we
have introduced a few Filipino translations. Our website has
enlarged text and text-to-speech options for those readers
with sight impairment.
Radio Interviews
Westmeath Visit
OA PODCAST APPEARANCE
In February, our team visited Westmeath Nursing Care
Home to serve tea and play bingo with the residents. We In July, the Ombudsman recorded his first-ever
wanted to give back to our community and do something podcast! The Ombudsman Association (OA) in the
a little different. We didn’t make a formal presentation UK covers the UK, Ireland, the British Crown Depen-
about our Office, but there was plenty of interest amongst dencies, and the British Overseas Territories. Mr.
the residents when it came to complaining about DeSilva joined Dónal Galligan, Chief Executive of
government services! We also participated that month the OA, to discuss his reflections on the Ombuds-
in the Mount Saint Agnes Academy career fair. That gave man sector, and the similarities and differences
us a chance to speak to some high school leavers about between different jurisdictions.
a career path in ombuds practice that they might not
ordinarily be aware of. Watch “That OA Thing” podcast here: https://you-
tu.be/Q22hBkmDspg?si=1BuqVBYQOkQzhixI
BBC Interview
questions, hand out flyers and brochures, and encourage
In July, we were interviewed by the BBC’s Gary Foster- public interest in our work.
Skelton shortly after we published our Annual Report for
2023, along with our Special Report, “For the Record: An
Investigation into the Disclosure of Spent Convictions for
Community Group Presentations
U.S. Visa Applications.” You can watch the BBC interview
about our Special Report here: www.facebook.com/ Our Office is available to make presentations to
share/v/1ByGottTEm/ community groups, public authorities and other interested
parties. We aim to educate the public about the work we
do and the positive impacts we try to make. In October,
Pop-ups we presented to members of the Filipino Association
of Bermuda and discussed our role in investigating
We have been holding ‘pop-ups’ since 2023 to meet complaints of maladministration against public
people in the street, advertise our key messages, and authorities. We paid particular attention to the cultural
ask questions about people’s views and experiences sensitivities that can be experienced by non-Bermudian
with the Ombudsman’s Office. We have been setting up contract workers when making complaints against the
in the Washington Mall where we are on hand to answer establishment in a foreign country.
Would you like to schedule a presentation from the Ombudsman’s Office for your community group?
Please call 296-6541, or email [email protected]. This is a free public service!
Our strategic plan calls for surveys and feedback forms to Our sampling of the general public so far suggests that
measure public awareness, confidence, and satisfaction support for our Office is strong amongst those who are
with our performance. We conduct informal surveys at our familiar with us, but we may not be widely recognised
pop-ups, and soon we will engage a local company to in the community — especially if you have not used
conduct formal surveys on an annual basis and compare our services. When asked what factors might prevent
the data over time. someone from making a complaint, two common
answers were that “it takes too long,” and “it won’t make a
What type of information are we looking for? difference.”
• Would you likely make a complaint about a Our community outreach activities intend to close these
government department if you felt dissatisfied? Or gaps by raising awareness of the work we do and making
would something hold you back? sure that anyone who needs our services knows how to
• Do you know what the Ombudsman’s Office does? reach us.
• Do you have confidence that the Ombudsman’s Office
conducts its inquiries with independence, impartiality
and fairness?
• If you have complained to the Ombudsman before,
what was your experience like?
Our Compliance regime comprises a system of measures to assign responsibility for and assessment of compliance
status for each external compliance obligation. Procedures and timelines for achieving compliance are then developed.
We have a number of external compliance obligations to fulfill each year.
Personal Information Protection Act (“PIPA”) Public Access to Information (“PATI”) Act
The Personal Information Protection Act (“PIPA”) 2016 is The Public Access to Information (“PATI”) Act 2010, which took
a data protection and privacy law that applies to all effect on 1st April 2015, ushered in a new era of transparency
organisations in Bermuda. It provides data protection and for the Government. By making PATI requests, members of
privacy principles, individual rights, and legal obligations the public may exercise their right of access to records held
that organisations have regarding the use, recording, by Bermuda’s public authorities, which in turn can help to
storage, and protection of personal information contained improve administrative practices in the Government.
in their records.
