Lessons for Investigators from the NSW Ombudsman’s July 2025 Casebook

The NSW Ombudsman’s Casebook (July 2025) offers a window into how investigations and complaint-handling play out across public authorities, local councils, and community service providers. While the report is aimed at government agencies, the lessons translate directly to the work of workplace investigators and factual investigators.

What is the Casebook?

Ombudsman NSW Casebook July 2025

The NSW Ombudsman’s Casebook is a twice-yearly publication tabled in Parliament. It summarises real investigations and complaint-handling matters from across NSW public authorities, including councils, government agencies, correctional centres, and community service providers.

The Casebook highlights both formal investigations (where maladministration or misconduct is found) and informal resolutions (where early intervention fixes issues before they escalate). It serves as a public accountability tool and a learning resource for agencies — and, importantly, for investigators across all sectors.

How often is it published?

The Ombudsman releases the Casebook every six months, covering investigations finalised in the first and second halves of each year. The July edition reports on matters from January to June. The January edition reports on matters from July to December. This regular schedule ensures ongoing transparency and gives practitioners insight into emerging themes in complaint handling and investigation practice.

What happened in the July 2025 edition?

Key Investigation: Mismanagement at Junee Correctional Centre

The NSW Ombudsman finalised an investigation into GEO Group Australia Pty Ltd, the operator of Junee Correctional Centre, after a complaint from an inmate who said he was unfairly charged with assault following a medical seizure.

What Happened

Inmates alerted officers when an inmate began seizing. Officers called health staff, but they did not arrive for three minutes.

During the seizure, the inmate stood, flailed his arms and legs, and his feet brushed against officers. Officers forced him to the ground, restrained him, lifted him, and placed him handcuffed on a stretcher before taking him to the clinic.

At the clinic, before medical clearance, an officer who had restrained him questioned him. That officer also directed him to complete paperwork while undergoing medical tests, even after noting his cognitive functioning was likely impaired.

The Inquiry and Penalty

The inmate was later charged with assault. During the inquiry hearing, he was recorded as pleading guilty while also saying, “can’t remember, sorry boss.” He received a 28-day reprimand and caution, with the records stating it was “due to medical episode”.

Ombudsman’s Findings

The Ombudsman found the alleged assault was not a deliberate strike, punch, or kick. It was uncontrolled, superficial leg contact that occurred while the inmate was in the middle of a seizure.

The Ombudsman further found that the assault charge legally unsound because assault requires voluntary action, which was absent during a medical episode. This meant that the investigation process ignored the legal threshold for assault and as such failed to comply with legislative requirements.

Furthermore, the officer who had restrained the inmate and was involved in the incident, went on to question him. This is a breach of impartiality standards.

Officers were also found to have produced inaccurate reports, with reviewers also failing to complete a proper assessment of them.

The incident was also never referred to the Use of Force Review Committee (the internal oversight mechanism used with NSW Correctional Centres) despite evidence that the restraint may have involved unreasonable or excessive force against an inmate.

Recommendations

The Ombudsman directed Corrective Services NSW to update records so the guilty finding would be marked as unsound and disregarded in the future. The Ombudsman also required GEO Group to provide the inmate with a written apology.

In addition, the Ombudsman recommended staff training and referral of the incident to the Use of Force Review Committee for remedial action.

Other Thematic Insights

The Casebook also found that many of the matters brought to its office were not originally complex or serious. Instead, they became significant because agencies failed to acknowledge complaints, delayed responses, or applied rigid processes that left people feeling ignored or treated unfairly.

In several examples — from incorrect council debt recovery to delayed health district reviews — a simple, early intervention could have resolved the issue without escalation.

Most complaints don’t start as major issues — they escalate because people feel ignored, delayed, or treated unfairly. The Casebook shows that timely communication, clear explanations, and flexible responses often resolve matters before they require a full investigation.

Principles for Effective Complaint Management

The Ombudsman closes with six principles that apply equally in the private sector:

1. Take ownership – don’t deflect blame.

2. Be timely – delays erode trust.

3. Respect people – treat complainants with dignity.

4. Communicate clearly – explain processes and reasons.

5. Be flexible – tailor approaches to vulnerable people.

6. Learn and improve – use complaints as a source of insight.

Whether in workers compensation, psychological injury claims, or workplace misconduct cases, investigators should adopt the same principles.

Furthermore, complaints are not just problems to “fix” – they are opportunities to strengthen systems and rebuild trust. Swift and thoughtful attention of complaint is critical to timely resolutions.

Why This Matters Now

Psychological injury claims, bullying complaints, and procedural fairness disputes are rising sharply across Australia — and NSW is under intense scrutiny with reforms to workers’ compensation and WHS obligations.

The Casebook shows that how organisations investigate and respond matters as much as what they decide.

For investigators, it’s a timely reminder that:

• Evidence must be gathered and assessed fairly.

• Complaint handling is both a compliance duty and a reputational safeguard.

• Small errors in communication or record-keeping can spiral into systemic failures.

Final Takeaway

The Casebook is more than a catalogue of government missteps — it’s a reminder of the standards all investigators, public or private, must uphold.

Whether you’re investigating workplace bullying, handling a factual investigation for insurance, or advising on compliance frameworks, the same principles apply: communicate, document, act fairly, and address complaints early.