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<pre>
  

 

Policy No.:   G0189 

 

 
 

Responding to  
Suspected or Alleged  

Offences Against a Child 
or Young Person 

Occurring at a SA Health 
Facility or Service 

Policy Guideline 
 

Version No.:  1.1 
Approval date: 21 May 2019 

 
  



  

 

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Contents  
 
1. Policy Statement .................................................................................................................. 3 
2. Roles and Responsibilities ................................................................................................... 3 
3. Policy Requirements ............................................................................................................ 5 
4. Implementation and Monitoring.......................................................................................... 13 
5. National Safety and Quality Health Service Standards ..................................................... 14 
6. Definitions .......................................................................................................................... 14 
7. Associated Policy Directives / Policy Guidelines &amp; Resources ......................................... 17 
8. Document Ownership &amp; History ................................................................................   .18   

Attachment 1:  Immediate Incident Response Requirements               ..19 
 

 

 

 

 

 

 

 

 

 

 

  



  

 

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Responding to Suspected or Alleged Offences against 
a Child or Young Person Occurring at a SA Health 
Facility or Service Policy Guideline 
 
1. Policy Statement 
 
This policy guideline provides advice to SA Health employees regarding how to report and 
manage suspected or alleged criminal offences including sexual abuse against a child or 
young person within a SA Health facility or service or in the grounds thereof. 
 
Moreover, this policy guideline aims to: 

  Inform all staff members employed in SA Health of the required immediate 
response for any criminal offence against a child or young person that has 
taken place or is alleged to have taken place to ensure that children or young 
people who disclose or report incidents of suspected or alleged criminal 
offences are supported. 
 

  Raise awareness about mandatory reporting requirements and, where 
necessary, the preservation of evidence.  
 

  Ensure that all duty of care requirements including any support for affected 
children or young people are met.  
 

  Safeguard against incidents or criminal offences against a child or young 
person. 
 

  Assist staff to provide critical information to affected children or young people 
and their parents/guardians/ carers about the processes within the health 
service to manage allegations of a criminal offence against a child or young 
person. 
 

  Highlight the respective duties and requirements of staff members and senior 
management personnel when responding to an incident.  
 

This guideline supports the Child Protection   Mandatory Reporting of suspicion a child 
 or young person (0   under 18years) is or may be at risk of Harm Policy Directive 
and the Child Safe Environment (Child Protection) Policy Directive and must be read and 
administered in conjunction with these Policy Directives. 
 
 
2. Roles and Responsibilities 
 
2.1 Chief Executive, SA Health is responsible for: 

  ensuring the reporting and management of suspected or alleged criminal 
offences against a child or young person within SA Health facilities are in 
accordance with this guideline;  
 

  receiving reports of incidents of suspected or alleged criminal offences 
against a child or young person.  






  

 

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2.2 Director, Safety and Quality is responsible for: 

  monitoring and evaluating the implementation of this guideline; 
 

  reviewing reports of  notifications through the Notifications module of the 
Safety Learning System. 

 
2.3 Local Health Network / SA Ambulance Service (SAAS) Chief Executive 

Officers are responsible for:  
  implementing systems and processes at health service level to minimise 

the occurrences of alleged criminal offences to preserve evidence and to 
support recovery of affected children or young people and their parents 
/guardians/carers;   
 

  delegating responsibility to senior staff for reporting and managing 
incidents, including fair and objective management of staff who are 
suspected of or alleged to have offended against a child or young person; 
 

  notifying the Chief Executive SA Health of incidents covered in this 
guideline. 

 
2.4 Executive Directors, Directors and other senior managers are responsible 

for: 
  ensuring health services are reporting and managing suspected or alleged 

criminal offences against a child or young person in accordance with this 
guideline using the Notifications module of Safety Learning System (SLS);  
 

  developing, implementing and monitoring local protocols that prevent 
and/or minimise the risk of any offending against a child or young person 
occurring within health facilities or services;  
 

  ensuring staff members and relevant contractors are aware of their 
obligations to report all incidents of suspected or alleged criminal offences 
against a child or young person;  
 

  ensuring that action is taken to minimise disruption to services, and to 
support recovery of the children or young people involved.  