The Office’s Information Statement aims to make it easy to
During 2024, our Office followed the Privacy Commissioner’s access key information about the Ombudsman’s activities,
“Road to PIPA” implementation plan in order to be ready including:
for the operational date of 1st January 2025. We also • who we are and what we do;
received a PIPA compliance presentation from Appleby • what we spend and how we spend it;
Bermuda in January; we attended the ‘PIPA Unveiled’ event • what our priorities are and how we are doing;
at City Hall in March; and we attended a training session • how we make our decisions;
with the Government’s PIPA/PATI Unit in October. • our policies and procedures; and
• lists and registers.
ombudsman.bm/wp-content/uploads/2023/01/2022-Ombudsman-Information-Statement.pdf
Annual Audit by the Office of the Auditor General (“OAG”) Occupational Safety and Health Act (“OSHA”)
Section 23(4) of the Ombudsman Act 2004 requires that The Occupational Safety and Health Act (“OSHA”) 1982,
the accounts of the Ombudsman shall be audited and and the accompanying 2009 Regulations, establish
reported on annually by the Office of the Auditor General a legislative framework in which employers have a
(“OAG”), and for that purpose the Auditor General or any duty to ensure, as far as is reasonably practicable, the
person authorised by her in that behalf shall have access health, safety, and welfare at work of all employees.
to all books, records, returns and other documents relating The legislation requires that accidents and dangerous
to such accounts. occurrences must be investigated and reported to a
Safety and Health Officer at the Department of Health
Our audit report for FY 2022/23 was received on 14th Octo- (“the Department”).
ber 2024. The Auditor General reported, “In my opinion, the
accompanying financial statement presents fairly, in all Employers who have ten or more persons employed are
material respects, the results of operations of the Office of also required to establish a Safety and Health Committee
the Ombudsman for Bermuda for the year ended March that deals with complaints, investigates accidents, makes
31, 2023 in accordance with public sector accounting recommendations for safety improvements, provides
standards generally accepted in Bermuda and Canada.” training and advice, and maintains records. All employers,
regardless of the size of the organisation, are required to
Since its inception in 2005, our Office has received the submit an annual report to the Department that sets out
same audit opinion, demonstrating consistent financial the number of accidents, dangerous occurrences, and
responsibility over a sustained period. minor injuries that occurred.
Our Policy and Standards regime comprises a combination of written policies, procedures, protocols, guidelines,
standards, and manuals. Collectively referred to as “policies,” these documents provide direction to our team,
ensure that our operations are compliant with local laws and regulations, provide good practices that are based on
international standards, and support the mission of the Office.
The Complaint Handling and Investigation Process For the purpose of the Government’s Financial
(“CHIP”) Manual is the core policy document that drives Instructions, the Ombudsman is the Accounting
our casework. CHIP establishes the procedures for dealing Officer for the Office. He ensures that all expenditure
with complaints from the moment of intake to the final is in line with Financial Instructions and that
investigation report, and everything in between. Through accounts are kept, maintained, and reported
the standardisation of our processes and templates, we annually as prescribed by the Accountant General.
provide greater consistency in the approach to our cases,
increase the efficiency of our team, and improve the pace Our Spending
at which we manage our caseload. Significant work was
done by our team to complete this project in 2024. Our approved budget for FY 2024/25 was $1,049,581.
The funds were allocated as follows:
Performance Measures
All Government Departments, including the Non-Ministry Departments (such as the Ombudsman, Information
Commissioner, Auditor General, Parliamentary Registrar, etc.) must report annually on their performance measures
contained in the Government’s Approved Estimates of Revenue and Expenditure (the “Budget Book”). Our Office submitted
the following performance measures for FY 2024/25:
Percentage of complaints outside of jurisdiction that are Discontinued 90% Discontinued Discontinued
declined (with value added) within 5 days of intake
Percentage of investigations that comply with timelines n/a 70% n/a 70%
prescribed in the Complaint Handling & Investigations
Policy
Number of internal progress reports and review of our Discontinued 52 Discontinued Discontinued
complaint handling performance
Percentage of compliance with outside body reporting 100% 100% 80% 100%
obligations (PATI, PIPA, Annual Report, Audit, etc.)
Number of engagements to reach groups that may not Discontinued 4 Discontinued Discontinued
already have easy access to our services
Percentage or cases where special measures are used Discontinued 100% Discontinued Discontinued
to accommodate mobility, health or interpreter needs
Percentage of surveyed public that reports overall n/a 50% 61% 50%
awareness of the work our office does
Percentage of surveyed public that reports overall n/a 60% 62% 60%
satisfaction with our office
We may also decline your complaint if it is lodged with our A financial compensation payment is used to restore
Office more than a year after you became aware of the the complainant to the position they were in before the
issue you are complaining about, or the Ombudsman has maladministration occurred.
determined that your complaint is frivolous. If we decline
your complaint, we may refer you to another body which Both forms of financial remedy are rarely recommended
may be able to assist you. and can only be recommended after a finding of
maladministration. Unlike the Courts, the Ombudsman’s
recommendations are not binding or enforceable.
