Failures of Record Keeping

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    Failures of record keeping Victorian Ombudsman Reports

    Public Record Office Victoria - Records Management Network Meeting

    Tuesday 29 May 2012

    Presentation by John R Taylor, Deputy Ombudsman for Victoria.

    _________________________________________________________________

    It is disappointing to find in a modern public service that very often

    Ombudsman investigations identify significant failures in record keeping.

    These failures include:

    Poor record keeping Inadequate storage The destruction of records Falsification of records Lack of records in key decision making.

    What are records?

    Very often our investigations identify that only paper records are maintained.That is, copies and originals of correspondence to and from an agency.

    However, when we delve further into an investigation we identify key decision

    making is often recorded in email, faxes and notes not maintained on the

    departmental file.

    For example, in the Ombudsmans investigation into the probity of the Hotel

    Windsor redevelopment tabled in Parliament in February 20111, we identified

    that the department of Planning and Community Development together with

    Heritage Victoria failed to make and keep adequate records regarding the Hotel

    Windsor planning and heritage permit application. These failures were

    particularly important as there had been significant media attention surrounding

    the then Ministers media plan regarding the development which wasinadvertently sent to an ABC journalist in February 2010. Subsequently, the

    Chairman of the Legislative Council Standing Committee on Finance and Public

    Administration requested that the Ombudsman investigate the probity of the

    Hotel Windsor redevelopment.

    You would think that when you are looking at a multi million dollar

    redevelopment that good record keeping would be an essential part of the

    decision making process by any government agency. However, our

    investigation found poor management practices, including the failure of officers

    to file documents accurately and to folio files.

    1Ombudsman Investigation into the Probity of the Hotel Windsor Redevelopment, February

    2011

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    You will see in our report that we identify numerous occasions where significant

    meetings took place for which there was inadequate or no records made. When

    it came to testing what had taken place it was very hard to establish the

    sequence of events. The Ombudsman noted that he was concerned that several

    witnesses also said that the failure of the department and Heritage Victoria tomaintain adequate records was not restricted to the Hotel Windsor planning

    and heritage permit applications.

    Emails are also a great source of information when determining what took place

    in relation to decision making. Very often we find information that puts the lie to

    documented decision making or provides amplification as to what took place.

    Very often copies of these emails are not filed on the departmental file.

    Poor record keeping

    Perhaps the most significant failure which we consistently identify is poorrecord keeping. A good example, of this is the investigation into record keeping

    failures by WorkSafe agents tabled in Parliament in May 2011.2That

    investigation identified poor record keeping at WorkSafe agents, of which there

    were six at the time. These are agents paid for a range of benefits provided to

    injured workers including weekly payments, medical treatment, ambulance

    transport, and personal and household help.

    In 2009-10, WorkSafe paid its agents fees of over $200 million to manage over

    56,000 claims by injured workers in Victoria.

    The investigation identified poor record keeping at the agents, which had the

    following consequences:

    Manipulation of the WorkSafe incentive scheme for agents Delays in payment Poor and delayed decision making and the reduced effectiveness of the

    scheme

    Breaches of privacy.Poor recording keeping at the agents was as a result of inadequate file

    maintenance; inadequate understanding of statutory obligations; and out dated

    information technology systems.

    2Investigation into Record Keeping Failures by WorkSafe agents,May 2011

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    Photograph 1

    Photograph 2

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    Photograph 3

    Photographs 1, 2 and 3 are examples of the poor file maintenance and storage

    systems at a number of the WorkSafe agents. You can see that, by their very

    nature, the files and their condition contributed to incorrect information being

    sent to individuals, medical records being lost or misplaced, and delayed

    decision making.

    Contraband is often seized within prisons and detention centres. It is then theresponsibility of Victoria Police to take appropriate action.

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    Photograph 4

    Photograph 4 is a seizure or exhibit located during an inspection at the Juvenile

    Justice Detention Centre. It contained contraband which was found on

    detainees during a search. There were no names, dates or identifying details in

    relation to the seizure.

    Inadequate storage

    Our investigation into the storage and management of ward records by the

    Department of Human Services tabled in Parliament in March 2012, exemplifies

    the problems that can occur when agencies fail to adequately record and store

    departmental records.

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    Photograph 5

    Photograph 6

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    Photograph 7

    Photographs 5, 6 and 7 illustrate boxes of records held by the department that

    are stored in approximately 80 linear kilometres of files on shelves. These

    historical records relate to former wards of the State of Victoria and are stored

    in boxes at numerous locations.

    The department has not inspected or indexed a considerable portion of these

    records. Accordingly, it cannot provide an accurate estimate of what portion ofthe total holding relates to wards of the State.

    Despite having had the majority of these records in its archives for over 15 years

    the department has only indexed and catalogue records relating to 26 of the

    150 plus years worth of records relating to wards and institutions it holds. The

    majority of these records remain in large part uninspected, unindexed and

    unscanned.

    The department is paying near $1 million a year to rent a facility that has been

    identified as being inadequate to store records and has been subject to flooding

    and rat infestation.

    The departments efforts to come to grips with its vast archive of documentshave been piecemeal and ultimately unsuccessful.

    Increasing numbers of former wards are seeking access to records relating to

    their time spent in care as a way to not only understand their past but also to

    seek and identify siblings and relatives. An internal departmental report noted

    that in the three years prior to May 2011 approximately 21 per cent of all

    searches for records relating to freedom of information requests for former

    ward and adoption records resulted in no documents being located.

    Prisoner health records

    Under the Health Records Act 2001medical information must be stored

    confidentially to protect the privacy of individuals.

