I have previously written about The Viewer in the context of paramedics accessing patient records to follow up on patients or to gather information before arriving on scene – see QAS paramedics accessing patient information via ‘The Viewer’ for ‘follow up’. (October 20, 2023) and Accessing ‘The Viewer’ before accessing the patient (June 5, 2024).

Williams v State of Queensland (Queensland Health) [2025] QIRC 228 is an appeal to the Queensland Industrial Relations Commission following disciplinary proceedings against a nurse regarding allegedly unauthorised access to The Viewer (and I thank Efthimia Voulcaris, solicitor for the Australian Paramedics Association (Queensland) for bringing this case to my attention).  Although the case was about a nurse, not a paramedic, the issues and what the Tribunal had to say will give guidance to all practitioners.

The applicant, Ms Williams is a nurse and midwife.  It was alleged that ‘On various dates between 28 April 2024 and 28 July 2024, on multiple occasions [she] accessed confidential patient records of individual that [she was] … not providing care or treatment to’ [2]. Following an invitation to respond to the allegation, the relevant decision maker found the allegations were established ([4]).  There was a further process to make submissions as to an appropriate penalty to be applied. Pending a final decision Ms Williams was suspended with pay, and was advised that the proposed disciplinary response was to terminate her employment ([45]). Prior to any decision on penalty, Ms Williams appealed to the Commission arguing that the decision maker should not have upheld the allegations ([5]-[7]).  Because there had been no decision on penalty, the role of the Commission was to determine ‘whether the disciplinary finding decision dated 20 February 2025, which found the two allegations to be substantiated, was fair and reasonable’ ([9]).  The Commission found that they were not and sent the matter back to be reconsidered ([10]).

The background

Ms Williams was a midwife but she also worked in the Kingaroy Hospital ED as a nurse. ‘Kingaroy Hospital is a small rural hospital, and … they lack an administration officer’.  Patient notes were entered in a book along with a patient sticker for transfer to the Hospital Based Corporate Information System (‘HBCIS’) that in turn led to records in The Viewer; but this did not always happen ([37]).

Ms Williams also said that maternity patients would present to Kingaroy and then be transferred to larger hospital. In those cases ‘maternity staff like to check up on them to see if they have birthed. The purpose of this is to assist the Appellant as Clinical Midwife in keeping the birth book up to date, but to also assist the midwife who does the Extended Midwifery Care (‘EMC’) or home visits’ ([38]).

On other occasions, women who had given birth elsewhere would present to Kingaroy:

 …following early discharge for admission or outpatient care with no information, discharge summary not given to them and no telephone call. The Appellant contends that this explains why she has accessed The Viewer to read their discharge summary to ensure that the patient receives the best care… the Appellant maintains that Kingaroy Hospital is not notified of discharges for birthing mothers’ ([39]).

Decision

The issue for the Commission was whether the decision was ‘fair and reasonable’.  Commissioner O’Neill noted that the allegations covered a number of dates ([86]) and 47 patients ([87]). Ms Williams was not given details of those patients nor access to their records to allow her to make a response ([90]-[92]). The decision maker ‘substantiated findings of inappropriate accessing of patient medical records by the Appellant in relation to two patients’ ([93]); but ‘No explanation is provided by the Decision-Maker in the decision letter as to what findings have been made about the multifarious allegations of inappropriate access to the records of the other 45 patients …’ ([94]).

In making the decision, the decision maker made detailed references to the patient records.  Ms Williams had no access to those records although the respondent said she could have asked for them. Commissioner O’Neill said ([102]-[105]):

The Appellant was requested by the Respondent to provide a response to a show cause notice in relation to an allegation of improperly accessing the medical records of 47 patients over a period of three months, with some of the patients’ records being accessed on multiple occasions.

The information provided to the Appellant to respond to the allegations were the dates she was rostered on, the patients she had responsibility for on those shifts, and the patient numbers whose medical records were accessed by the Appellant, and the dates and times when this occurred.

In my view the Appellant to some extent was given an impossible task to provide an appropriate show cause response given the information provided to her. In the submissions provided in support of the Appeal Notice, the Appellant notes that she could have adduced further and more significant evidence if patient records were reviewed by her.

The failure by the Respondent to inform the Appellant of her ability to request access to the various patients’ medical records, and to afford her the opportunity to view those records prior to providing her response to the show cause notice in my view means that the process adopted in this disciplinary process was not fair.     

With respect to finding the allegations proved, the Commission noted (at [117]-[118]):

The finding that the allegation had been substantiated in relation to the two patients was predicated on the basis that a ‘desktop review’ of relevant medical records in HBCIS and Emergency Department Information System (‘EDIS’) was undertaken and had failed to establish that the two identified patients presented  at Kingaroy Hospital in any capacity on any of the nominated dates when the Appellant has accessed their medical records.

Given this factual finding, the Decision-Maker was not satisfied that the Appellant was providing treatment or care to the patients on those dates such that her use of The Viewer to access the medical records would be authorised.

But, as noted, Ms Williams indicated that often the paper records were not transferred to the electric records in the absence of an administrative officer.  Commissioner O’Neill said (at [126]-[127]):

The decision letter makes reference to there being a ‘desktop review’ of both the HBCIS and EDIS records in relation to the two identified patients. The decision letter does not confirm what the ‘desktop review’ of those records entailed. There is no evidence available to me that the review extended to a review of any hard copy medical records that the Kingaroy Hospital may hold in relation to the two identified patients.