 
2.5  All SA Health employees will:  

  adhere to the principles and aims of this guideline, including recognising 
and reporting an incident to senior staff appropriately; 
 

  comply with the Child Protection Reporting of Suspicion that a Child or 
Young Person (0  under 18 years) is or may be at Risk of Harm Policy 
Directive 

  comply with the Information Sharing Guidelines for promoting safety and 
wellbeing. 

 
 
 
 




  

 

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3. Policy Requirements 
 
3.1 Scope 
This policy guideline applies to all SA Health staff or persons (such as contractors, 
volunteers, pastoral carers, visitors and students on placement) who provide services on 
behalf of SA Health who suspect or are made aware that an alleged criminal offence 
against a child or young person has taken place within a SA Health facility or service or in 
the grounds thereof. The child or young person may be an inpatient, an outpatient or 
visiting the site.   
 
This policy guideline applies to suspected or alleged criminal offences (under the Criminal 
Law Consolidation Act 1935) that occur within a SA Health facility or service regardless of 
the position or role of the suspected perpetrator e.g. whether this person is a staff 
member, parent/guardian/ care-giver, volunteer, another client/ patient or a visitor and 
regardless of age (i.e. the person who is suspected may be a minor).   
 
In relation to child or young person visitors, staff may form a reasonable suspicion as a 
witness or they may be given information that will require a response. The information 
contained in this guideline will assist staff to provide a timely and appropriate response.   
 
3.2 Principles 
All South Australian children and young people require a nurturing and supportive family 
and community environment and have the right to be protected from all forms of harm (i.e. 
physical violence, injury or abuse (including sexual abuse), neglect or negligent treatment, 
maltreatment or exploitation.  
 
The following principles frame this policy guideline: 

  SA Health and its staff members are committed to ensuring and maintaining a 
child safe environment. 
 

  Every child or young person has the right to feel safe and to be protected from 
all forms of harm whilst at or in the care of SA Health services.  

 
  SA Health supports the rights of the child or young person to justice and to 

appropriate support and care where they have been affected by a suspected 
or alleged offence. 

 
  SA Health staff members acknowledge their responsibility in staying alert to 

the possibility of children or young people being subjected to or having been 
affected by an alleged offence. 
 

  SA Health and all its staff members acknowledge that children or young people 
may provide information directly or indirectly including through their behaviour.  
Any such information given by a child or young person must be responded to 
immediately.   

 
  Affected children or young people are entitled to dignity in their care and 

treatment, privacy, confidentiality and support to recover and to pursue legal 
redress if applicable and where desired. SA Health supports the rights of the 
protective family members to appropriate support. 

 





  

 

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  Suspected or alleged perpetrators are entitled to a just, transparent and fair 
approach during investigative, disciplinary or judicial processes. 

 
  SA Health does not condone harm in any form, and supports actions to ensure 

that there are appropriate consequences for perpetrators including cooperating 
with requests and requirements of SA Police.  

 
  Delegated senior staff will take responsibility for, and follow consistent 

objective processes, in management of these incidents, and in ongoing 
monitoring and targeted improvement of services.  

 
3.3 SA Health has a duty of care to provide a safe environment for consumers and staff.  
All SA Health staff and services must take reasonable care to protect children and young 
people from a reasonably foreseeable risk of harm. 
 
Health professionals have a responsibility to be alert to children and young people, 
especially vulnerable children or young people in their care.   
 

This can be achieved by: 
1. being open to the possibility that any child or young person no matter their 

age or social background, could be subject to sexual or physical abuse or 
assault or harm or other criminal offence such as abduction; 
 

2. being mindful of situations and behaviours that suggest a child s or young 
person s vulnerability; 
 

3. acting appropriately and promptly in situations where a suspected or alleged 
criminal offence has been witnessed or reported; 
 

4. being alert, sensitive and responsive to a child s or young person s allegations 
of harm by others; 
 

5. identifying if there are other children or young people in the family or any other 
children or young people within a social group that may be at risk; 
 

6. remaining calm and providing support to the child or young person and any 
protective (non-offending) parent, carer or family members; 
 

7. assessing the immediacy of the situation and calling SA Police immediately 
when required; 
 

8. seeking the immediate support of the senior staff member in the relevant work 
area or After Hours Coordinator to support, coordinate and oversee any 
immediate service response. 

