NSW Ombudsman Annual Report 2024-25

The NSW Ombudsman Annual Report 2024-25 outlines our work over the past financial year in pursuing fairness for the people of NSW.

It is a privilege to present my fifth Annual Report as Ombudsman, particularly in this year when the NSW Ombudsman celebrates 50 years of pursuing fairness for the people of NSW.

I am honoured to hold the role during such a significant milestone, as we highlight the achievements and progress made over the past 5 decades, reflect on the enduring legacy of our work, and look ahead to the continuing importance and impact of our functions into the future.

To those seeking to understand the role, functions and impact of this office since its establishment in 1975, I recommend our publication, 50 years pursuing fairness for NSW 1975–2025, authored by Dr Lisa Murray and released this year to coincide with our public exhibition at NSW Parliament House.

Looking to more recent times, this year also marks the final year of our 2020–25 Strategic Plan. Reflecting on the beginning of that plan provides significant context to how far we have come in a relatively short space of time. When the plan was launched we were in the midst of the COVID-19 pandemic, in a situation of chronic underfunding, and burdened with outdated processes and IT systems. At the same time, significant elements of our better-funded and high-profile jurisdictions had moved over to other bodies – including NSW Police complaints, and reportable conduct allegations in disability and child-related workplaces.

Through sustained effort and the implementation of our 2020–25 Strategic Plan, we have seen a significant transformation. We have re-invested and re-focused on our core role as Ombudsman – the pursuit of fairness in public administration and in the delivery of services with public funds. This includes enhancing our complaints and investigations capabilities, providing ongoing monitoring and oversight of systems and programs, as well as contributing to providing educational and resource support to empower agencies to improve themselves and prevent maladministration before it happens.

With improved Government commitment to both the independence and adequacy of our funding, we have re-built our resourcing, with staff numbers bouncing back from an historic low 5 years ago of around 120, to now over 250 people this year. Through the ongoing transition to cloud technologies, a redesigned website, new AI assistant, and case management system upgrade, we are increasingly focused on improving the efficiency, security and customer experience for those engaging with our office.

The core role of the Ombudsman continues to grow and in 2024–25, we saw a 22% increase in contacts received and a 15% rise in actionable complaints received. At the same time, the number of complaints on which we have taken investigatory action has also been increasing – all actionable complaints we receive are assessed, with 23% the subject of further action such as preliminary inquiries (informal investigation) and conciliation.

Our formal investigations work has continued to expose and correct serious and systemic instances of maladministration. This year, the impact of this work has included Corrective Services NSW commencing a wholesale review of the system of inmate discipline within correctional institutions.

Following the commencement of the Public Interest Disclosures Act 2022 (PID Act) in October 2023, we held the inaugural PID Awareness Week in 2024, continuing our support to agencies in their work to implement the new PID Act and embed a speak-up culture. This work has further expanded with the formation of our Whistleblower Support Team, which provides confidential and impartial support to NSW public officials who have reported, or are thinking of reporting, serious wrongdoing.

We also saw the creation of a Complaint-Handling Systems Review Unit in 2024–25, which is tasked with engaging with agencies and conducting reviews on the complaint-handling systems of public authorities and community service providers. A self-assessment review of agencies’ complaint-handling practices and a complaint-handling staff survey have been launched, and we anticipate reporting on these in the coming year.

An important role of the NSW Ombudsman over the years has been to support Parliament by conducting and reporting on the operation of new legislative schemes and powers – with past reviews including Police use of drug dogs and consorting laws. This year, we tabled our first review report on the Mandatory Disease Testing Act. Our core recommendation was that consideration be given to whether the Act should be continued, and the Government is now consulting publicly on our recommendations in its statutory review of the Act.

Another seminal report we published in 2024–25 is OCHRE 2024: Current status and future direction, examining the Government’s flagship Aboriginal affairs program. The report’s core recommendation was “that the NSW Government unequivocally recommit to OCHRE as the state’s overarching plan for Aboriginal affairs”, and we await the Government’s substantive response to our recommendations.

In total, during this reporting period we tabled 4 statutory reports and 7 special reports, which are outlined in Section 3.2 (‘Public Reports’) of this publication.

As one Strategic Plan ends, we embark on the next exciting chapter for the Ombudsman. Since the reporting period ended, I was proud to launch the new 2025–30 Strategic Plan, supported by the implementation of a new executive structure aimed at maximising our impact.

I look forward to working with the executive and our dedicated staff towards our renewed key priorities as the Ombudsman embarks on the next 50 years.

A big thank you goes to everyone working at the Ombudsman for your commitment towards pursuing fairness for the people of NSW. The Ombudsman is about much more than one position. It is built on the collective contributions of hundreds of individuals, without whom we would not achieve the outcomes and impact we continue to strive towards.

Paul Miller

NSW Ombudsman

2024–25 NSW Ombudsman snapshot

1.1 The NSW Ombudsman

The NSW Ombudsman is an independent integrity agency that pursues fairness for the people of NSW. We strive to ensure that those entrusted with public power and resources fulfil their responsibilities and treat everyone fairly.

One of our central functions is to receive and respond to complaints from the public about NSW public authorities and community service providers funded by the NSW Government.

Anyone can complain to us if they believe they have been treated unfairly by any of the bodies we oversight, or to report concerns about possible maladministration.

Our services are free to the public. We are fully independent and we act impartially in the public interest.

People who complain to us are protected by law if anyone tries to retaliate against them for making a complaint. Additional protections apply for public official whistleblowers who report serious wrongdoing to us under the Public Interest Disclosures Act 2022.

The NSW Ombudsman can investigate when we suspect serious maladministration, whether as a result of complaints or reports we have received, or on our own motion. Maladministration is when administrative conduct is unlawful, unjust, unreasonable, improperly discriminatory or otherwise wrong. We can also investigate and make findings when administrative conduct is lawful and in accordance with established practice, but where the law or practice is itself unjust, unreasonable or improperly discriminatory.

As well as dealing with complaints and investigating serious wrongdoing, we proactively monitor and review certain public and community sector services and systems.

We can:

• monitor and assess the delivery of the NSW Government’s Aboriginal programs
• oversight the operation of the public interest disclosures (PID) scheme
• monitor and review the provision of NSW Government- funded community services
• review the systems and practices that public authorities and service providers themselves use to deal with the complaints they receive
• monitor the operation of the mandatory disease testing scheme
• receive notifications when children and young people are segregated in detention.

In connection with these functions, we aim to support public sector agencies and community service providers by providing guidance and training, with a view to helping them to improve their services and avoid maladministration in the future.

We also review the deaths of certain children and convene the Child Death Review Team (CDRT), which registers and conducts research on child deaths in NSW. Our focus in this work is on the child protection, health and other public and community services systems, with a view to identifying lessons and improvements that may prevent or reduce the risk of future deaths.

We must conduct most of our complaint-handling, investigations and other functions confidentially. However, as an independent integrity agency we report directly to Parliament. We are required to report to Parliament periodically on our various work and activities, and we can also make a special report to Parliament at any time, on any matter of public interest relating to our functions.

Our statutory functions

Complaint-handling

We receive complaints over the phone, in person or in writing, including via our online complaint form.

Any person can complain to us about:

• the conduct of a ‘public authority’: any action or inaction, or alleged action or inaction, relating to a matter of administration (unless it is excluded conduct) — Ombudsman Act
• the conduct of ‘service providers’ with respect to the provision, failure to provide, withdrawal, variation or administration of a community service — CS CRAMA.

We can also receive and deal with PIDs about serious wrongdoing in the public sector, which are disclosed to us by public officials under the PID Act. Such a disclosure could be both a PID (under the PID Act) and a complaint (under the Ombudsman Act).

We can generally deal with complaints about the conduct of:

NSW state government departments

As at the date of this report, there are 12 principal departments:

1. Premier’s Department
2. The Cabinet Office
3. Department of Education
4. Department of Climate Change, Energy, the Environment and Water
5. Department of Creative Industries, Tourism, Hospitality and Sport
6. Treasury
7. Department of Planning, Housing and Infrastructure
8. Ministry of Health
9. Department of Transport
10. Department of Primary Industries and Regional Development
11. Department of Communities and Justice (DCJ)
12. Department of Customer Service.

Local health districts, health specialty networks and hospitals

Public schools, TAFE NSW and other statutory education bodies

These include TAFE Digital and the NSW Education Standards Authority.

Custodial services

This includes Corrective Services NSW and Youth Justice NSW (Youth Justice) (a division of DCJ), and the Justice Health and Forensic Mental Health Network. We can also deal with complaints about the state’s privately-run correctional centres.

