Timeframe for review:                    Every five years, or earlier if required

Document authorisation:               ACEM Board

Document implementation:           Chief Executive Officer

Document maintenance:                Manager, Governance and Standards

Copyright 2025. Australasian College for Emergency Medicine. All rights reserved.

The Board of the Australasian College for Emergency Medicine (ACEM; the College) has established a role of Independent External Reviewer within the College, which is akin to that of an ‘ombudsman’ or ‘reviewer’.  The establishment of this role seeks to provide independent oversight of College complaints[1] and whistleblower handling processes, as well as decision review processes under the applicable College policies and procedures, and seeks to ensure concerns can be raised and issues addressed fairly, without fear of reprisal or retribution.

The role does not, however, replace usual College processes whereby notification of complaints, including complaints relating to discrimination, bullying or harassment, are ordinarily made in writing to the Chief Executive Officer and handled through that office. In addition, the role does not provide an alternative avenue through which complaints involving ACEM staff are considered as such complaints will be handled by the relevant employment processes or, where the complaint is made against a member or trainee of the College, handled under the College Complaints Policy.

College Member

means a person admitted as a member of the College pursuant to the provisions of the ACEM Constitution and  associated regulations, and any external person serving on any College entity.

Reviewer

for the purposes of this policy, means the person appointed by the College for the purpose of conducting the assigned functions as described in this and any other relevant policies, procedures and regulations.

Trainee

means an individual enrolled in an ACEM training program and, for the purposes of this policy, undertaking College requirements for the purpose of attaining eligibility for election to Fellowship of the College.

Whistleblower

is a person who reports serious wrongdoing in accordance with the provisions of the Whistleblower Policy.

Whistleblowing

means the disclosure by or for a witness of actual, suspected or anticipated wrongdoing in the College that relates to fraud corruption, illegal activities, gross mismanagement, malpractice or other serious wrongdoing.

3.1 Role

The key role of the Reviewer is to provide independent oversight of the College’s handling of complaints, including Discrimination, Bullying and Sexual Harassment (DBSH) and whistleblower complaints, as well as decision review processes under the applicable College policies and procedures.  For the purposes of this policy, decision review processes include applications for reconsideration, review and appeal. The role does not replace the expectation that a complainant will, ordinarily, have utilised existing College mechanisms, such as reconsideration, review and appeal, and complaints handling processes.

The Reviewer is an independent external person who College members, trainees and others can approach if, for some reason, they are not confident in utilising established College processes for fear of repercussions, reprisal or bias.  The Reviewer will make a determination as to whether there are grounds for those concerns and, if not, the matter will be referred to the Chief Executive Officer or President, if applicable, to be handled in accordance with the relevant College policy(ies) and processes.  If the Reviewer determines that there are grounds, then they will assume a role in assisting with the handling of the complaint to ensure it is handled appropriately.

The role does not circumvent usual College processes for the reconsideration, review and/or appeal of a College decision or the reporting and handling of a complaint.

The Reviewer shall also receive complaints under the provisions of the Whistleblower Policy in circumstances where the complaint relates to the President and/or the Chief Executive Officer and/or which are not able to be adequately addressed through the processes described therein.

3.2 Powers

1. The Reviewer shall provide independent oversight of the operation of the College’s decision review processes.  The Reviewer shall not participate in the reconsideration, review or appeal of any College decision; rather, oversee the conduct of these processes and provide annual reports to the ACEM Board for its information and consideration, including the making of recommendations to the ACEM Board if applicable.
2. Where the Reviewer is approached by a College member or trainee who is not confident in utilising existing College processes for fear of repercussion, reprisal, bias or similar, the Reviewer shall make a decision as to whether there are grounds for those concerns.

Where the Reviewer is of the view that the concerns are not warranted and that the matter can be appropriately addressed through existing College processes, they will liaise with the Chief Executive Officer or President as applicable, to have the matter addressed through those processes with appropriate oversight, if warranted, by the Reviewer to ensure the matter is handled appropriately.

Where the Reviewer is of the view that the concern is warranted and there is a genuine risk of repercussion, reprisal, bias or similar in the handling of the complaint or matter through ordinary processes, they shall liaise with the Chief Executive Officer or President as applicable, to establish an alternative way, within the overarching framework of the applicable College policy(ies) and/or procedures, in which the matter is to be handled.

3. Where the Reviewer receives a complaint under the provisions of the Whistleblower Policy and 3.2(b) (above), they may assume the role of the President or Chief Executive Officer in facilitating the complaint or report of wrongdoing made under relevant policy.
4. In assessing a complaint or concern, the Reviewer shall ensure that the College and any other relevant parties are accorded natural justice and fairness and with appropriate opportunity to consider the issues and respond.
5. The Reviewer may, for good reason, refuse to assess or investigate a matter where it is appropriate to do so, and will provide the complainant with written reasons for that decision.
6. The Reviewer shall provide the ACEM Board with an independent, validated report on an annual basis or otherwise as requested, in relation to the College’s handling of complaint matters and the reconsideration, review and appeal of College decisions.

Limitations on Powers

7. The Reviewer cannot override a decision of the College, nor issue directions to the College or its staff.
8. The Reviewer cannot impose a decision on the College and cannot make a decision between a complainant and the College where that would override any previous decision by the College.
9. The Reviewer does not review the merits of a College decision and the process is not an opportunity for further ‘appeal’ of a College decision(s) regardless of whether an appeal has been previously lodged and/or an appeal decision made.
10. The Reviewer does not consider or review basic management and/or operational decisions of the College in relation to matters such as fees or general College activities.
11. The reference of a complaint or concern to the Reviewer does not take away from any complainant their rights otherwise available at law or otherwise available through College processes.

3.3 College Assistance

The College will provide such assistance to the Reviewer as the Reviewer reasonably requests.  Subject to legal and professional privilege, privacy considerations or where disclosure would not otherwise be appropriate, the College shall provide copies of all relevant information and documents relating to a decision review, complaint or concern.  The College shall advise the Reviewer as to the reason(s) why any relevant information and documents have not been made available.

4.1 Annual Report

The Reviewer will provide an annual report, to the ACEM Board, at a time determined in consultation with the College Chief Executive Officer, to provide assurance that complaint and decision review handling has been undertaken appropriately, and to validate statistics in relation to such matters.  The Reviewer may review a sample of reconsideration, review, appeal and complaints to be satisfied that due process has been afforded.

At the discretion of the ACEM Board, information from the review report may, in deidentified form, be released publicly and/or to College members and trainees.

4.2 Referral Matters

The College, through the ACEM Board, may also initiate a review by the Reviewer of its processes on specific matters in order to seek the Reviewer’s comments and advice.  Circumstances that might generate such a review may include two-yearly review of an applicable College policy.

The Reviewer shall provide the ACEM Board with a report of those matters handled under Section 3.2(b) and Section 3.2(c) above.

• ACEM Constitution
• ACEM Regulations
• ACEM Core Values module
• Code of Conduct (COR235)
• Complaints Policy (COR166)
• Conflict of Interest Policy (COR139)
• Discrimination, Bullying and Sexual Harassment Policy (COR133)
• Independent External Reviewer Declaration of Acceptance of Appointment (COR693)
• Independent External Reviewer Position Description (PD653)
• Intellectual Property Policy (COR64)
• Member/Staff Relations Policy (COR304)
• Policy on the Appointment and Remuneration of Community Members (COR498)
• Policy on Procedural Fairness (COR140)
• Procedures for Submission and Resolution of Complaints (COR656)
• Privacy Policy (COR200)
• Reconsideration, Review and Appeals Policy (COR355)
• Whistleblower Policy (COR450)