 
3.4 Indicators of suspected or alleged criminal offences against a child or young 

person include: 
  the witnessing of an incident by a staff member and/or another person 

(observation of the actual offence taking place); 
 

  a child or young person discloses that someone has harmed/hurt them or done 
things to them that they did not want; 



  

 

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  any unexplained bruising on an infant;  

 
  a child or young person complains of physical symptoms, such as pain; 

 
  a child or young person is wary of physical contact with others; 

 
  a complaint or allegation made by staff, visitors, parents/guardians/carers, 

patients or any combination of these; 
 

  observation of physical signs such as bruising (unexplained), or clothes may 
have been disturbed; 
 

  observation of behavioural signs of distress, fear or anxiety, or the child s or 
young person s  behaviour changes significantly (this may include sleep 
disturbances, acting out behaviours, or persistent and inappropriate sexual 
behaviour based on the child s age); 
 

  clinical findings of assault; or 
 

  discovery or sighting of pornographic images of a child or young person that 
have been taken within or shown within SA Health facilities or services in the 
possession of a consumer, visitor or staff member. 
 

3.5 Early response 
3.5.1  SA Police must be contacted immediately on 000 (or 131 444) in the following   

situations:  
  witnessing  sexual abuse or assault, physical assault, or sexual misconduct 

incident against a child or young person;  
 
  where a child or young person is in immediate physical danger;  

 
  abduction; or 

 
  where the suspected or alleged perpetrator of the offence is present or on site.   

 
3.5.2   The Mandatory Reporting obligations as described in the Child Protection   

Mandatory Reporting of Suspicion that a Child or Young Person is or may 
be at Risk of Harm (0-18 years) Policy Directive must be complied with. 

 
  Staff must make a report /notification via the Child Abuse Report Line 

(CARL) by telephoning 131 478.   
 

  The online reporting system (eCARL) is not to be used for incidents covered 
by this policy guideline. 

 
3.5.3   Once the affected child s or young person s safety is established, staff are 

required to provide the affected child or young person with support and assistance. 
If the child or young person requires immediate medical attention, a medical 
practitioner or ambulance can be called, or the child or young person can be taken 
to the nearest Emergency Department.  

 



  

 

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A young person 16 years and above who alleges sexual assault can contact Yarrow 
Place Rape and Sexual Assault Service for free and confidential information and advice 
regarding options for medical care (including forensic medical examination), legal action, 
or counselling. 
 
A child under 16 years may be referred to the applicable Local Health Network Child 
Protection Service. The Department for Child Protection and/or SA Police will facilitate 
this referral.  However SA Health staff may choose to consult with the Child Protection 
Service following the notification to CARL or SA Police.  
 
The protective parent/guardian/carer (the child s parent/carer/guardian who is not the 
subject of the allegation/concern) must be informed of the alleged criminal offence against 
the child prior to any referral occurring. 
 
3.5.4 SA Police may recommend a forensic medical examination. The examination of 
alleged criminal offences against a child or young person is a specialised area.  
 
The SA Health Child Protection Services conduct forensic medical examinations for 
children under 16 years, with Yarrow Place Rape and Sexual Assault Service providing 
this service for young people 16 years and over.  
 
If a forensic medical examination is required, staff are advised to encourage the affected 
child or young person not to shower or change. If the child or young person feels that they 
must shower or change, they must be asked to place the clothing they were wearing at 
the time in bags, which must be sealed, labelled and placed somewhere secure.   
 
3.5.5 Initial reporting and response actions 
Not all circumstances can be covered in this policy guideline.  Staff are to use their 
judgement to determine the immediacy of the response required to any situation which 
may constitute an offence against a child or young person. If the staff member is not sure, 
they must immediately seek the advice of the senior staff member in the work area.  
 
3.5.6 Staff member(s) who first suspects or becomes aware of an alleged offence 
must immediately assess the situation and take steps to ensure a safe environment.  
Next actions include:  

  reporting to the senior staff member in the relevant work area of the suspicion 
or allegation and any actions already taken;  
 

  for any urgent situation, SA Police is to be contacted on 000 or 131 444; 
 

  report concern to the Child Abuse Report Line (CARL) 131 478; 
 

  assist SA Police (SAPOL)  with any investigation if required; 
 

  provide information to assist the clinical risk manager or most senior staff 
member on duty to make the required report into the Safety Learning System 
(SLS). 