Other NSW government entities in our jurisdiction, including:

• NSW Government agencies — such as Fire and Rescue NSW and the Office of Sport
• statutory bodies — such as NSW Trustee and Guardian, the Rental Bond Board, the Health Care Complaints Commission, the NSW Land and Housing Corporation, the Art Gallery of NSW and other NSW cultural agencies
• state-owned corporations — such as Sydney Water, Water NSW, Essential Energy and Forestry Corporation
• public universities established under NSW legislation (noting the National Student Ombudsman (NSO) commenced operation on 1 February 2025, and we have made an agreement with the NSO in relation to referral of complaints).

Local government

This includes councils, county councils and joint organisations. We can handle complaints about the conduct of councillors and council employees, and the administrative conduct of the council itself.

Community service providers

Under CS CRAMA, we handle complaints about:

• services provided under community welfare legislation by DCJ
• services provided by entities that are funded, authorised or licensed by the Minister for Families and Communities, the Minister and for Disability Inclusion, the Minister for Seniors, and certain other entities.This includes the following types of services and service providers:
• child protection
• out of home care (OOHC) and permanency support
• early intervention and family support services

short-term accommodation and homelessness support.

Own motion matters

We can examine conduct of the agencies and officials referred to above even if we have not received a specific complaint about that conduct. Inquiries or investigations initiated by us (‘own motion’ matters) can arise from information that comes to our attention through a range of means, including our various monitoring functions and our community engagement activities.

Investigation

While we take investigatory action in respect of many complaints, most complaints do not result in an ‘investigation’ under the Ombudsman Act. Generally, only those complaints or own motion inquiries that identify potentially serious or systemic maladministration are the subject of a formal investigation. Formal investigations result in reports that include any findings of wrong conduct and may include recommendations for action.

Review of agencies’ complaint-handling systems

Public authorities and community service providers will have their own systems for handling complaints. Agencies have their own complaint management systems. We usually expect people to contact the agency first about their complaint before making a complaint to us. If this is hard to do or someone does not feel safe doing this, we help them.

Complaints often come to us because an agency’s systems have failed to result in a satisfactory resolution of the complaint.

Under the Ombudsman Act (for public authorities) and CS CRAMA (for service providers), as well as handling individual complaints, we are able to conduct a proactive review into a complaint-handling system, to ensure it is functioning effectively and fairly, and in accordance with good practice.

Monitoring and assessment of Aboriginal programs

We have an express legislative function to monitor and assess ‘Aboriginal programs’.

Under Part 3B of the Ombudsman Act we have responsibility for oversighting OCHRE (Opportunity, Choice, Healing, Responsibility, Empowerment) — the plan launched by the government in April 2013 and coordinated by the Premier’s Department (Aboriginal Affairs NSW). OCHRE commits the NSW Government to working with, and in support of, Aboriginal communities by building strong working partnerships, which have at their heart respect for local Aboriginal culture, leadership and decision-making.

Since August 2024 we also have the discretion to monitor and assess any other NSW Government programs primarily directed to the health, or cultural, economic, educational or other wellbeing, of Aboriginal persons or communities.

Our office monitors and assesses Aboriginal programs by engaging with key stakeholders, visiting communities and attending community forums. We provide feedback to agencies and partners to enable them to address any issues we identify.

We also table public reports on our oversight of Aboriginal programs in Parliament as required.

Oversight of public interest disclosures scheme

The Ombudsman has responsibility to oversight the PID Act. Our functions include to:

• promote public awareness and understanding of the PID Act and to promote the objects of the PID Act
• provide information, advice, assistance and training to agencies and public officials on matters relevant to the PID Act
• publish guidelines and other materials for the assistance of:
  • agencies in connection with their functions under the PID Act
  • public officials and other persons in connection with the operation of the PID Act and the protections available to them under the PID Act
• audit and monitor the exercise by agencies of their functions under the PID Act, other than functions exercised by an integrity agency in relation to disclosures that do not relate to the integrity agency
• provide reports and recommendations to the Minister (currently the Premier and Special Minister of State) about proposals for legislative and administrative change to further the objects of the PID Act

perform other functions conferred on the Ombudsman by or under the PID Act.

The Ombudsman also chairs, and staff provide secretariat support to, the PID Steering Committee, which provides advice on the operation of the PID system and on possible legislative reforms.

Community services monitoring, reviews and inquiries

Under CS CRAMA we monitor and review the delivery of community services. This includes community services that are provided by the non-government sector with funding or authorisation from the NSW Government.

Our functions include to:

• review, on application or on the Ombudsman’s initiative, the situation of a child or a person in care (or a group of children)
• monitor and review the delivery of community services, inquire into matters affecting service providersand receivers, and make recommendations for improvements in the delivery of community services
• review and report on the systems of community service providers for handling complaints.

Mandatory disease testing

We monitor and report on the operation and administration of the Mandatory Disease Testing Act 2021 (MDT Act), including how agencies exercise their functions under the Act. The Act provides for the mandatory blood testing of a person. This can occur when:

• the person’s bodily fluid comes into contact with a health, emergency or public sector worker, as the result of the person’s deliberate action, and
• the worker may be at risk of contracting a blood-borne virus.

Agencies must notify us after determining a mandatory testing order application. The Chief Health Officer must also notify us following determination of a review.

Reviewing the deaths of children

Under Part 6 of CS CRAMA, we review deaths of children who were in care or detention, and children who died as a result of abuse or neglect, or whose death occurred in circumstances suspicious of abuse or neglect.

Under Part 5A of CS CRAMA, we also convene and support the NSW CDRT, which examines and maintains a register of all deaths of children in NSW and undertakes research to prevent or reduce the risk of child deaths in the future.

Monitoring the segregation of detainees in youth detention

Under the Children (Detention Centres) Regulation 2015, Youth Justice is required to notify us if a young person in detention is segregated for more than 24 hours. We are also notified if a young person is separated for more than 24 hours (for example, because of medical advice). These notifications allow us to examine the circumstances of the segregation or separation and to make inquiries if appropriate.

Special reports to Parliament

We are required to make various annual and other periodic reports to Parliament in respect of specific functions. These include an annual report on our work oversighting the PID Act, a report every 3 years on our work monitoring the operation of the MDT Act, an annual report on our work convening the CDRT, and a report every 2 years that analyses the deaths of children in NSW.

Under section 31 of the Ombudsman Act, we can also make special reports to Parliament at any time on any matter arising in connection with the discharge of any of the Ombudsman’s functions.

1.2 Organisational structure

The following chart shows the Ombudsman’s current organisational structure as at the date of publication of this report. This follows an organisational restructure that was finalised on 13 October 2025.

The organisational structure that was in place during 2024–25 is set out in Section 4.

Find out more about our Ombudsman and current Executive here.

Former Executives during 2024–25

• Leanne Townsend - Deputy Ombudsman, Aboriginal Programs (until 22 October 2025)
• Monica Wolf - Chief Deputy Ombudsman and Commissioner for Community Services (until 27 June 2025)
• Louise Lazzarino - Deputy Ombudsman, Systems Oversight (until 20 June 2025)
• Leonie Muldoon - Director, Enabling Services (until 30 May 2025)
• Jacqueline Fredman - Deputy Ombudsman, Complaints & Resolution (until 16 May 2025)

As at 30 October 2025, the following Executive roles are being recruited, with temporary acting arrangements in place:

• Deputy Ombudsman, Capacity Building & Education Services
• Director, Information Technology & Artificial Intelligence
• We intend commencing recruitment for the Deputy Ombudsman, Aboriginal Programs before the end of the year.

1.3 Factors affecting us in 2024–25

1.4 Organisational outlook

In 2024–25, we commenced transitioning to a new executive leadership structure to support the delivery of our new 5-year strategic plan, and in recognition of the organisational changes that have occurred over the last few years.

Recruitment for the new executive structure will be finalised in 2025–26, including appointments of additional executive roles for: complaint resolution, sector education and capacity building, and an executive role to lead technology, including innovations in artificial intelligence.

As noted in the Ombudsman’s message, we have developed a new strategic plan for 2025–30. This has been shaped by our people, and guided by our legislative functions, the expectations of our stakeholders and the changing environment in which we operate.

With the aim to focus and streamline our efforts for the greatest impact, implementation of the new plan begins in 2025–26 with an office-wide action plan, further supported by comprehensive planning at a branch and unit level.

2.1 Strategic highlights

Strategic Plan 2020–25

Our Strategic Plan 2020–25³ identified the 4 outcomes we need to achieve to help realise the plan’s vision that: Everyone receives the right services and fair treatment from those we oversight.

Outcome 1 is about ensuring that the people of NSW are satisfied with our customer service. To achieve this outcome, we: listen to their complaints or questions; provide information and guidance; provide an impartial assessment of an agency’s conduct; help where possible to conciliate and resolve complaints; and, where necessary, investigate matters of serious or systemic concern.

Outcome 2 aims to support democratic principles and the rule of law, and to ensure citizens are protected from abuse of power and unfair treatment, by holding public authorities and community service providers to account when they engage in wrong conduct.

