Inquiry Search
Rec-ID | Code | Recommendation |
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REC252-2574 | 32 - Doctrine, standards, and reform | St John Ambulance should ensure the positive gains in clinical governance achieved since the Inquiry become embedded throughout the whole organisation. |
REC252-2570 | 25 - Inquiry, audit, lessons management and after action review | Western Australia Health should carry out targeted clinical audits in volunteer country sub-centres until longer term solutions are in place |
REC252-2570 | 25 - Inquiry, audit, lessons management and after action review | Western Australia Health should carry out targeted clinical audits in volunteer country sub-centres until longer term solutions are in place |
REC252-2569 | 32 - Doctrine, standards, and reform | Western Australia Health should consider publishing information on St John Ambulance’s complaints processes to assist Western Australia Health staff. |
Rec-ID | Code | Recommendation |
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REC228-1607 | 32 - Doctrine, standards, and reform | The Justice and Community Safety Directorate, in managing future amendments to the Emergencies Act 2004, should propose amendments which require the Emergency Services Agency to maintain information on privately-owned assets of public interest that are vulnerable to bushfire without the need to include this information in the Strategic Bushfire Management Plan. |
REC228-1613 | 32 - Doctrine, standards, and reform | The Emergency Services Agency should continue to work with National Land managers and develop a National Land bushfire management framework to address bushfire risks on National Land. |
REC228-1606 | 32 - Doctrine, standards, and reform | The Emergency Services Agency should comply with the Emergencies Act 2004 requirements for the Strategic Bushfire Management Plan by including in this Plan an explicit statement of all resources needed to meet the objectives of the Plan. |
REC228-1612 | 32 - Doctrine, standards, and reform | The Emergency Services Agency should develop a strategy for monitoring the development and implementation of all Government land managers’ operational plans. |
REC228-1611 | 32 - Doctrine, standards, and reform | The Emergency Services Agency should specify preparation and approval requirements for bushfire operational plans, particularly those for lands in the Bushfire Abatement Zone. |
REC228-1621 | 32 - Doctrine, standards, and reform | The Emergency Services Agency should improve its management of the Community Fire Unit Program by: |
REC228-1609 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency should undertake audits to meet the requirements in the Strategic Bushfire Management Plan for the preparation, sharing and publication of annual progress reports. Annual progress reports should be made available to the ACT Bushfire Council. |
REC228-1620 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency, in consultation with the Territory and Municipal Services Directorate, should review the Farm FireWise Program, including: |
REC228-1608 | 32 - Doctrine, standards, and reform | The Emergency Services Agency should review the operations of the Strategic Bushfire Management Plan Implementation Working Group to determine if it is the most appropriate mechanism for ‘monitoring the scope and effectiveness’ of the Strategic Bushfire Management Plan. If it is retained, ways to improve its effectiveness should be identified and implemented. |
REC228-1614 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency, in consultation with the ACT Bushfire Council, should conduct a review of the ACT Bushfire Council against its recently developed terms of reference (July 2013) within two years. |
Rec-ID | Code | Recommendation |
---|---|---|
REC227-2846 | 17 - Assets and technology | I recommend that Border Protection Command continues to examine ways of improving its surveillance capability around Christmas Island so that the risk of SIEVs arriving undetected is reduced. |
REC227-2859 | 17 - Assets and technology | I recommend that the issue of RHIB jet intake protection be allocated a high priority and that there be ongoing investigation of possible solutions to reduce the problem. |
REC227-2855 | 32 - Doctrine, standards, and reform | I recommend that arrangements be put in place which would remove the requirements for Masters of Volunteer Marine Rescue vessels to hold a commercial certificate of competency. Operators could then be qualified through the FESA Volunteer Marine Rescue Training pathway as skippers and crew. This would increase the number of available skippers in the event of a search and rescue incident and would make appropriate training easier to arrange. |
REC227-2851 | 17 - Assets and technology | I recommend that consideration should be given to acquiring two personal water craft for deployment by appropriately trained and equipped staff of the AFP or the VMRS or both on Christmas Island. |
REC227-2850 | 17 - Assets and technology | I recommend that the AFP be provided with a search and rescue vessel which is suitable to the specific conditions of Christmas Island. I further recommend that steps be taken to ensure that if for any reason the search and rescue vessel is not available, there is a replacement vessel on Christmas Island capable of providing an emergency response in difficult sea conditions. |