 
If the allegation is against a senior clinician or manager, who would be part of the 
standard line of escalation, communication must be made directly to the Clinical Risk 
Manager or Chief Operating Officer. 
 



  

 

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3.5.7 If the suspected or alleged perpetrator is present if possible and only if safe to 
do so, separate the child or young person from the suspected or alleged person or stay 
with the child or young person or ensure that the child or young person is not left alone 
with the alleged perpetrator. 
 
3.5.8 If any person is exhibiting aggressive or threatening behaviour, a Code Black 
(personal threat) must be called immediately following local LHN/ SAAS health service 
protocols.  
 
3.5.9 The senior staff member in the work area is required to: 

  ensure that the appropriate senior manager(s) is immediately made aware of 
the incident, using the health service s escalation process and timeline; 
  

  act to  preserve evidence as appropriate and advised by senior manager or SA 
Police (SAPOL); 
 

  make available additional staff if needed to take over staff member s duties or 
support patient care whilst response requirements are met; 

 
  ensure non suspected parent or guardian or carer are contacted immediately 

and provided with any appropriate support or assistance as needed; 
 

  liaise with Department for Child Protection;  
 

  where the alleged affected child or young person or their protective 
parent/carer/guardian provide consent, support can be accessed through 
referral to the relevant SA Health Child Protection Service;  
 

  act to minimise disruption to the service. 
 

3.5.10 If the alleged or suspected perpetrator is a visitor and it is considered 
necessary, security are permitted to search the person s possessions, remove the person 
from the premises, and/or restrain the person until SA Police can attend. At sites where 
security are not on site/available SA Police will need to attend. 
 
3.5.11 The most senior manager of the relevant work area where the allegation has 
been made is responsible for: 

  ensuring that a mandatory notification is made as soon as practicable and 
within a 24 hour period; 
 

  reporting the incident to Local Health Network / SAAS Chief Executive Officer 
(CEO) who will in turn report to the Chief Executive SA Health; 
  

  advising the affected child or young person and the protective 
parent/carer/guardian that the allegation will be reported to the SA Police, 
regardless of consent or objection to do this;  
 

  ensuring that the incident review and resolution processes are carried out in a 
timely manner, and in collaboration with additional expertise, such as Work 
Health Safety or Human Resources or SA Health Child Protection Services in 
the relevant LHN or Yarrow Place Rape and Sexual Assault Service; 

 



  

 

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  recording the incident and its subsequent management into the Notifications 
module of the Safety Learning System; 

  
  ensuring open disclosure and de-briefing is offered. 

 
3.6 Communication and follow-up to persons involved  
3.6.1 The alleged affected child or young person 

  Counselling from appropriate services must be offered. 
 

  Communication using open disclosure principles and practices is required for 
the alleged affected child or young person and, where relevant, their 
parent/carer.  
 

  Consumers (child or young person or adult) must be supported to make 
complaints or provide feedback.  

 
3.6.2 A consumer who is the suspected or alleged perpetrator 

  If a consumer is the suspected or alleged perpetrator, steps must be taken to 
re-locate them to another area, reduce risk to others, preserve evidence and 
review their physical and mental status and their care plan. 

 
3.6.3 A staff member who is the suspected or alleged perpetrator/perpetrator  

  If a staff member is the alleged perpetrator SA Police must be notified 
immediately. 
 

  Human Resources/Workforce must be notified within 24 hours. 
 
  For Australian Health Practitioner Regulation Agency (AHPRA) registered 

practitioners, AHPRA must be notified within 24 hours. 
  

  If the staff member is not registered with AHPRA the Health and Community 
Services Complaints Commissioner receives notifications about alleged 
improper conduct by employees. 
 

  Consideration should be given, in consultation with senior management, to 
reporting the matter to the Office for Public Integrity, in keeping with the 
obligations to report to the Independent Commissioner Against Corruption. 
  