Outcome 3 is about fostering enduring reforms that prevent future failings and improve public administration and service delivery. This includes by helping government and service providers to learn from complaints and reviews; promoting public sector whistleblowing; providing advice, suggestions and recommendations that are evidence-based, realistic and effective; and providing education and training to government agencies and service providers to encourage good administrative practice and build capability.

Outcome 4 is about providing a trusted source of independent advice to Parliament. Although we are independent of all stakeholders, we report directly to the Parliament of New South Wales, in its capacity as the representative body of the people.

See Section 3.2 for information on our work towards achieving each of those 4 outcomes.

Our Strategic Plan 2020–25 articulated:

• The strategic initiatives we would pursue over the period of the plan, each of which is linked to 1 or more of our 4 outcomes.⁴ An annual plan was developed each year for the activities we would carry out in respectof those strategic initiatives. Implementation of the annual plan was overseen by the Executive team with tracking of progress completed on a quarterly basis. Some of our highlights from 2024–25 can be found in Section 2.3.
• Progress towards achieving our 4 strategic outcomes to be measured by reference to a series of key performance indicators (KPI) ascribed to each outcome. Performance against KPIs is set out in Section 3.3.

2.2 Strategic Plan 2020–25 on a page

The following is a summary of our Strategic Plan 2020–25:

2.3 Strategic action plan highlights

With the aim of finalising our current 5-year strategic plan, 2024–25 focused on actions grouped by 5 key themes:

• Services and impact
• Leadership and governance
• Engagement and relationships
• People and culture
• Systems and processes.

3.1 Connecting with us

Accessing our services

We strive to be accessible to everyone and offer multiple ways to get in touch, including our online complaint form, phone and in-person visits to our office, or appointments at our office. Additionally, individuals can share their concerns with our staff during community outreach events or approach us directly at correctional or youth justice centre visits.

Some community members may be less likely to access our services without assistance — the very factors that may contribute to a person needing the help of the Ombudsman may also limit their ability or willingness to approach or engage with us. We undertake a range of community outreach activities to reach those who may not have knowledge of our office or our services, or may otherwise face impediments to accessing our services.

Contacts to our office

We categorise contacts received by our office into 6 categories (see Appendix for more detail):

1. Actionable complaints — complaints about a public authority or community service provider that we are authorised to deal with under the Ombudsman Act 1974 (Ombudsman Act) or the Community Services (Complaints, Reviews and Monitoring) Act 1993(CS CRAMA).
2. Excluded complaints — complaints about a public authority or community service provider that we are not authorised to deal with because the complaint is about ‘excluded conduct’ as set out in Schedule 1 of the Ombudsman Act.
3. Requests for information — where someone is not complaining but asking for our help or advice.
4. Notifications — where agencies report things to us because they are legally required to do so (for example, when a young person is segregated alone in a youth justice centre for 24 hours or more).
5. Misdirected complaints — where someone contacts us about a person or body that is not a public authority or a community service provider, and over which we have no jurisdiction (such as a banking provider or an Australian Government department).
6. ‘Feedback Assist’ — where our office assists with identifying the appropriate agency to manage feedback (complaints, compliments or suggestions) provided by the public via a NSW Government ‘Feedback Assist’⁹ widget or another agency’s website.

We can examine the conduct of agencies even if we have not received a specific complaint about that conduct. Inquiries or investigations initiated by us — ‘own motion’ matters — can arise from information that comes to our attention through a range of means including our various monitoring functions and our community engagement activities. In 2024–25, we opened 43 own motion matters.

Figure 1: How we received contacts¹⁰

Contacts received in 2024–25

In 2024–25 we received 36,167 contacts. This represents a 22% increase in the number of contacts received from the previous year (29,644). The number of actionable complaints increased by 15%.

Figure 2: Contacts received

*The total includes 355 contacts that were pending assessment as of 30 June 2025.

Figure 3: Contacts and actionable complaints received over 5 years

Table 1: Notifications received by type

The total number of youth justice notifications, regarding segregation and separation exceeding 24 hours, has decreased from 878 in 2023–24 to 715 in 2024–25. This is due to a drop in the number of notifications regarding separation, notably those in the security and safety, medical and classification categories.

The number of PID notifications about arrangements to exercise functions on behalf of an agency increased from 67 in 2023–24 to 148 in 2024–25.

The number of child deaths notified during the year (423) was similar to the previous reporting period (417: 2023–24).

The number of mandatory disease testing determinations (43) was similar to the previous reporting period (49: 2023–24).

Changes in contacts over time

The number of contacts we received in 2024–25 grew for a fourth consecutive year. The 22% increase in 2024–25 built on the 7% increase in 2023–24.

Despite the increase in contacts received, we saw the proportion of contacts within our jurisdiction drop. This was primarily due to a 50% increase in misdirected complaints. We receive misdirected complaints about a range of organisations, including the private sector (including telecommunications and internet providers, airlines, and other retailers and service providers), as well as in relation to Commonwealth issues (such as the National Disability Insurance Scheme (NDIS) and aged care provision) and government entities (such as Centrelink). When we receive a misdirected contact, we assist a complainant to navigate to the appropriate ombudsman or other complaint-handling avenue.

With our new website, online AI assistant providing 24/7 support and a complaints portal that integrates with our case management system set to be fully functional in 2025–26, we anticipate a reduction in misdirected complaints we receive moving forward as part of our complaint-handling.

Figure 4: Contacts received in jurisdiction over 5 years

Access to digital services and self-navigation

In 2024–25, we launched a new website and integrated AI assistant as part of our commitment to improving accessibility and user experience across our digital services. These improvements were designed to help members of the public and future complainants self- navigate our processes, access our services, and identify the appropriate ombudsman or complaint-handling service for their issue.

The redesigned website offers a clearer, more intuitive structure and improved search functionality, making it easier for people to find relevant information quickly. Complementing this, the AI assistant provides a guided, conversational interface to assist complainants and agency staff in real time. It helps triage enquiries by directing people to the correct service pathway, answering questions about our services, and providing simple answers written in plain English.

Between 24 February 2025 and 30 June 2025, the AI assistant handled 1,186 conversations. These early adoption metrics and user feedback indicate that the new digital tools are positively contributing to how users navigate our website, helping more people reach the right information.

3.2 Reporting on our strategic outcomes

Under our Strategic Plan 2020–25, we used our 4 strategic outcomes as the basis for reporting our performance.

Our four outcomes

Activities contribute to the delivery of multiple outcomes

Each of our 4 strategic outcomes are interrelated, and activities contribute to the achievement of multiple outcomes. For example, resolving complaints (Outcome 1) may result in an agency being held to account by findings of wrong conduct (Outcome 2). The resulting public report and recommendations can drive broader improvements in public administration (Outcome 3) at the same time as providing evidence for Parliament to scrutinise the government and pursue legislative reform (Outcome 4).

In this section we outline our work during 2024–25 and indicate graphically the extent to which our activities are contributing to each of the strategic outcomes.

Initial assessment undertaken of 16,658 (100%) of actionable complaints finalised in 2024–25

We assess all the complaints we receive.

Many complaints are finalised at this stage, and without us making inquiries or otherwise engaging directly with the agency concerned. Complaints at this stage may be finalised by providing information and advice to the complainant — such as explaining the agency’s decision or actions, and why it does not appear to us on our impartial assessment that these have involved maladministration.

If a complainant has not already complained to the agency directly before contacting us, we may advise them to do so. This provides the agency with an opportunity to address their concerns. In suggesting this, while we finalise the complaint made to us, we also invite the complainant to come back to us if they are not satisfied with the agency’s response.

Figure 5: How we finalised complaints

*This includes where we provided information/advice to allow the complainant to make their complaint to the agency and where we contacted the agency on the complainant’s behalf.

Figure 6: Time taken to finalise actionable complaints

Complaints finalised by areas of jurisdiction

In 2024–25, we finalised 16,658 actionable complaints across all areas of our jurisdiction. As shown in Table 2, this includes complaints about state government, local government, privately managed correctional centres, public universities, NSW Government-funded community service providers, and other public authorities. Complaints about state government represent 70% of all complaints that we finalised in 2024–25 and includes complaints about correctional centres and corrections-related services, and community services provided by state government.

*includes Local Aboriginal Land Councils and agencies that could not be grouped into the other categories.

Finalised complaints about state government

In 2024–25, we finalised 11,706 actionable complaints about NSW State government departments and their agencies and entities. We finalised most complaints about bodies in the Communities and Justice portfolio (6,641), followed by the Health portfolio (1,527) and the Customer Service portfolio (1,361).

Table 3: Finalised actionable complaints about NSW State government, by portfolio

Table 4: Finalised actionable complaints about NSW State government, by agencies/organisations/entities (top 15 by number)

Finalised complaints concerning people in custody or on a community corrections order

We finalised 4,590 actionable complaints (28% increase from 2023–24) about adult correctional centres in 2024–25. We finalised 951 actionable complaints about Justice Health and the Forensic Mental Health Network.

