We can launch investigations based on information we receive, or by referral from the Victorian Minister for Health. Investigations generally follow a formal process, including a detailed examination of a complaint. Investigations are sometimes conducted in more complex matters but may also be used in simple matters like following up any undertakings made in a complaints resolution process. We may investigate public or private organisations as well as individual providers.

Why we investigate

The primary aim of any investigation is to establish the facts. This allows us to understand what measures, if any, should be taken to protect the public from serious risks to their health, safety or welfare.

We may look into ongoing issues or significant concerns about the appropriateness of care provided to consumers. We might investigate if we consider the complaint too complex for our complaint resolution process or where a health service provider has unreasonably refused to participate in the complaint resolution process. Allegations about serious breaches of the general code of conduct, which applies to general providers not registered with AHPRA or operating outside their registration, may also be investigated.

How we investigate

The HCC will notify relevant parties of the decision to investigate and of the subject matter of the investigation, in writing. However, notification may not be appropriate in some cases if there is a serious risk to the health, safety or welfare of a person or the public.

We have powers to obtain any information relevant to an investigation. We may require access to clinical notes, relevant internal reports, policies and procedures or names of other providers involved. During the evidence-gathering phase, we may conduct hearings or interviews, seek independent expert advice or exercise our compulsory powers.

Procedural fairness

We are committed to acting fairly, impartially and independently towards all parties involved in the investigation. We also act as quickly and with as little formality as is reasonably possible. Before making a decision affecting a person, the HCC will give that person an opportunity to make submissions about the decision.


We aim to complete investigations as quickly as possible, but time frames will depend on the nature and complexity of the matter. More straightforward investigations might be completed within a matter of weeks, while more complex matters involving many providers and wide-ranging issues may take much longer to investigate. In any event, the HCC will provide regular updates to all parties during the investigation.

Outcomes of an investigation

After completing the investigation a report containing evidence, comments or recommendations will be prepared. This report may be shared with the health service provider, complainant, AHPRA, Health Minister, Department of Health Secretary and other relevant parties.

If a report recommends a health service provider undertake quality improvements, we will ask the provider to report back to us on the implementation of those recommendations. If we believe the provider has failed to make these quality improvements we may take further action.

We can also launch a follow-up investigation if a provider fails to undertake:

  • any actions agreed to during a complaint resolution
  • any actions recommended in an investigation report.

In the case of general health service providers, we can issue prohibition orders and public warning statements where the Commissioner is satisfied there is a serious risk to the health, safety or welfare of an individual or the public.