If we investigate a complaint, the Ombudsman will make Can I complain to the Ombudsman instead of
findings based on the evidence he has reviewed. He may
taking an authority to Court to receive payment?
determine the evidence does not support a finding of
maladministration on the part of an authority. If he does so, In most cases when complainants are seeking a financial
he is not likely to take any further action. payment from an authority, the complainant can pursue
this payment in the Courts or with a tribunal. We cannot
The Ombudsman may determine the evidence reviewed
investigate complaints until either: a) the Court or
supports a finding of maladministration. If he finds that
tribunal’s process the complainant has the right to pursue
there was wrongdoing by the authority, he may make
is complete; or b) the time limit for exercising that right
recommendations as he sees fit. Recommendations may
has expired. We will usually decline these complaints and
include that:
suggest that the complainant speak with a lawyer. example, it is unlikely the Ombudsman will award financial
compensation for distress or for pain and suffering.
The Ombudsman does have the discretion to investigate
a complaint which otherwise would be pursued with a A consolation payment can range from $50 – $5,000,
tribunal or in the Courts. However, this discretion is only depending on the severity of the maladministration
exercised when it would not be reasonable to expect the found; the amount of the payment is determined at
complainant to pursue their claim in the Courts or with a the Ombudsman’s discretion. When deciding whether
tribunal. a complainant should be financially compensated,
the Ombudsman considers questions such as: Has
the complainant suffered a financial loss as a result of
maladministration? Is the loss quantifiable?
What does the Ombudsman consider when
deciding to recommend a financial remedy?
COMPLAINT STAGES
STAGE PURPOSE
Intake Receive and record cases as well as assess our jurisdiction to assist
Preliminary Inquiry Gather and assess information and documents to determine whether or not to investigate a
complaint of maladministration
Early Resolution Promote resolution of the issues identified by (re-) establishing direct and clear communication
between the complainant and the authority, along with potential solutions, as soon as possible after
receipt of the complaint
Mediation Promote resolution of the issues identified by facilitating a formal meeting (or series of meetings)
between the complainant and the authority
Outcome Review Assess whether to uphold the complainant’s request for a review of a decision not to investigate
Pre-Investigation Assess whether the matter should be investigated and further review any potential challenges our
Office may face in carrying out an investigation. Also carry out initial planning (investigation sub-
stage 1)
Investigation Gather and assess the evidence necessary to determine whether or not to uphold a complaint of
maladministration, through formal and informal means of evidence gathering (investigation sub-
stage 2)
Post-Investigation Issue Draft Investigation Report to parties for their input, before finalisation (investigation sub-stage
3)
Investigation Conclusion Receive and assess Authority’s statutory response to Final Investigation Report (investigation sub-
stage 4)
Implementation Review Follow up on the Authority’s implementation of recommendations in Final Investigation Report
(investigation sub-stage 5)
Abandoned Complainant did not provide sufficient contact information or respond to our attempts to make contact
(see s.9(2)(a) re decision not to investigate).
Closed After We decided not to proceed with the complaint after making inquiries or based on an initial assessment
Inquiries because: (a) the issues within jurisdiction were adequately addressed; or (b) the questions we raised to
the authority were sufficiently answered (see s.8 re preliminary inquiries). We may have used alternative
resolution techniques (see s.10 re mediation; and s.8 re preliminary inquiries). We also may have made
general suggestions to assist the authority in improving its processes.
Closed At the conclusion of a formal investigation, the Ombudsman made findings of maladministration, and the
Maladministration authority provided its statutory response (see s.15(3) re procedure after investigation; and s.16 re authority
to notify Ombudsman of steps taken).
Closed Mixed At the conclusion of a formal investigation, the Ombudsman made findings of maladministration and
Maladministration no maladministration, and the authority provided its statutory response (see s.15(3) re procedure after
investigation; and s.16 re authority to notify Ombudsman of steps taken).
Closed No At the conclusion of a formal investigation, the Ombudsman made findings of no maladministration (see
Maladministration s.15(1) re procedure after investigation).
Closed - Settled We decided not to proceed with the complaint during preliminary inquiries or investigation because the
issues were successfully resolved and adequately addressed. (see s.9(2)(c) re decision not investigate)
Declined Issues raised were outside of our jurisdiction because of the subject matter and/or body complained of
(see s.6(1)(3) and the Schedule re actions not subject to investigation). Or, issues raised may have been
within jurisdiction but were out-of-time (see s.9(1)(a) re decision not to investigate) or determined to be
frivolous (see s.9(1)(c) re decision not to investigate). In these cases, we may have declined outright or
made inquiries to establish jurisdiction (see s.8 re preliminary inquiries). We make no suggestion as to
potential redress because there likely is none at present.