Complaints received from people in custody are primarily received by telephone (calls to our office are free and not monitored by prison authorities). We also receive complaints in writing and during visits to custodial facilities. This year we conducted 38 visits to adult custodial facilities (including 2 transitional centres). Some visits took place over multiple days.

Table 5: Finalised actionable complaints about adult correctional centres, including privately managed correctional centres (top 10 by number)

*Privately managed correctional centres.

^Privately managed before returning to a government-managed centre as of 31 March 2025.

We receive the most complaints from large correctional centres and centres housing maximum security inmates. Actionable complaints from the top 10 centres (as per Table 5) represent 68% of all complaints about adult correctional centres that we finalised in 2024–25.

Finalised complaints about local councils

In 2024–25, we finalised 2,907 actionable complaints about local councils (9% increase from 2023–24).

Table 6 shows the 10 councils with the highest number of actionable complaints finalised. Actionable complaints about these councils represent 29% of all local government actionable complaints that we finalised in 2024–25.

Table 6: Finalised actionable complaints about local councils (top 10 by number)

*Rate of complaint per 100,000 residents (%) has been calculated using the Australian Bureau of Statistics (ABS) 2021 Census data and published council website data.

**We may receive multiple complaints from 1 resident.

Finalised complaints about community service providers

In 2024–25, we finalised 851 actionable complaints (increase of 40%) about DCJ Community Services and NSW Government-funded community service providers (non-government).

Most finalised community services complaints were about out of home care services (57%) and statutory child protection (26%).

Table 7: Finalised actionable complaints about community services provided by the Department of Communities and Justice (DCJ) and NSW Government-funded community service providers (non-government)

Finalised complaints about public universities

In 2024–25, we finalised 602 actionable complaints about public universities (15% increase from 2023–24).

On 1 February 2025, the federal government launched the National Student Ombudsman (NSO), providing a free, independent and impartial complaints service for higher education students to address unresolved issues with their higher education providers, including NSW public universities.

Our office liaised closely with the NSO to ensure appropriate referral pathways were established.

Table 8: Finalised actionable complaints about public universities

Warm referral

1,524 warm referrals in 2024–25

We have arrangements with larger agencies that allow us to ‘warm refer’ complaints directly to them, with the complainant’s consent. We do this where we assess the agency has not had a reasonable opportunity to address the complaint itself. This is helpful as it means the complainant does not have to start the process of complaint again by contacting the agency directly, and the agency is aware that the issues have been raised with us.

Of our actionable complaints, 9% (1,524) were finalised by way of warm referral. This is a 34% increase in warm referrals from 2023–24.

Preliminary inquiries made on 22% (3,703) of the actionable complaints finalised in 2024–25

After receiving a complaint, we may make preliminary inquiries under s 13AA of the Ombudsman Act. This means we engage with agencies to seek answers to questions raised by a complaint or request documents or other material to help us understand and address the issues raised, and to consider if there may have been serious maladministration that could warrant formal investigation.

Most complaints in which we make preliminary inquiries are finalised following such inquiries, and without proceeding to formal investigation of maladministration. Sometimes this is because the information we receive suggests no further action is warranted and we are in a better position to explain to the complainant why this is the case. In other cases, our inquiries prompt agencies to take action to resolve the complaint (for example, by reviewing a decision, providing an apology or undertaking some other corrective action) or to provide the complainant with reasons or further information that addresses their concerns.

Comments or suggestions

84 comments or suggestions were made in respect of 52 actionable complaints finalised in 2024-25.

Section 31AC of the Ombudsman Act allows us to provide information or make comments to an agency in respect of a complaint. In the process of resolving a complaint, we may formally make such comments or suggestions to an agency. Comments are generally aimed at assisting an agency to improve its service delivery or its own complaint handling. Of the 84 comments or suggestions made:

• 74 suggestions were fully accepted by agencies
• 7 suggestions were partially accepted
• 3 suggestions were not accepted by agencies.

Formal conciliation of complaints

18 actionable complaints finalised by conciliation conferences in 2024–25.

Under section 25A of the Ombudsman Act we can invite the complainant and subject agency to participate in a voluntary conciliation conference. In doing so, we facilitate a discussion and encourage the parties to reach an agreement that can resolve the issues between them.

In 2024–25, 18 actionable complaints were finalised by formal conciliation and have reached full agreement.

Referrals for investigation

10 complaints were referred to the agency for investigation, and 1 complaint was finalised following a satisfactory response to a referral.

Under section 12A of the Ombudsman Act, the Ombudsman may decide to refer a complaint about the conduct of an agency back to that agency for investigation.

An agency that receives a referral under section 12A of the Ombudsman Act must:

• consider any recommendations we make in deciding how to deal with the referred complaint
• on the request of the Ombudsman, provide documents and other information relating to the complaint
• report to the Ombudsman on the outcome of the referral.

In 2024–25, we referred 10 complaints to agencies for investigation and finalised 1 complaint following a satisfactory response to a referral. We continue to monitor the agency responses to our referrals.

Referral of community services complaints for resolution or investigation

10 complaints were referred for resolution/ investigation and 13 complaints were finalised following a satisfactory response to a referral.

Under section 25 of the CS CRAMA, the Ombudsman may refer a community services complaint to another person or body (including a service provider) if the complaint raises issues that may require resolution or investigation.

In 2024–25, we referred 10 complaints to agencies for resolution/investigation and finalised 13 complaints following a satisfactory response to a referral (which includes matters that had been referred in the previous financial year).

Formal Ombudsman Investigations

15 new investigations were commenced and 9 investigations were finalised in 2024–25, with 17 investigations remaining in progress.

The Ombudsman may make the conduct of a public authority the subject of a formal investigation under the Ombudsman Act where it appears that any conduct of that authority may be contrary to law, unreasonable or otherwise wrong.

In 2024–25, we commenced 15 new investigations, and we finalised 8 investigations with findings of wrong conduct under section 26 of the Ombudsman Act. We discontinued 1 investigation and made suggestions under section 31AC of the Ombudsman Act. We continue working on 17 investigations.

Reviews of our decisions

Our policy is to allow complainants an opportunity to request a review where we have closed their complaint and they are dissatisfied with what we have done.

In 2024–25, we received 16 requests seeking a review of a decision we made about a complaint.

Of the 16 requests for a review:

1. We affirmed our decision to finalise the complaint in 5 of those cases.
2. We re-opened 6 complaints and made further inquiries with the agency in relation to the complaints.
3. As at 30 June 2025, 5 reviews were still open.

In 2024–25, we finalised 36% of reviews within 3 months from receipt, and 91% within 12 months.

Investigation findings and recommendations

Under section 17 of the Ombudsman Act, our investigations must be conducted in the absence of the public.

When the investigation is completed, if findings of wrong conduct are made, we provide a final report on the investigation to the relevant agency and its responsible minister under section 26 of the Ombudsman Act.

The report may include recommendations for corrective action in respect of the particular wrong conduct, as well as for systemic and administrative improvements.

Investigations summary report

While not all investigations result in a special report being tabled in Parliament, our current practice is to include a summary of all completed investigations in our six-monthly Casebook of investigations and complaint-handling case studies report to Parliament. During the year we tabled 2 Casebooks — the July 2024 Casebook and the January 2025 Casebook.

Monitoring implementation of investigation recommendations

When we make recommendations following an investigation, we seek to ensure that they are evidence-based, practical and likely to lead to demonstrable improvements in administrative practice. We monitor the implementation of our recommendations to ensure that accepted recommendations are implemented in a timely manner. Below are some examples of outcomes achieved, and improvements made by agencies that responded positively to our recommendations made in investigation reports.

Department of Communities and Justice — An onerous and ineffective child protection safety plan

In July 2024, we finalised an investigation into the Department of Communities and Justice’s (DCJ) imposition of a safety plan concerning 2 children in out of home care (OOHC), which required the authorised carer to live outside of the family home for over 3 years and be supervised by his wife in the presence of the children.

We found that the plan was onerous, impractical and ineffective in ensuring the safety of the children, and had not been reviewed either during or after an investigation into the carer’s conduct. The plan was not replaced by a long-term safety plan as it should have been.

DCJ accepted our recommendations and has apologised to the carers. It is in the process of complying with our recommendation to compensate the carers.

Corrective Services NSW — Inmate discipline in NSW correctional centres

In August 2024, we finalised an investigation about the disciplinary system that governs inmates who are alleged to have committed a ‘correctional centre offence’ while in custody.

We found that there was a systemic failure to follow the requirements of the legislation and relevant policies relating to inmate discipline, which can lead to unjust and potentially unlawful decisions. We also found poor practices amounting to maladministration at all steps in the disciplinary process across centres and decision-makers.