REC227-2848 | 17 - Assets and technology | I recommend that the AFP take steps to determine whether access can be obtained to the National Search and Rescue Council endorsed SARMAP program covering the Australian Search and Rescue Region as well as adjoining tiles for Indonesia. Steps should be taken to ensure that if possible coverage would include high traffic areas where SIEVs enter the Australian Search and Rescue region allowing timely search and rescue plans to be drawn up for any potential incidents. |
Rec-ID | Code | Recommendation |
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REC171-0070 | 32 - Doctrine, standards, and reform | That a review be conducted of DEC’s ability to manage major fires and consideration be given to increased direct involvement by FESA in fire management role in the case of major fires on reserves or on unallocated Crown lands. |
REC171-0069 | 17 - Assets and technology | That in any consideration being given to the allocation of responsibility for control of operations in respect of major fires, consideration be given to the availability of technology and other resources, particularly when particular skills are required to make best use of such technology or resources. |
REC171-0068 | 32 - Doctrine, standards, and reform | That if the Bushfires Amendment Bill 2009 is to be enacted, procedures be put in place which would ensure that in the event of an escalating fire, FESA would receive sufficient information to make an informed judgment as to whether or not to take control of all operations. |
Rec-ID | Code | Recommendation |
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REC170-0054 | 22 - Role of local Gvt | SEMC and EM WA should: work with local government to ensure up-to-date, comprehensive local arrangements are in place |
REC170-0062 | 25 - Inquiry, audit, lessons management and after action review | Agencies should: annually assess their capability to respond to emergencies and take measures to address any shortfalls |
REC170-0053 | 32 - Doctrine, standards, and reform | SEMC and EM WA should: submit outstanding legislative changes to Parliament as a matter of priority |
REC170-0061 | 32 - Doctrine, standards, and reform | Agencies should: identify overlaps between Westplans and develop written procedures for these circumstances |
REC170-0052 | 32 - Doctrine, standards, and reform | SEMC and EM WA should: ensure agencies fulfil their obligations under the Act |
REC170-0060 | 32 - Doctrine, standards, and reform | Agencies should: update out-of-date Westplans and support plans as a matter of urgency |
REC170-0051 | 32 - Doctrine, standards, and reform | SEMC and EM WA should: review procedures for plan preparation and approval so that agencies can prepare their plans in a more timely way |
REC170-0056 | 32 - Doctrine, standards, and reform | SEMC and EM WA should: define key roles within the emergency management framework |
REC170-0064 | 32 - Doctrine, standards, and reform | Agencies should: ensure their internal emergency management arrangements are up-to-date and regularly reviewed |
REC170-0055 | 22 - Role of local Gvt | SEMC and EM WA should: monitor and take action to ensure local plans are in place and cover areas where the hazard could occur |
REC170-0063 | 32 - Doctrine, standards, and reform | Agencies should: ensure their Westplans and support plans have supporting local arrangements in place |
Rec-ID | Code | Recommendation |
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REC159-3060 | 32 - Doctrine, standards, and reform | ACTAS should develop a policy that provides direction on what type of feedback it will seek, from whom it will seek the feedback, and how this feedback will be used to improve the patient care experience. |
REC159-3058 | 25 - Inquiry, audit, lessons management and after action review | ACTAS should improve patient care processes by: |
REC159-3057 | 32 - Doctrine, standards, and reform | ACTAS should conduct formal reviews of its clinical procedures manuals in consultation with its Clinical Advisory Committee, and develop guidance to oversight these reviews. |
REC159-3056 | 32 - Doctrine, standards, and reform | ACTAS should specify and document the role of each of its various clinical governance processes, how they relate to each other, and how these will be managed, measured and monitored within an overarching clinical framework. |
REC159-3053 | 32 - Doctrine, standards, and reform | ACTAS should develop policies and guidelines to assist ambulance officers’ decisions on whether or not to transport a patient to hospital. This guidance might include appropriate responses when a mentally impaired patient declines transport or treatment, and when to call on management or clinical guidance. |
REC159-3061 | 32 - Doctrine, standards, and reform | ACTAS should develop and implement policies and guidance to staff on how complaints should be assessed and actioned, including timeliness targets. |
REC159-3051 | 32 - Doctrine, standards, and reform | ACTAS should: |
Rec-ID | Code | Recommendation |
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REC126-1945 | 32 - Doctrine, standards, and reform | That s. 47 of the ACT Coroners Act 1997 be expanded to explicitly state that an inquest and the inquiry are not adversarial in nature and are solely inquisitorial, with a view to establishing the truth |