Declined and Issues raised were outside of our jurisdiction because of the subject matter and/or body complained of (see
Referred s.6(1)(3) and the Schedule re actions not subject to investigation). Or, issues raised may have been within
jurisdiction but were out-of-time (see s.9(1)(a) re decision not to investigate). We may have made inquiries
to establish jurisdiction and/or determine whether there were other forms of redress available (see s.8 re
preliminary inquiries). These inquiries may have included general or specific questions about the issues. We
determined that there were other ways for the complainant to seek redress and provided information to the
individual on possible next steps (see s.9(1)(b) re decision not to investigate – alternative remedies).
Deemed Complaint subject matter and authority were in jurisdiction, but the person had not yet complained to that
Premature authority or had not yet exhausted that authority’s existing complaint handling procedure. In these cases,
we could have made inquiries, but it probably meant getting ahead of ourselves. The authority complained
of was always the authority that the complaint should have been raised with.
Enquiry Person contacted us to seek information, not necessarily to complain, with questions about an authority’s
processes and/or our services. Person may have been aware that there were other steps to pursue before
complaining to us. This may have included complaint letters addressed to authorities or other bodies that
were copied to us.
Informally Complaint was resolved between the authority and the complainant with informal intervention from us.
Resolved We may have facilitated resolution by making brief, informal enquiries that prompted the authority’s action
and/or by coaching the complainant on how to approach the authority (see s.9(2)(c) re decision not to
investigate – settled; and s.8 re preliminary inquiries).
Referred Complaint subject matter and authority were in jurisdiction, but there was a more appropriate remedy still
available to the complainant (see s.6(1) and (2) re restrictions on jurisdiction to investigate). Complainant had not
raised the issue with the correct authority or had not yet exhausted the authority’s complaint handling procedure,
and we determined that it was necessary and fair for the complainant to give the authority adequate opportunity
to address the issues raised (see s.9(1)(b) re decision not to investigate – alternative remedies).
Signposted Complaint subject matter and/or body complained of were not within our jurisdiction, and we suggested
the complainant contact a body not within our jurisdiction.
Withdrawn Complainant requested that we take no further action on the complaint. This may have been done at any
stage during the process (see s.9(2)(b) re decision not to investigate).
Ombuds offices worldwide benefit from shared tools and guidance on assessing public bodies’ actions. In our
complaint handling and investigation work, we routinely refer to the “Principles of Good Administration” published by
the UK Parliamentary and Health Service Ombudsman in 2007. These guiding principles provide clear and succinct
language for defining good administrative practices. We also routinely describe those principles in our presentations
and correspondence to authorities regarding their complaint handling.
There are other useful resources for guidance on what Also, for structured guidance to reflect on other
administrative fairness means. These publications are complaint-handling practices, we refer you to:
based on decades of experience investigating complaints.
We share this information to promote an understanding of • “Good Practice Guide to Dealing with Challenging
how our Office will consider cases and how we will assess Behaviour” from Australia’s Victorian Ombudsman
the authorities’ delivery of service to the public. Here is (2018)
our updated list of resources for exploring what good
• “Managing Unreasonable Complainant Conduct
administration means:
Practice Manual” from Australia’s New South Wales
• “Fairness by Design: An Administrative Fairness Ombudsman (2012)
Self-Assessment Guide” from various Canadian
• “Being Complained About – Good Practice Guidelines”
Ombudsman offices in collaboration (2019)
from the University of Glasgow and Hirstworks (with
• “Good Conduct and Administrative Practice: input from the Scottish Public Services Ombudsman)
Guidelines for State and Local Government” from (2019)
Australia’s New South Wales Ombudsman (2017)
• “Complaints: Good Practice Guide for Public Sector
• “Principles of Good Administration and Good Agencies” from Australia’s Victorian Ombudsman
Records Management” from Wales’ Public Services (2016)
Ombudsman and Information Commissioner’s Office
• “Complaints Improvement Framework” from the
in collaboration (2016)
Scottish Public Services Ombudsman (2017)
• “Administrative Fairness Guidebook” from Canada’s
• “Effective Complaint Handling Guidelines” from
Alberta Ombudsman (2013)
Australia’s New South Wales Ombudsman (2017)
• “Defining Fairness in Local Government” from the
• “Effective Complaints Management Self Audit
Ombudsman Toronto (2013)
Checklist” from Australia’s Queensland Ombudsman
• “Principles of Good Complaint Handling” from the UK (2006)
Parliamentary and Health Service Ombudsman (2008)
Dundonald Place, Suite 102, 14 Dundonald Street West, Hamilton HM 09, Bermuda