Corrective Services NSW (CSNSW) accepted all recommendations. It has fully complied with 1 recommendation and made substantial progress on the others, including:

• revised procedures, staff training, communication plan and consultation
• legislative changes introducing a new power for the Commissioner to review findings of guilt, penalties and compensation orders
• 2,845 orders to inmates to compensate CSNSW for damaged property have been reviewed and so far $92,000 has been reimbursed to those inmates were found to have been overcharged or wrongly charged
• consultation with the Chief Magistrate of the Local Court and the Department of Communities and Justice about the circumstances in which disciplinary offences should be referred to a Visiting Magistrate
• updates made to the offender database to reflect changes to procedures.

Serco Australia Pty Ltd — Actions taken against bystander inmates following an incident at Clarence Correctional Centre

In August 2024, we finalised an investigation into Serco’s management of inmates who witnessed an inmate assault on an officer in September 2023. Bystander inmates were locked in cells for 5 days, placed on segregation orders, charged with correctional centre offences and placed on behaviour management contracts that restricted their time out of cell to 2 or 4 hours a day for 8 weeks.

Our investigation found that Serco’s conduct when managing bystander inmates was, in some aspects, contrary to law, and otherwise unreasonable and oppressive.

CSNSW accepted and implemented all recommendations. Serco complied with all recommendations made to it, except for apologising to all affected inmates.

Corrective Services NSW — Inmate charged for providing false or misleading information

In August 2024, we finalised an investigation into CSNSW after receiving a complaint that an inmate had been unfairly charged and found guilty of a correctional centre offence for giving false or misleading information. He was penalised by not being able to buy items from the inmate shop (known as buy-ups) for 56 days, which is the maximum allowable length for this penalty type.

CSNSW accepted the finding and has complied with our recommendation.

Serco Australia Pty Ltd — Unlawful findings relating to disciplinary charges concerning misuse of offender telephone system

In September 2024, we finalised an investigation into Serco’s disciplinary charges against 2 inmates at Clarence Correctional Centre for misusing a telephone¹¹ and disobeying a direction.¹² Both inmates told us they had lent their centre-issued tablets to another inmate, whose tablet was not working, so that inmate could make telephone calls. The 2 inmates claimed they had not been told that lending their tablets to another inmate was an offence. We found that the offences could not be proven beyond reasonable doubt and charges should not have been laid in the first place.

Serco has implemented our recommendations.

School Infrastructure NSW — Drainage dispute with residential neighbour

In August 2024, we finalised an investigation into School Infrastructure NSW’s (SINSW) handling of a drainage dispute between a NSW public school and the owner of a residential property adjoining the school. The owner complained to us after SINSW insisted he take immediate action to redirect his stormwater drainage, which had flowed into Council’s drainage infrastructure on the school property for the past 25 years. SINSW had told the complainant it would terminate the stormwater connection within days if he did not act.

Once we became involved, SINSW agreed to consider an easement for the residential property to access the stormwater drainage, but then insisted the complainant pay the first of 2 instalments totalling almost $20,000 within 10 calendar days to secure this arrangement.

We found that SINSW had set unreasonably short deadlines for the complainant to act and had failed to act in line with its own stakeholder engagement guidelines and communication strategy.

SINSW has complied with our recommendations.

University of Western Sydney — Fee increases for continuing student

In September 2024, we finalised an investigation into the University of Western Sydney’s decision to increase subject fees by 100% in relation to a student who was enrolled in, and part-way through, their postgraduate course.

The university’s student fees policy stated that tuition fees for all fee-paying programs are reviewed annually and may increase over the period of enrolment. It also specified that any increases would apply to all students irrespective of the date of enrolment.

The university explained to the complainant that it had increased the fees to bring them in line with fees charged by other universities and other courses in the relevant school.

We found the university’s conduct unreasonable. We formed the view that students should be able to expect that any future annual adjustments to course fees would be relatively modest and generally reflective of changes in a university’s costs of providing the course. In this case, the fee increase of 100% was far greater than what students could have reasonably anticipated and was not justified on the basis of relevant changes to the university’s cost of delivering the course.

The university has implemented our recommendations.

GEO Group Australia Pty Ltd — Management of inmate during and after seizure

On 30 June 2025, we finalised an investigation into the conduct of GEO (which, at the relevant time, operated Junee Correctional Centre) relating to its use of force and restraining of an inmate who was having a seizure, the way he was questioned after the incident, and the conduct of any reviews into the incident. We also investigated GEO’s conduct in connection with the subsequent charging of the inmate with the correctional centre offence of assault, and the inquiry process, determination of the charge and the imposition of penalties.

We are awaiting CSNSW and GEO’s responses to our recommendations.

Public reports

Special reports and statutory reports to Parliament

Under section 31 of the Ombudsman Act, the Ombudsman can make special reports to Parliament on any matter arising in connection with the discharge of the Ombudsman’s functions.

We may make a special report following a particular investigation and tend to do so especially where these may have broader implications beyond the particular complaint and the agency or service provider involved.

We are also required to provide annual or biennial reports to Parliament for particular functions. In 2024–25, we tabled 11 reports to Parliament:

Monitoring and assessment of Aboriginal programs

Since 2013, we have held a specific legislative function to monitor and assess the NSW Government’s Aboriginal Affairs plan known as OCHRE (Opportunity, Choice, Healing, Responsibility, Empowerment). This role enables us to hold government agencies accountable for delivering meaningful, community-level outcomes and driving systemic, long-term change through OCHRE.

Following our 2019 report and its associated recommendations, we monitored their implementation and impact, culminating in the 2OCHRE 2024: Current status and future direction report to Parliament tabled 28 January 2025. The report makes a core recommendation that the NSW Government unequivocally recommit to OCHRE as the state’s overarching plan for Aboriginal affairs.

In April 2025, the Hon David Harris, Minister for Aboriginal Affairs and Treaty, responded to the report, acknowledging its value and the importance of sustained community involvement. We await the government’s substantive response to our report recommendations.

Monitoring the delivery of community services and related programs

Reviewing the deaths of children

Convening the NSW Child Death Review Team (CDRT)

Under Part 5A of CS CRAMA, we convene and support the CDRT, which consists of experts in health, child development, child protection and research, and representatives of key government agencies.

The CDRT’s purpose is to analyse the trends and patterns in deaths of children by cause, demographic and other factors, and to make recommendations that may assist in preventing or reducing the likelihood of child deaths. The CDRT maintains a register of child deaths and undertakes research that aims to assist with the prevention or reduction of child deaths.

Approximately 450–500 children aged 0–17 years die in NSW each year. The next biennial report of the deaths of children in NSW in 2022 and 2023 will be tabled in November 2025.

The CDRT reports annually to Parliament on its activities and agency progress on the implementation of CDRT recommendations. The CDRT annual report for 2024–25 will be tabled on 30 October 2025.

CDRT research

The CDRT undertakes research, either alone or with others, that aims to help prevent or reduce the likelihood of child deaths and to identify areas requiring further research.

The CDRT Research Framework was developed to guide the prioritisation, delivery and communication of research projects; ensure the CDRT’s approach to research is consistent, equitable and inclusive; support collaboration with stakeholders; and align research projects with the CDRT’s strategic priorities and the NSW Ombudsman’s strategic plan.

The CDRT has 3 current research projects:

Reviews of deaths of children in circumstances of abuse or neglect or children in care

Under Part 6 of CS CRAMA, a child’s death is reviewable by the NSW Ombudsman if that child:

• was living in care or had been in detention at the time of their death, and/or
• died because of abuse or neglect, or in circumstances suspicious of abuse or neglect.

These are referred to as ‘reviewable deaths’. Our reviewable death function aims to identify agency practice and systemic issues that may have contributed to reviewable deaths, or that may expose other children to risks in the future. As part of this work, we consider how agencies and service providers identified and responded to risks and vulnerabilities evident in the lives of the children and their families. We may also consider how relevant agencies responded to the death, such as subsequent critical incident investigations.

The Ombudsman is required to report biennially on its reviewable deaths work and activities. The next biennial report of the reviewable deaths of children in NSW in 2022 and 2023 will be tabled in late 2025 and will include information in relation to:

• progress in relation to recommendations to agencies about issues identified in our reviews regardingtheir responses to children and families involved in reviewable deaths
• a Clinical Excellence Commission review of a death that occurred within 12 months of presentation to a NSW Health facility, following our recommendation of this review in November 2023
• the outcome of consultation with agencies about missed opportunities for cross-agency learning about systems reform to improve child safety and wellbeing, identified across 10 reviewable deaths.

Oversighting the public interest disclosures scheme

We are responsible for oversighting the Public Interest Disclosure (PID) scheme in NSW. The Ombudsman’s functions under the Public Interest Disclosures Act 2022 (PID Act) are to:

• promote public awareness and understanding of the Act and its objects
• provide information, advice, assistance and training to agencies and public officials on contacts relevant to the Act
• publish guidelines and other materials to assist agencies, public officials and other persons
• audit and monitor how agencies exercise their functions under the Act
• provide reports and recommendations to the Premier and the Special Minister of State about proposals for legislative and administrative change to further the objects of the Act.