This is relevant to the question of whether the evidence available to the Decision-Maker had the requisite “clarity” or “cogency” in order to induce, on the balance of probabilities, an actual persuasion of the Decision-Maker’s mind as to the existence of the matters grounding the substantiation of the allegation.

In other words the decision maker could not have been satisfied that a review of the electronic records but not the hospital’s paper records, would establish that the patients had not attended the hospital.

A similar situation applied to discharge summaries. The Commission said (at [129]-[133]):

There appears to be a fundamental disagreement between the parties regarding the extent to which discharge summaries are provided to the returning facility. In the decision letter dated 27 March 2025, the Decision-Maker rejected the Appellant’s response that she was required to review The Viewer for patient births at alternative facilities and for subsequent follow-up care requirements…

The Decision-Maker noted that it is her understanding that the patient discharge summaries are provided to the returning facility, sometimes accompanied by a telephone call or email correspondence detailing the specific follow-up care requirements. The Decision-Maker did not clarify the basis of her understanding or the source of information which grounded that understanding regarding the discharge summaries. On the basis of that understanding, the Decision-Maker concluded that she did not foresee a need for the Appellant to monitor patients via The Viewer because she would receive a notification where required.

In the Appellant’s reply submissions (and in the submissions from the Appellant dated 2 April 2025), the Appellant disagrees with that factual finding and instead contends that discharge summaries are not provided to the returning facility in the form of facsimile or email. The Appellant submits that such an approach is no longer custom nor practice, and nor is a telephone call received from the transferring facility. The Appellant contends that The Viewer is used to monitor where the patients have birthed (elsewhere) and to organise home visits, and other testing.   

I consider this to be a significant factual dispute which will require additional investigation by the Respondent and positive findings of fact being made to confirm whether the version of the Respondent or the Appellant is correct. If the Appellant’s version is correct, this may in fact provide a valid explanation for her accessing the relevant patient medical records for the purposes she has identified in her submissions.

His Honour concluded (at [144]):

I am not satisfied that the evidence before the Decision-Maker, nor the analysis of that evidence by the Decision-Maker was sufficient to demonstrate ‘clear and cogent proof’ supporting an ‘actual persuasion of the mind as to the existence of the matters of complaint’ given the serious nature of the allegation raised against the Appellant.

For the various reasons set out above, I am not satisfied that the Decision-Maker could safely reach the determination that the allegation had been substantiated. I therefore find that the decision to substantiate the allegation was not fair and reasonable.

That is not however the end of the matter, the Commission ordered that the matter be returned ‘to the Decision-Maker with a copy of the decision on appeal and a direction that a fresh consideration of the matter be undertaken in accordance with these reasons for decision.

Discussion

The way this case was determined tells us little about acceptable access to The Viewer.  The case turned on issues of practice and appears as a classic case of the decision maker looking for records that ‘should’ have been produced. Every patient should have had a Hospital Based Corporate Information System record and ultimately a record in The Viewer so if there was no such record, they must not have attended the hospital.  Every patient returning to Kingaroy should have had a discharge summary so there was no need to look to The Viewer.  But Ms William’s evidence ‘from the front line’ was that in a less than perfect world these things do not always happen.  It is up to the decision maker to consider evidence as to actual, not ideal practice.

Whilst trying to respond to the generic and inadequately particularised allegations, Ms Williams gave a general explanation of her use of The Viewer, She said (at [91]):

Outside of looking after inpatients on the ward, I am also responsible for looking after outpatients that are not always admitted on the unit with varying complaints from labour to minor medical complaints. We even have women that arrive unbooked from outside the South Burnett region.

Because of this, I utilise The Viewer to see where the women have been, when their next appointments are due, ultrasounds they have had. Information I need to be able to provide adequate care to them. We do not have a medical officer available to our unit after hours. They are on call only. It is our responsibility to be able to access this information ourselves.

My role also includes looking after general patients that are overflow from the Inpatient Unit. Again, I utilise The Viewer to read their emergency department notes, check CT reports, ultrasound reports.

I have utilised The Viewer on patients we have transferred to another facility to birth at, and to check on their wellbeing at a doctor’s request. But also for any follow up we may need to provide them with.

I have utilised The Viewer to check the patient’s prescription history as she did not remember how much metformin she took on her admission to hospital.

I have utilised The Viewer to see when our booked women have birthed elsewhere as they have not birthed here in Kingaroy as planned. And I update our bookings list every month to reflect this.

I have had women and babies present requiring NST and weights after birthing elsewhere. I have utilised The Viewer to access their discharge summary.

I often have been asked to review patients in ED on behalf of medical officers who are pregnant. I have utilised The Viewer to see their history, where they have been receiving antenatal care and their ultrasounds if they have had any.

Recognising that I am not a clinician, I would have thought that accessing information for those reasons is exactly why The Viewer exists.

The problem is that there was no clear allegation as to what she did wrong, and that is why the process was found to be unfair, but in the interim, the approach of Queensland Health should, I suggest, leave Queensland practitioners with great uncertainty as to what is or is not acceptable access to The Viewer. 

What one might infer is that if Queensland Health is going to take this sort of approach to The Viewer – where following up on patients to see if they have birthed elsewhere to allow Kingaroy to adjust its books ie to know that a person they expected to come in won’t be coming in – is not permitted, then a paramedic following up so they can have ‘closure’ on a tough case or confirm their diagnosis will certainly not be permitted. 

This blog is a general discussion of legal principles only.  It is not legal advice. Do not rely on the information here to make decisions regarding your legal position or to make decisions that affect your legal rights or responsibilities. For advice on your particular circumstances always consult an admitted legal practitioner in your state or territory.