REC126-2011 | 25 - Inquiry, audit, lessons management and after action review | That the taskforce review the recommendations of the seven reviews of the Emergency Services Bureau carried out before the McLeod inquiry and ensure implementation of any of those recommendations that remain relevant but have not been implemented |
REC126-1964 | 32 - Doctrine, standards, and reform | That all firefighting agencies adopt a policy and practice that all fires in remote areas of the ACT be responded to as quickly as possible, with vigorous and sustained efforts made to suppress the fires and not leave them unattended – especially at night – unless there are compelling reasons relating to firefighter safety or lack of resources |
REC126-1972 | 5 - Hazard reduction burns | That clarification be provided and information be made public in connection with the hazard reduction proposed under the Strategic Bushfire Management Plan for the area designated ‘Land Management Zone’, which appears to cover about 70 per cent of the ACT landscape and might be excluded from fuel-reduction burning |
REC126-1944 | 32 - Doctrine, standards, and reform | That s. 59 of the ACT Coroners ACT 1997 be amended by deleting the words ‘by instrument’ in s. 59(1) and by deleting the words ‘by his or her instrument of appointment’ in s. 59(2)(b) |
REC126-2010 | 25 - Inquiry, audit, lessons management and after action review | That the taskforce review the extent to which the recommendations in the McLeod report have been implemented in order to ensure implementation of those not yet implemented |
REC126-1962 | 32 - Doctrine, standards, and reform | That version 2 of the Strategic Bushfire Management Plan be completed and introduced without delay |
REC126-1971 | 5 - Hazard reduction burns | That a hazard-reduction program be introduced, involving regular and strategic burning in all areas of the ACT – including the catchment areas – with a view to having fuel-reduced areas in a pattern across the landscape, excluding only small areas of particular ecological or conservation importance |
REC126-1943 | 32 - Doctrine, standards, and reform | That the ACT’s Director of Public Prosecutions Act 1990 be amended by repealing s. 6(d) of the Act |
REC126-1989 | 32 - Doctrine, standards, and reform | That formal protocols be developed and agreed with NSW authorities, so that a concerted effort that combines the resources of both NSW and the ACT can be brought to bear in the future - without impediment caused by lines on a map that make the ACT an island within the state of NSW |
REC126-1952 | 25 - Inquiry, audit, lessons management and after action review | That regular periodic reviews be undertaken of changes made to the operational and management arrangements for dealing with wildfires and other emergencies in the ACT, to ensure that those arrangements continue to comply with the Australian Inter-Agency Incident Management System Incident Control System |
REC126-1966 | 32 - Doctrine, standards, and reform | That the Emergency Services Agency investigate and implement arrangements that will provide the capacity to use fire retardant in remote areas |
REC126-1978 | 32 - Doctrine, standards, and reform | That it be a matter of policy and practice that the relevant land management agency is responsible for the initial response to any fire or fires on the land under its care or management – within the overall operational response of the ACT Rural Fire Service |
REC126-1947 | 25 - Inquiry, audit, lessons management and after action review | That the ACT Government commission a review of coroners’ jurisdiction in order to determine whether that jurisdiction ought to be limited or expanded and, if so, to what extend |
REC126-1965 | 32 - Doctrine, standards, and reform | That helicopters be used wherever possible to facilitate the rapid deployment of remote area firefighting crews |
REC126-1975 | 5 - Hazard reduction burns | That prescribed burning operations be conducted according to agreed standard burning prescriptions |
REC126-1946 | 32 - Doctrine, standards, and reform | That the ACT Government consider amending the Coroners Act 1997 to include what were ss. 56(1)(d) and 56(2)(c) of the 1956 Coroners Act |
REC126-1964 | 32 - Doctrine, standards, and reform | That remote area firefighting resources be deployed to a fire in a remote area as a matter of priority and in preference to the deployment of large tankers |
REC126-1973 | 5 - Hazard reduction burns | If it is not part of the proposed version 2 of the Strategic Bushfire Management Plan, that the plan be revised to provide for a fuel-reduction burning regime in the ‘Land Management Zone’ that is equivalent to that contemplated for the corridors designated as the ‘Landscape Division Zone’ and that the regime involve burning areas in rotation to achieve an appropriately varying fire age spectrum across the entire landscape |
Rec-ID | Code | Recommendation |
---|---|---|
REC113-3903 | 32 - Doctrine, standards, and reform | Government should: establish emergency management legislation which clarifies State and local government responsibilities, and which rectifies the deficiencies in the State’s bushfire Emergency Management Plan, Westplan Wildfire. |