We are required to issue an annual report outlining, among other things, the Ombudsman’s activities under the Act.

This report will be tabled before the end of 2025.

Engagement and training for agencies

The PID Act applies to a wide range of agencies and service providers across NSW.

We facilitated the first NSW PID Awareness Week in August 2024, aimed at raising awareness of the PID Act among NSW public officials. We delivered nine sessions on key PID-related topics, with over 1,194 participants attending online or watching the recordings following the event.

PID scenario-based training for managers and disclosure officers was developed in 2024–25, delivering 21 sessions to 267 people across regional NSW and metropolitan Sydney. We continued to facilitate access to e-learning courses, allowing agencies to either upload to their learning management systems or attend an Ombudsman hosted course, facilitating access for 101 public officials. We also developed additional resources including a fact sheet for managers, 6 new PID Bytes and curated a PID playlist for public officials and agencies.

The PID Community of Practice (CoP) met 3 times during the reporting period, boasting 134 members with a range of responsibilities under the PID Act.

Table 9: PID sessions and participants

Engaging the Aboriginal Land Council network

Aboriginal Land Councils (ALCs) are agencies under the PID Act. Chief Executive Officers (CEOs), Board Members/Councillors, staff and voting members of ALCs are public officials and can report serious wrongdoing under the PID scheme.

We have provided virtual and in-person training and awareness sessions to CEOs, disclosure officers and managers of ALCs across NSW. We travelled across NSW to hold 22 in-person training and awareness sessions, engaging over 72 CEOs and Board Members/Councillors of ALCs. We are also refining our learning materials and products for ALCs.

Advice and guidance on the PID Act

Under the PID Act, we can provide advice to NSW government agencies about their functions under the Act, and to public officials and other persons about the operation of the Act and the protections available to them. In 2024–25 we responded to 201 requests for advice from NSW government agencies.

In 2024–25 we identified several common issues including uncertainty about internal reviews, confusion about detrimental action offences and associated reporting requirements, and poor understanding about what constitutes an anonymous PID. We are addressing these issues by revising our guidelines and making them a focus during training and engagement activities.

Auditing and monitoring

Oversight of mandatory disease testing

Our monitoring of the MDT Act

The Mandatory Disease Testing Act 2021 (MDT Act) came into effect in July 2022. It provides for the mandatory blood testing of a person where that person’s bodily fluids come into contact with a health, emergency or public sector worker:

• as a result of the person’s deliberate action, and
• the worker may be at risk of contracting a blood-borne disease.

We monitor and report on the operation and administration of the MDT Act, including how agencies exercise their functions under the Act.

Agencies must notify us after determining a mandatory testing order (MTO) application. The Chief Health Officer must also notify us following the determination of any application for a review.

Report on our monitoring

During 2024–25 we received 43 notifications of determinations made by agencies on MTO applications.²⁶ Of these, 39 notifications were received from the NSW Police Force, and 2 notifications each were received from NSW Ambulance and Corrective Services NSW.

Agencies approved 21 MTO applications and refused 10, and there were 12 that were the subject of application to the court (because they related to persons identified as being a minor or other vulnerable person).²⁷ Of the 12 MTO applications made to court, 10 applications were granted by the court and 2 applications were withdrawn prior to hearing.

During 2024–25 we did not receive any notifications of determinations of reviews by the Chief Health Officer.²⁸

Reviewing complaint-handling systems

During 2024–25 we established a Complaint-Handling Systems Review Unit to engage with agencies and conduct reviews on the complaint-handling systems of public authorities (under the Ombudsman Act) and community service providers (under CS CRAMA).

During the reporting period we launched a self-assessment review of agencies’ complaint-handling practices and a complaint-handling staff survey. We anticipate reporting on the self-assessment reviews and survey results in 2025–26.

Supporting agencies and service providers through training and resources

Guidance and resources

Education and training sessions

We provide education and training to government agencies and other service providers to encourage good administrative practices and build sector capability to understand administrative law in the public sector, handle complaints, establish effective complaint-handling systems and manage unreasonable conduct by a complainant.

Table 10: Annual training delivered

Table 11: Annual learners

Table 12: Breakdown of training delivered 2024–25 (excluding PID)

Table 13: 2024–25 training feedback

During 2024–25 we developed new and refreshed courses, including:

• Fact Finding in Complaint Management: providing learners with an understanding of the 3 stages of complaint-handling, and the tools to conduct complex inquiries into a complaint.
• Effective Complaint Management Guidelines e-Learning: freely available to anyone, replacing the 2017 NSW Government CHIP training module, and aligned to the recently updated and published Effective Complaint Management Guidelines.

Supporting members of Parliament to serve their constituents

Complaint referrals from members of Parliament

In 2024–25, members of Parliament referred or made 19 actionable complaints to us.

Presentations

We are committed to ongoing engagement with Parliament about the role of our office and how we can support members of Parliament and their constituents. In August 2024 and March 2025, the Ombudsman presented to Members of Parliament and their staff on our functions and how we can support Members and their offices.

Our parliamentary oversight committee

The Ombudsman is accountable to a statutory joint parliamentary committee: the Parliamentary Committee on the Ombudsman, the Law Enforcement Conduct Commission and the Crime Commission. We keep the Committee informed about issues affecting our office, including those that impact our ability to perform our functions effectively. The new committee members were briefed on our role and functions during a visit to the Ombudsman in September 2024. The Committee conducts an annual review of our office, and we appeared before the Committee for that purpose in March 2025.

Contribution to parliamentary inquiries

We also assist Parliament, especially parliamentary committees, by contributing to inquiries where our experience, expertise and data are relevant to the issues being canvassed. This advice contributes to public debate, effective law-making and scrutiny of Executive action.

During 2024–25 we contributed to 1 parliamentary inquiry and appeared before the Budget Estimates Committee in August 2024. Refer to Section 3.4 for more information.

The annual Parliamentary Ombudsman Meeting brings together representatives from Ombudsman offices across Australia and New Zealand.

2025 attendees from left: Iain Anderson, Commonwealth Ombudsman; Paul Miller, NSW Ombudsman; Dr Grant Davies, Tasmanian Ombudsman and Health Complaints Commissioner; Marlo Baragwanath, Victorian Ombudsman; Bridget Hewson, Deputy Ombudsman, Ombudsman New Zealand; Anthony Reilly, Queensland Ombudsman and Inspector of Detention Services; Emily Strickland, South Australian Ombudsman.

3.3 Reporting on our key performance indicators

Our key performance indicators were formulated around our 4 strategic outcomes, incorporating key operational data metrics as well as results from our ongoing survey program. Our surveys focus on complainant and stakeholder satisfaction, inmate awareness and satisfaction, and general community awareness, providing a key source of information to help us understand how we are performing, and ways we can improve.

3.4 Parliamentary committees and independent reviews

We assist parliamentary committees and independent reviews by providing information and submissions where our experience, expertise and data are relevant to the issues being canvassed.

This year we engaged with one NSW Parliament committee in the Ombudsman’s capacity as Convenor of the CDRT.

We also appeared before the Portfolio Committee No. 1 Budget Estimates inquiry in August 2024.

Contributions to other inquiries and reviews

Our office contributes to other parliamentary inquiries, independent inquiries and reviews where we can provide useful information about our work of relevance to the terms of reference for the inquiry. In 2024–25, we made 3 submissions.

4.1 Our people (and PMES)

As at 30 June 2025, our workforce consisted of 259 people (250.1 full-time equivalent staff levels). Our people have diverse skills and experience and come from a range of backgrounds, including community and social work, legal, planning, investigative, law enforcement and child protection.

Our staff are employed under the provisions of the Government Sector Employment Act 2013, along with associated rules and regulations and the Crown Employees (Public Service Conditions of Employment) Reviewed Award 2009. These industrial instruments set out the working conditions and entitlements offered to staff.

Our organisation chart as of 30 June 2025 was as follows:

Table 14: Full-time equivalent staff levels (as at 30 June)

*This includes the Ombudsman and Band 2 senior executives.

Table 15: Senior executive remuneration — number of senior executives by gender (as at 30 June)

*As at 30 June 2025, 6 senior executives were on temporary (‘acting up’) assignments which resulted following the departure of 3 executives and a hybrid executive model being in place during the implementation of a new Executive structure (see Section 1.4).

Table 16: Senior executive remuneration — average range across all positions (as at 30 June)

Table 17: Senior executive remuneration — percentage of total employee-related expenditure (as at 30 June)

2024 People Matter Employee Survey (PMES)

In August, we conducted the 2024 PMES, which achieved an office-wide response rate of 95%. Flexible working (95%), ethics and values (87%), and risk and innovation (82%) were our highest scoring areas.