3.6.4 Other people, team members  
  Other children or young people may be affected psychologically by the incident 

and the investigation process, and appropriate support for their recovery must 
be considered. 
 

  If there is a reasonable suspicion of other affected children or young people at 
the LHN site or elsewhere within SA Health, the manager will facilitate a 
process with SA Police for identifying and contacting other potential affected 
children or young people and their families.  

 
3.7 Considerations of confidentiality and protection of information 
To maintain confidentiality and protect those involved, and the information that has been 
gathered as part of investigation, the health service / organisation will ensure that: 

 






  

 

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  only nominated senior staff members, for example Directors and/or Risk 
Managers or similar nominated staff members on duty have access to the      
Notifications module of SLS (that is, are able to record the notification and add 
and view entries describing the subsequent investigation and review 
processes); 
 

  all reports, briefings, and related documents generated during review or 
investigation to be attached as a Level 1 secure document in the Documents 
section of the notification report; 

 
  any personal medical information documented into SA Health s electronic 

health record (EPAS) as a result of patient care provided as the result of an 
incident, will be accessed in accordance with the clinician s security rights as 
per standard practice. 

 
3.7.1 Prohibitions on disclosure of identity of children or young people 

  Where an affected person is a child or young person (under 18 years) the 
name of the child or young person or anything that might identify the child or 
young person cannot be published or disclosed by SA Health staff except by or 
under law.  This includes the identity of carers/parents/guardians or other 
persons related to the child or young person. 
 

  Care must be taken to ensure that nothing is said that might identify the 
alleged affected child or young person to members of staff who are not directly 
involved or to members of the public or the media.  

 
  When a person has been or is about to be charged with a sexual offence, staff 

must also comply with section 71A of the Evidence Act 1929 which restricts the 
publication of the identity of the alleged affected child or young person and of 
the alleged perpetrator.   

 
  The Young Offenders Act 1993 prohibits the publication of anything that might 

identify both the perpetrator and the affected child or young person where 
each is under the age of 18 years of age.   

 
  The Information Sharing Guideline, Sections 151 and 152 of the Children and 

Young People (Safety) Act 2017 and Section 93 of the Health Care Act 2008 
allow for reporters to report all information to CARL and SA Police.  
 

3.8 Documenting incidents 
  The staff member involved in the incident and the senior staff member in the 

relevant work area / After Hours Coordinator may be required to make 
extensive notes, provide statements to SA Police and to give evidence in court 
proceedings.   
 

  Documenting any conversations or communications together with their time 
and date will help staff to recall any information more accurately.   

 
  All staff members involved, including the senior staff member in the relevant 

work area or After Hours Coordinator and any other relevant staff members 
involved need to keep a written record of all conversations relating to any 








  

 

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allegation.  Wherever it is possible notes must be made in the course of a 
conversation or immediately thereafter.   

 
  Notes may be subpoenaed for court proceedings and therefore, they must be 

completed in a legible and professional manner.   
 

  All notes must be uploaded into the Safety Learning System (SLS) in the 
relevant section. 
 

3.9 Assisting SA Police (SAPOL) 
  SA Health staff must be available to assist the SA Police with any investigation 

if required in accordance with the SA Health Policy Guideline for police 
requests for information and witness statements in the public health system in 
South Australia. 
 

  Staff must seek advice from SA Police as to whether the alleged perpetrator is 
to be told of the report to the police, and subsequent actions, for example to 
preserve evidence as appropriate. 

 
  The SA Police investigation may include the SA Health Child Protection 

Services, Yarrow Place Rape and Sexual Assault Service, the LHN and/or 
SAAS Risk Manager and the Department for Child Protection.  

 
3.10 Safety and Learning System (SLS) reporting  

  Suspected or alleged sexual assault must be recorded in the Notifications 
module of SLS under  alleged sexual assault  by a member of the Safety and 
Quality/Risk team (this section of the SLS is restricted).   
 

  Most incidents of the type identified in this policy guideline are likely to be 
categorised under the Safety Assessment Code (SAC) as SAC 1: either 
 Extreme  (Incidents which may involve media interest) or  Major  (Patient 
assault requiring external involvement e.g. police, external emergency 
services). There are requirements for uploading relevant documents such as 
SA Police reports into the SLS. Refer to the Patient Incident Management and 
Open Disclosure Policy Directive. There are also requirements for Open 
Disclosure processes.  Follow the procedures of the LHN in seeking advice 
from the relevant Safety and Quality/Risk team. 