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    All prisoner medical records at the Melbourne Assessment Prison are held on

    site. Although these records are monitored by medical staff, one of their

    physical locations is in a thoroughfare and is accessible to all staff.

    Photograph 8

    Photograph 8 shows medical records stored on open shelves at the Melbourne

    Assessment Prison. This situation was identified in our investigation intoprisoner access to health care in a report tabled in parliament in August 2011.

    As a result of bringing this issue to the attention of Justice Health the then

    Director advised that Justice Health was in the process of designing the

    refurbishment of office space and storage and that lockable cupboards were

    now in place for the storage of medical records in the centre.

    Destruction of records

    It is not uncommon to find departmental records missing during an

    investigation. This is particularly the case where misconduct is involved as was

    identified in our investigation into procurement3, where in a number of

    instances officers obtained a benefit from a supplier of toner cartridges and the

    invoices had been destroyed.

    In one case involving a project officer from Arts Victoria the invoices which

    listed gifts that the officer had received were missing. When questioned about

    this, the project officer said I generally did not keep copies of the invoices. In

    this particular case we were able to establish from invoices obtained from the

    company that in 2009-10, the project officer received $8,300 in Coles-Myer

    vouchers and prepaid visa cards from the company.

    3Corrupt Conduct by Pubic Officers in Procurement,June 2011

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    In another case in 2009 involving a building inspector at a council, the councils

    hard copy building file for a property involved in an unorthodox transaction,

    could not be located. When questioned the building inspector acknowledged

    that a hard copy file for the 2008 building inspections had existed but denied

    destroying it, despite having told his manager that he had done so.4

    Falsification of records

    Departmental records, by their very nature, are required to represent the history

    of a case, transaction or business event. However, at times we have identified

    instances where records have been falsified to cover up improper conduct.

    In an investigation involving the allegation of mistreatment of a male resident of

    a supported residential service managed by the Department of Human

    Services5, we identified that two documents allegedly created in response to

    the incident were fabricated by a senior staff member to give the false

    impression that the department had investigated the matter. This of course

    amounts to serious misconduct and as a result discipline action was takenagainst the officer.

    Improper use of records

    There are times when departmental offices will improperly use information for

    their own purposes. In one case, an employee of the Victorian Institute of

    Forensic Medicine6took home autopsy information concerning deceased

    persons for their own prurient interest. When we obtained access to his

    computer and records at his home we located 49 hard copy autopsy reports

    and over 1,200 work related photographs on a CD and hard drive of his

    computer.

    In addition we identified that this person had been circulating photographs of

    inquest material to friends for their enjoyment. The officer resigned during the

    investigation.

    4Whistleblowers Protection Act 2001, Conflict of Interest and Abuse of Power by the

    building inspector of the Brimbank City Council, June 20095Ombudsman Investigation, Assault of a Disability Service Client by Department of Human

    Services Staff, March 20116Investigation into the Improper Release of Autopsy Information by a Victorian Institute of

    Forensic Medicine employee, May 2011

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    Lack of records in key decision making

    Good public administration requires that key decision making be adequately

    documented. This is particularly important where significant government

    expenditure is involved.

    It is concerning when our enquiries identify that decision making in relation tomajor public expenditure is either not documented or poorly documented.

    Photograph 9

    One example as illustrated in photograph 9 was that the only document located

    which established the expenditure of over $27 million in relation to funding for a

    major IT project within Victoria Police, was a one page document with hand

    written annotations.

    This document was illustrative of a poorly run area within a major organisation

    where numerous documents were located in unregistered and informal files.

    Interviewees also said that files they knew had been raised could not be

    located. Further enquiries identified that a number of decisions taken at a

    committee level were not documented in signed records.7

    More recently in our investigation into the Food Bowl Modernisation Project the

    investigation identified that the decision to commit significant funding in

    relation to the Food Bowl Modernisation Project was based on oral discussions

    and earlier projects with virtually no documentation to support the decision

    making. The background report which had been commissioned by a private

    organisation and provided to the then Treasurer could not be located.

    7Own Motion Investigation into the Tendering and Contracting of Information Technology

    Services within Victoria Police, November 2009

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    Subsequently the government committed to $600 million without adequate

    planning or documentation.8

    Conclusion

    The Ombudsmans statutory function is to investigation complaints aboutadministrative actions. Inevitably our stories are about wrong doing, errors and

    mistakes. However the case studies are illustrative of where things go wrong

    and how such problems could be avoided by careful planning and

    management.

    Even the wrong doing identified for example in the toner affair could have been

    prevented by appropriate supervision and management of expenditure and

    records.

    We frequently ask the question Who is responsible?. It is easy to blame the

    individual who failed to keep the record or destroyed a document. However

    there is also a responsibility in terms of leadership within an organisation.The challenge for the public sector is to ensure that not only do managers lead

    by example but also to encourage staff to act appropriately in all

    circumstances.

    The Ombudsman has regularly reported on his concerns about the failure of

    leadership in the public sector. Many of the problems identified in our

    investigations are because of a lack of leadership and management.

    Good leadership in the public sector is important because it:

    Assists in developing a culture where administrative excellence andethical conduct is encouraged

    Protects against improper conduct and can assist in its early detection Ensures adequate scrutiny is applied to areas such as expenditure of

    public funds

    Sets and achieves realistic and beneficial goals Establishes an operating norm of efficiency and diligence.

    Despite progress made by some agencies, we continue to identify agencies that

    fail to learn from their mistakes and fail to fully implement revised policies and

    procedures that our enquiries and investigations have identified.

    8Investigation into the Food Bowl Modernisation Project and Related Matters, November

    2011