This year we have focused our actions on improving our scores in senior executive leadership (54%), feedback and performance management (59%), action on survey results (57%), communication and change management (60%), as well as teamwork and collaboration (61%). These include:

• building a sense of belonging, connection, teamwork and collaboration
• promoting development opportunities and supporting growth at all levels
• creating a respectful, safe and inclusive workplace
• fostering a culture of trust and supporting clarity in a changing environment.

Table 18: NSW Ombudsman PMES results (2020–24)

4.2 Consultants

We use guidance provided in TPG 25-03 Financial Reporting Code for NSW General Government Sector Agencies, and the definition provided by the NSW Procurement Board, to assess whether certain expenses are to be classified as consultant expenses.

There are no consultant expenses valued at $50,000 or more in the 2024–25 reporting period.

There was one consultant expense valued at less than

$50,000 in the reporting period: $33,583 for management services related to our strategic planning.

4.3 International travel

No international travel was undertaken by staff in 2024–25.

4.4 Research and development

Research into the role of Generative Artificial Intelligence (GenAI) in empowering complainants

This year the University of Newcastle delivered a final research report, Utilising Generative Artificial Intelligence to Assist Complainants Who Speak English as a Second Language.³³ We provided funding and review support to the research project.

The project comprised of experimental research with consumers and complaint-handlers, and a literature review. The researcher team found that: ‘GenAI-assisted tools increase ESL consumers’ capability to complain and improves perceptions that the complaint will likely be successfully resolved, while also reducing their perception of language discrimination.’

The report highlights the potential for tech-driven solutions to create more equitable service experiences for complainants.

4.5 Technology

Information communications technology

4.6 Events arising after end of annual reporting period

Other than those identified throughout the annual report, there are no events after the end of the annual reporting period that have a significant effect on our operations.

Key events arising after the end of the annual reporting period include:

• We recruited and onboarded new executive staff as part of the transition to a new executive leadership structure. See Section 1.2 for information about newly appointed executives and ongoing recruitment.
• On 1 August 2025, we publicly launched our Strategic Plan 2025–30, setting our direction for the coming years, with the aim to focus and streamline our efforts for the greatest impact.

4.7 Internal audit, risk management and insurance activities

As an independent office, we are accountable to the people of NSW through the NSW Parliament.

Our work is scrutinised by the Parliamentary Committee on the Ombudsman, the Law Enforcement Conduct Commission and the Crime Commission. The Committee monitors and reviews the exercise of our functions and the annual appropriation for our services, examines our annual reports and other reports to Parliament, and may report to Parliament, with any comment it thinks fit, on any matter about or connected to our work. However, the Committee cannot reconsider our decisions about individual complaints and investigations.

4.8 Internal audit and risk management policy attestation statement

4.9 Quality assurance

In 2024–25, we continued to enhance our commitment to quality and accountability by completing the International Ombudsman Institute’s self-assessment tool. The tool is designed to help Ombudsman offices benchmark their functions and capabilities against regional and international best practice. Outcomes from the self-assessment contributed to the development of our new Strategic Plan 2025–2030.

Building on the foundations established last year, we conducted 7 reviews through our Quality Assurance Framework, resulting in 34 recommendations for process improvement. All recommendations from finalised reviews have been accepted, highlighting a focus on continuous improvement and excellence in service delivery.

As a result of the reviews, improvements have included:

• the introduction of data tools for external training allocation and management
• additional guidance material for our complaint-handling staff.

4.10 Privacy and Personal Information Protection Act compliance

Our Privacy and Information Management Plan addresses the requirements of both the Privacy and Personal Information Protection Act 1998 (PPIPA) and the Health Records and Information Privacy Act 2002.

In the reporting period we received 2 complaints about our compliance with the PPIPA. Under the PPIPA, people have the right to apply for an internal review of conduct that may have affected their privacy. The Privacy Commissioner must be notified of internal reviews and proposed findings and actions, and has the right to make submissions about internal reviews.

In one case, we concluded that there had been no breach of our PPIPA obligations after conducting an internal review under the Act.

In the other case, we determined that there had been a breach of privacy, took steps to prevent similar breaches occurring in the future, and apologised to the person affected. At the person’s request, we also carried out an internal review. The review confirmed the earlier determination, including that no further action was required in light of steps already taken.

There are also proceedings currently underway in the NSW Civil and Administrative Tribunal that relate to a person’s applications for review of conduct that occurred in 2023 and early 2024.

4.11 Government Information (Public Access) Act reporting

Under the Government Information (Public Access) Act 2009 (GIPA Act) there is a conclusive overriding public interest against the disclosure of information relating to our complaint-handling, investigative and reporting functions. This information is ‘excluded information’ under the GIPA Act. The secrecy provisions of the Ombudsman Act 1974 also limit the information we can make publicly available.

This means that we tend to receive few GIPA Act applications, and those we do receive are frequently invalid (as they seek excluded information). Where an applicant applies for information, some of which is excluded information and some of which is not, we will assist the applicant to make a valid application for information that is not excluded information.

We also consider requests for information (including for excluded information) and decide whether it might be appropriate for us to exercise discretion to voluntarily disclose requested information under section 8 of the GIPA Act or other legislation.

In accordance with the GIPA Act, we also proactively release ‘open access information’ such as information guides, policy documents and reports tabled in Parliament.

In addition, our website provides information about our most recent publications, activities and other information that may be of public interest. This includes public reports and publications, and selected policies, such as our strategic plan and code of ethics and conduct.

Statistical information about access applications

We received no valid GIPA applications and 12 invalid GIPA applications in 2024–25.

The following information is reported in accordance with clause 8 of the Government Information (Public Access) Regulation 2018:

• Clause 8(a) requires the provision of details of the review carried out by the Ombudsman under section 7(3) of the GIPA Act during the reporting year and details of any information made publicly available by the agency as a result of the review.

In our yearly review, we reviewed the kinds of government information we hold from carrying out our functions. We determined that there had been no significant changes to the kinds of information held that should be released in the public interest.

We determined that the reasons for maintaining the confidentiality of the information held remains unchanged from the previous reporting period. This information relates to matters that we are required to deal with privately and that are sensitive in nature.

No information beyond that already published was made publicly available.

• Clause 8(b) requires the provision of the total number of access applications received by the Ombudsman during the reporting year (including withdrawn applications but not including invalid applications).

We received no such applications.

• Clause 8(c) requires the provision of the total number of access applications received by the Ombudsman during the reporting year that the agency refused either wholly or partly, because the application was for the disclosure of information referred to in Schedule 1 to GIPA (information for which there is conclusive presumption of overriding public interest against disclosure).

We received no such applications.

Table 19: Invalid applications

Table 20: Number of applications reviewed under Part 5 of the GIPA Act (by type of review and outcome)

*The Information Commissioner does not have the authority to vary decisions, but can make recommendations to the original decision-maker. The data in this case indicates that a recommendation to vary or uphold the original decision has been made by the Information Commissioner.

Table 21: Applications for review under Part 5 of the GIPA Act (by type of applicant)

4.12 Public interest disclosures

NSW Ombudsman public interest disclosure policy

As an agency covered by the PID Act, our office is required to have policies and procedures in place to facilitate the reporting of wrongdoing by staff. We have made our people aware of the PID Act and assured them that they will be protected and supported if they make a public interest disclosure (PID).

We have a PID policy, which is available on our staff intranet and website. New staff are required to read the policy as part of their induction, and information about reporting wrongdoing is regularly communicated to staff. We also provide training to all PID disclosure officers and people managers in the office about the important role they play in handling disclosures staff may make to them.

4.13 Complaints about us

We welcome feedback about our services, and we take any complaints about our own services and decisions seriously. Complaints provide us with an opportunity to look at the quality of our services and the feedback we receive is used to improve our performance and services.

In 2024–25, we received 15 complaints about the services we provided or the actions of our staff. Issues raised in the formal complaints included allegations of:

• poor customer service
• failure to deal appropriately with a complaint
• failure to respond.

In 2 cases we found the complaints were substantiated. Our resolution included apologising to the complainant and reviewing our policies and practice. These complaints are treated separately from requests for review of our decision: see Section 3.2.

4.14 Report production information

Cost of production

We engaged the following services for this report:

• an external designer to design and produce the report, at a cost of $15,070
• a proofreader, at a cost of $2,750
• an indexer, at a cost of $380.

5.1 Modern Slavery Act 2018

NSW Government agencies are required by the Public Works and Procurement Act 1912 to take reasonable steps to ensure that goods and services procured are not the product of modern slavery within the meaning of the Modern Slavery Act 2018.

No modern slavery issues were raised by the Anti-slavery Commissioner during the financial year in relation to the operations of our office. The procurement team continues to monitor and assess modern slavery risks as part of ongoing day-to-day processes.

5.2 Workplace diversity

Our office is committed to building a workforce that is inclusive and respectful where our staff and the stakeholders we work with feel valued and supported.