 
3.11 Follow-up action by Health Service senior managers  

  After immediate response and required reporting, senior managers must 
review the incident, and where relevant recommend and/or implement 
strategies to prevent or reduce the occurrences of similar incidents in the 
future.  
 

  To promote shared learning and recovery, senior managers must encourage 
debriefing and use of relevant counselling and support services. 

 
3.12 A further offer of counselling and any other support for the affected child or 
young person and the affected child s or young person s family must be made as soon as 
SA Health learns that the accused person has been charged.  This offer must be followed 
by a letter confirming the offer of counselling and other supports.   
 





  

 

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4. Implementation and Monitoring 
 
SA Health will ensure in the implementation of this policy guideline that: 

  All cases of alleged or suspected criminal offences against a child or young 
person are reported appropriately and immediately. 
 

  Systems are in place to assist staff identify actual or suspected criminal 
offences against a child or young person as defined in the Criminal Law 
Consolidation Act 1935 for the purposes of this guideline. 

 
  Staff are aware of their legal obligations to report actual or suspected criminal 

offences against a child or young person as defined in the Criminal Law 
Consolidation Act 1935 for the purposes of this guideline. 

 
  Staff are knowledgeable about child protection requirements.  

 
  All incidents are reported on the Notifications module of the Safety Learning 

System. 
 

Compliance will be measured through the SLS system i.e.: 
  Number of incidents reported to SA Police and recorded on SA Health SLS 

system. 
 

  Audits of compliance with SLS system to determine if alleged criminal offences 
are being reported and actioned in accordance with this guideline.  

 
  Number of complaints relating to alleged criminal offences against a child or 

young person at a SA Health facility or service. 
 

  Review of incident reports and recommendations. 
 

  Review of the response and management of the incident. 
 

Measures and indicators to monitor and evaluate this policy guideline include:  
  The number of incidents reported will be compared with those previously 

logged over a comparable period of time. 
  

  The accuracy and number of incidents recorded in the Notifications module, by 
the correct personnel. 

  
  Audits of compliance with Notifications module of the Safety Learning System 

will determine whether alleged criminal offences or misconduct against a child 
or young person are being actioned in accordance with this guideline as 
defined in the Criminal Law Consolidation Act 1935. 
 

  The number of complaints received that relate to SA Health s management 
and reporting of alleged criminal offences or misconduct against a child or 
young person as defined in the Criminal Law Consolidation Act 1935. 









  

 

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  Comments received in consumer experience surveys.  

 
  Misconduct, malpractice, disciplinary reviews.  

 
  Claims made against health services.  

 
 
5. National Safety and Quality Health Service Standards  
 
The Australian Commission on Safety and Quality in Health Care has developed 
the National Safety and Quality Health Service Standards (the Standards). 
 
The Standards provide a nationally consistent and uniform set of measures of 
safety and quality for application across a wide variety of health care services. 
They propose evidence-based improvement strategies to deal with gaps between 
current and best practice outcomes that affect a large number of patients. 
 
Please identify how this policy directive contributes to any of the below listed 
standards: 

 
 
6. Definitions  
 
In the context of this document: 

  The Australian Health Practitioner Regulation Agency (AHPRA) means the 
organisation responsible for the administration of the National Registration and 
Accreditation Scheme across Australia. 

 
  Alleged perpetrator means the person who is suspected or alleged to have 

offended against a child or young person. 
 

  Child or young person means a person who is under 18 years of age. Under 
the Consent to Medical Treatment and Palliative Care Act 1995, a young person 
aged 16 years or above may make decisions about their own medical treatment. 

                   
  Child Abuse Report Line (CARL) is the Department for Child Protection 24 hour 

centralised point of intake.  The report line is open 24 hours a day, 7 days a week. 