We continued to embed our Diversity & Inclusion Framework supported by the Diversity & Inclusion Forum and celebrated a number of diversity and inclusion events to promote greater inclusion in the workplace.

Diversity and inclusion

This year we have achieved the following diversity and inclusion milestones:

• became a member of Menopause Friendly Australia and commenced work towards accreditation as a Menopause Friendly Workplace
• became a member of Diversity Council Australia
• continued to partner with Pride in Diversity, and ACON to deliver specialised LGBTQIA+ awareness and inclusivity training
• renewed our Disability Confident Recruiter accreditation in partnership with the Australian Disability Network continued to partner with Pipeline Talent to increase workforce diversity focusing on Aboriginal and Torres Strait Islander recruitment.

In addition to the above, we continue to celebrate a wide range of diversity and inclusion events through the staff-led Diversity and Inclusion (D&I) Advisory Forum that supports the implementation of a range of D&I initiatives to promote greater inclusion in the workplace.

Inclusive recruitment

All candidates are now asked if they require reasonable adjustments at every stage of the recruitment process, and hiring managers are being educated and guided through the process. We are committed to continuing this journey by building knowledge and awareness of inclusive recruitment practices to ensure candidates have a positive experience at every step of the recruitment process.

During 2024–25 we successfully renewed our accreditation as a Disability Confident Recruiter with the Australian Disability Network. Reaching accreditation involved a comprehensive review of our end-to-end recruitment process, and we have identified and removed any unintended barriers for candidates. We will continue to build our knowledge and awareness of inclusive recruitment practices for all candidates.

Equitable remuneration

Our office had a gender pay gap in average full-time equivalent remuneration of 13.6% as at 30 June 2025. This is an increase from 7.5% as at 30 June 2024.

Our gender pay gap primarily reflects a higher proportion of female staff being in less senior roles compared to men, and this year the recent departure of 3 female executives also contributes to this. We continue to monitor our gender pay gap to ensure our recruitment and remuneration practices do not adversely impact the equitable remuneration of our staff.

Table 22: Trends in the distribution index

Note 1: A distribution index score of 100 indicates that the distribution of members of the workforce diversity group across salary bands is equivalent to that of the rest of the workforce. A score of less than 100 means that members of the workforce diversity group tend to be more concentrated at lower salary bands than is the case for other staff. The more pronounced this tendency is, the lower the score will be. In some cases, the index may be more than 100, indicating that members of the workforce diversity group tend to be more concentrated at higher salary bands than is the case for other staff.

*The distribution index is not calculated when the number of employees in the workforce diversity group is less than 20 or when the number of other employees is less than 20.

Table 23: Trends in the representation of workforce diversity groups

Note 1: The benchmark of 50% for the representation of women across the sector is intended to reflect the gender composition of the NSW community.

Note 2: The NSW Public Sector Aboriginal Employment Strategy 2014–17 introduced an aspirational target of 1.8% by 2021 for each of the sector’s salary bands. If the aspirational target of 1.8% is achieved, the cumulative representation of Aboriginal employees in the sector is expected to reach 3.3%.

Note 3: A benchmark from the Australian Bureau of Statistics (ABS) Census of Population and Housing has been included for people whose first language spoken as a child was not English. The ABS Census does not provide information about first language but does provide information about country of birth. The benchmark of 23.2% is the percentage of the NSW general population born in a country where English is not the predominant language.

Note 4: In December 2017 the NSW Government announced the target of doubling the representation of people with disability in the NSW public sector from an estimated 2.7% to 5.6% by 2027. More information can be found online.34 The benchmark for ‘People with disability requiring work-related adjustment’ was not updated.

Table 24: Workforce diversity actual staff numbers at census date (as at 1 July 2025)

5.3 Our work health and safety

Work health and safety

We have the following work health and safety (WHS) policies and practices in place:

• work health and safety policy
• bullying, harassment and discrimination policy and procedure
• flexible ways of working model
• mandatory disease testing policy
• reporting and managing incident and hazard reports
• resolving WHS issues at NSW Ombudsman
• return to work program
• workplace adjustment policy and procedure
• WHS risk assessment form and guidance
• working at home policy.

Emergencies are managed in accordance with the emergency management plan for our building and risk management practices are informed by the NSW Ombudsman Risk management framework and policy.

During the year, we developed our workplace adjustment policy and procedure and revised the bullying, harassment policy and procedure.

We also broadened the scope of our WHS risk register to include the management of all the hazards listed within the SafeWork NSW Code of Practice: Managing Psychosocial Hazards at Work.

Work Health and Safety Committee

We have a WHS Committee, comprised of management and staff representatives from our branches, who actively collaborate to identify and resolve safety concerns and provide feedback about safety policies, procedures and tools, and the physical and psychosocial risk register.

The committee reviews and actions WHS inspections, identifies WHS hazards and risks, and understands how operational and business requirements can impact upon the physical and psychological safety of our staff, contractors, complainants and visitors.

Work health and safety injuries and incidents

There were 13 work-related incidents logged in 2024–25 that were reported and managed for risk. This rise in the number of reported incidents, in comparison to 2023–24, was attributed to an increase in awareness about the need to report physical and psychosocial incidents. We also completed an internal audit focused on psychosocial wellbeing and safety, which has identified a range of recommendations and corrective actions now being implemented to help manage health and safety risks.

Workers’ compensation claims

We participate in the Treasury Managed Fund, a self-insurance scheme for the NSW public sector.

As of 30 June 2025, there were 6 open workers’ compensation claims.

Table 25: Workers’ compensation claims — 2-year comparison

*One new claim related to 2024–25 was incorrectly attributed to 2023–24 in last year’s annual report and has been corrected in this report.

Table 26: Workers’ compensation claim rate — 2-year comparison

*One new claim related to 2024–25 was incorrectly attributed to 2023–24 in last year’s annual report and has been corrected in this report.

5.4 Environmental sustainability

Assessing our environmental risks

In 2024–25, we undertook a comprehensive climate risk assessment supported by the NSW Government Climate Risk Ready NSW Guide and in alignment with the NSW Climate Change Adaptation Strategy. Through this process, we identified our climate change risks and associated mitigation strategies, as well as opportunities arising from these risks or their treatments.

Maintaining our greenhouse performance

In 2024–25, we maintained our greenhouse emissions performance by:

• operating in a carbon-neutral certified, 5-star-rated (with 79% renewable energy) green building
• using energy-efficient equipment
• using timers on lights, equipment and supplementary air conditioners.

Reducing our environmental impact

We report progress against the Government Resource Efficiency Policy (GREP). In 2024–25, we focused on reducing our environmental footprint by:

• using 100% recycled paper in printers
• using sorting bins and encouraging recycling through internal communication channels
• maximising diversion of waste by recycling toner cartridges.

6.1 Financial information

Revenue, expenses and financial position

Revenue

The majority of our revenue comes from the NSW Government in the form of a consolidated fund appropriation. This is used to meet both recurrent and capital expenditure. In 2024–25, we received $53.0 million appropriation, an increase of $1.6 million from $51.4 million received in 2023–24.

Training revenue increased slightly to $0.9 million from $0.8 million in 2023–24. Acceptance by the Crown of employee benefits and other liabilities decreased to $1.8 million, which is offset against an expense of the same amount. We also received $0.5 million in interest income. Refer to the financial statements for additional detail.

Figure 7: 2024–25 Revenue ($’000)

Figure 8: Training revenue ($’000)

Expenses

Total expenses recorded was $57.0 million, in line with $56.8 million budgeted expenses. Employee-related expenses accounted for 69% of total expenses. Other significant operating expenses included contractors ($4.2 million (2023–24: $5.4 million)), information technology services ($3.9 million (2023–24: $3.7 million)) and professional services ($1.7 million (2023–24: $1.0 million).

Figure 9: 2024–25 expenses ($’000)

Key financial statistics

Our expenditure is managed within Net Cost of Service (NCOS) control limits set by NSW Treasury. We have delivered our programs and approved expenditure within the approved NCOS limits this year, as we have done for the last 5 years (shown in Figure 10. Net cost of services 2020-25). NCOS excludes direct appropriations and Crown-accepted revenue items.

Figure 10: Net cost of services 2020-25 ($’000)

Financial statements

The financial statements are prepared in accordance with legislative provisions and accounting standards and are audited by the Audit Office of NSW. The independent auditor’s report and financial statements can be found in Section 6.2.

Payment of accounts

The charts below indicate that on-time payments in 2024–25 declined slightly compared to 2023–24; on average 96% of invoices were paid on time (82% for small business invoices). Late payments were mainly due to internal delays in purchase order processing.

Figure 11: Payment of accounts — all suppliers

Figure 12: Payment of accounts — small business suppliers

6.2 Audited financial statements (including Independent Auditor’s Report)

Please see page 87-110 of the Annual Report.

Please see page 111-127 of the Annual Report.