 
 

National Standard 
1 
 

Clinical 
Governance 

 
 

National 
Standard 2 

 
Partnering 

with 
Consumers 

 
 
 

 
 

National 
Standard 3 

 
Preventing &amp; 
Controlling 
Healthcare- 
Associated 
Infection 

 
 

National 
Standard 4 

 
Medication 

Safety 
 
 
 
 

 
 

National 
Standard 5 

 
Comprehensiv

e Care 
 
 

 
 

National 
Standard 6 

 
Communica

ting for 
Safety 

 
 
 
 

 
 

National 
Standard 7 

 
Blood 

Management 

 
 

National 
Standard 8 

 
Recognising &amp; 
Responding to 

Acute 
Deterioration 

 
 

? ? ? ? ? ? ? ? 






















































  

 

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All serious concerns must be reported via the report line and not via the online 
reporting system eCARL. Telephone:  13 14 78. 
 

  Child Protection Services (CPS) refers to the SA Health Child Protection 
Services (WCHN, NALHN, SALHN). The CPS provides specialist assessment and 
treatment services to children and their families where there is a suspicion of child 
abuse, psychological maltreatment and /or neglect. They offer consultation to 
professionals to discuss child protection matters, provide information and advice. 
The CPS accepts referrals from DCP and SA Police for forensic medical and 
psychosocial assessments for children. 

 
  Consumer means individuals who are using SA Health services. 

 
  Contractor means any person who may be working at a SA Health site who is 

providing services through a contract for the provision of services and is not 
directly employed by any SA Health service.   
 

  Department for Child Protection (DCP) was formed in November 2016 in 
response to recommendations from the Child Protection Systems Royal 
Commission, led by the Honourable Margaret Nyland AM. The department has 
responsibility for the Family and Community Services Act 1972.and the Children 
and Young People (Safety) Act 2017. 
 

  Disclosure   the use of this term in the context of this policy guideline document 
refers to the everyday meaning of  disclosure  that is, revealing information.  

 
  eCARL the electronic CARL is the online reporting system for less serious, non-

imminent concerns. eCARL at  www.reportchildabuse.sa.gov.au to make a 
report online you must register and login to the online child protection reporting 
system.  

 
  Health record includes a patient s medical record, patient/client record, case note 

or patient/client file. 
 

  Identifier means any person who has witnessed a criminal act, identified the 
suspected/alleged child or young person harm.  
 

  Mandated reporter refers to a person who under the Children and Young People 
(Safety) Act 2017 Section 30 (3) (4) (5) is required to report any suspicion that a 
child or young person is, or may be at risk of harm to the Department for Child 
Protection. This applies to suspicion occurring in the course of their employment.  

           This applies to: 
(a) prescribed health practitioners;  

 
(b) police officers; 

 
(c) community corrections officers under the Correctional Services Act 

1982;  
 

(d) social workers;  
 

(e) ministers of religion;  













  

 

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(g) teachers employed as such in a school (within the meaning of 

the Education and Early Childhood Services (Registration and 
Standards) Act 2011 or a pre-school or kindergarten;  

 
(h) employees of, or volunteers in, an organisation that provides health, 

welfare, education, sporting or recreational, child care or residential 
services wholly or partly for children and young people, being a person 
who  

   (i) provides such services directly to children and young people; or 
 

(ii) holds a management position in the organisation the duties of which 
include direct responsibility for, or direct supervision of, the provision of 
those services to children and young people. 

 
A reference to a person being employed will be taken to include a reference to a 
person who:  

(a) is a self-employed person;   
 

(b) carries out work under a contract for services;  
 

(c) carries out work as a minister of religion or as part of the duties of a 
religious or spiritual vocation;   

 
(d) undertakes practical training as part of an educational or vocational 

course;   
 

(e) carries out work as a volunteer.  
 

A prescribed health practitioner refers to:  
(a) medical practitioners;   

 
(b) pharmacists;   

 
(c) registered or enrolled nurses; 

 
(d) dentists;  

 
(e) psychologists.  

 
  Protective parent/guardian/carer refers to the child s or young person s 

parent/carer/guardian that is not the subject of the allegation/concern/suspicion 
and is acting protectively in meeting the child's or young person s protective 
needs. The parent/guardian/carer is able and willing to protect the child or young 
person when they are aware of the concerns and are capable and willing to take 
action to ensure the child s or young person s safety. This includes circumstances 
where the alleged person is one parent/guardian/carer or another person. 

 
 
 
 
 





  

 

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7. Associated Policy Directives / Policy Guidelines &amp; Resources 
 
Child Protection - Mandatory Reporting of Suspicion that a Child or Young Person (0- 
under 18 Years) is or may be at risk of Harm Policy Directive  

Child Safe Environments (Child Protection) Policy Directive 

Information Sharing Guidelines for Promoting Safety and Wellbeing: SA Health ISG 
Appendix Policy Directive  

Interagency Code of Practice - Investigation of Suspected Child Abuse or Neglect  

Protective Security Policy Directive 

Reporting and Management of Incidents of Suspected or Alleged Sexual Assault of an 
Adult or Sexual Misconduct by an Adult within SA Health Facilities and Services Policy 
Directive 

Patient incident Management and Open Disclosure Policy Directive 

Preventing and responding to Challenging Behaviour Policy Directive 

Same Gender Accommodation Policy Directive 

Criminal and Relevant History Screening Policy Directive 

Employees Charged with Criminal Offences Policy Directive  

SA Health (Health Care Act) Human Resources Manual  

Coronial Process and the Coroners Act 2003 Guideline 

Protocol for Police Requests for Information and Witness Statements in the Public Health 
System in South Australia 

Framework for Active Partnership with Consumers and the Community 

Charter of Health and Community Services Rights Policy Directive 

Guide for Engaging with Consumers and the Community Policy Guideline 

Worker Health and Wellbeing Policy Directive 

Employee Assistance Program Directive  

Safety Learning System 

SA Health, Your Rights and Responsibilities   A Charter for Consumers of the South 
Australian Public Health System (revised June 2008) 

Criminal Law Consolidation Act 1935  

Children and Young People (Safety) Act 2017  

 Evidence Act 1929  

Health Care Act 2008  

Mental Health Act 2009  

Health and Community Services Complaints Act 2004  

Public Sector Act 2009  

Family Law Act 1975  

Family Law Regulations 1984   


































  

 

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Family Law (Child Abduction Convention) Regulations 1986  

Family Law (Child Protection Convention) Regulations 2003  
Family Law (Hague Convention on Intercountry Adoptions) Regulations 1998  

SA Health Privacy Policy Directive 

Charter on the Rights of Children and Young People in Healthcare Services in Australia 

Standards for the Care of Children and Adolescents in Health Services 

Code of Ethics for the South Australian Public Sector  

Guideline of the Commissioner for Public Sector Employment - Extent of Obligation on 
Employees to Report they have been charged with a Criminal Offence  

Guideline of the Commissioner for Public Sector Employment - Managing Unsatisfactory 
Performance (Including Misconduct)  

 
 
8. Document Ownership &amp; History 
 
Document developed by:  Child Safety Strategy Team, WCHN 
Next review due:  14/06/2023  
Policy history: Is this a new policy (V1)?  N   
 Does this policy amend or update an existing policy 

version Y 
 If so, which version? V1 
 Does this policy replace another policy with a different title? N 
 If so, which policy (title)?  
 
ISBN No.:                             978-1-74243-974-7 
 

Approval 
Date Version 

Who approved New/Revised 
Version Reason for Change 

21/05/19  V1.1 Director Corporate Governance and Policy 
Minor Amendments 
 

14/06/18  V1.0 SA Health Policy Committee Original SA Health Policy  Committee approved version. 
 













  

 

Attachment 1:  Immediate Incident Response Requirements - Responding to 
Offences against a Child Occurring at a SA Health Facility or Service Policy 
Guideline 
 
 
 

Immediate Incident Response 
 
 
 
INCIDENT 
 

 
       IMMEDIATE RESPONSE 

Alleged Criminal Offence 
  including physical 
abuse, sexual abuse, 
abduction, identification 
of child pornography 
being  accessed  on SA 
Health site  
 

1. Ensure the child is safe 
 

2. Call SA Police (000 or 131 444) 
 

3. Ensure that the senior manager is aware of 
the situation 

 
4. Contact the Child Abuse Report Line 

 
5. Advise the parent / caregiver of the child 

what action has been taken and what can be 
expected 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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