Health Ombudsman v Cole [2026] QCAT 10

Health Ombudsman v Esposo [2025] QCAT 166

[1] This proceeding is concerned with an application brought by the Health Ombudsman ('applicant') against Elizabeth Carolyn Cole ('respondent'). On 11 February 2026, after hearing from the parties, Ms De Luchi of Counsel who appeared on behalf of the applicant and Ms Cole who appeared in person, the Tribunal made the following findings and orders:

1. Pursuant to s 107(2)(b)(i) of the Health Ombudsman Act 2013 (Qld), in respect of allegation 1 the respondent has behaved in a way that constitutes unsatisfactory professional performance.
2. Pursuant to s 107(2)(b)(ii) of the Health Ombudsman Act 2013 (Qld), in respect of the first of the allegations under allegation 2, the respondent has behaved in a manner that constitutes unprofessional conduct.
3. Pursuant to s 107(2)(b)(iii) of the Health Ombudsman Act 2013 (Qld), in respect of the second of the allegations of allegation 2 the respondent has behaved in a way that constitutes professional misconduct.
4. Pursuant to s 107(3)(a) of the Health Ombudsman Act 2013 (Qld), in respect of allegation 1 and the first of the allegations in allegation 2, the respondent is cautioned.
5. Pursuant to s 107(3)(a) of the Health Ombudsman Act 2013 (Qld), in respect of the second allegation in allegation 2, the respondent is reprimanded.

In respect of that reprimand the Tribunal strongly recommends that it be removed from the public record four (4) months from today's date.

[2] Brief reasons for those findings and orders were given on 11 February 2026 but it was made clear that more detailed reasons would be published in due course. The parties were content to proceed on that basis, and the following are the full reasons underlying those findings and orders already made.

[3] At all relevant times the respondent was a registered paramedic employed by the Queensland Ambulance Service ('QAS').

[4] On 13 May 2023 the QAS placed the respondent on alternative duties pursuant to s 101(1)(b) of the Public Sector Act 2022 after receiving information to the effect that she had failed to advise the QAS operations centre ('OPCCN') of her movements at the commencement of her shift and she had delayed responding to a Code 1 incident.

[5] On 6 July 2023, the QAS sent a letter of notification to the applicant, setting out the incident on 12 May 2023 where the respondent delayed responding to a Code 1B incident.

[6] On 19 September 2023, the QAS sent another letter of notification to the respondent inviting her to respond to the allegations of:

(a) several instances where she failed to accurately update the OPCCN on her and her partners whereabouts; and

(b) two instances where the respondent delayed responding to Code 1(B) and 2B incidents.

[7] On 1 November 2023, the respondent provided her response to those allegations in which she acknowledged that they had occurred.

[8] There were three allegations made against the respondent when the proceedings were brought before the Tribunal. The first allegation concerned delays from 4 to 37 minutes in notifying the QAS of her movements following completion of callouts. The next two allegations involved two incidents in delay in responding to callouts. The first involved a response delay of 5 minutes to a Code 2B incident. The second, a delay of 10 minutes in responding to a Code 1B incident.

[9] In respect of both allegation 1 and allegation 2 the applicant submitted that it was appropriate for the Tribunal to find that the respondent behaved in a way that constituted professional misconduct as defined in s 5 of the National Law. The applicant also sought that the respondent be formerly reprimanded and that there be no order as to costs.

[10] It should be noted that the respondent, as a consequence of her conduct, had been the subject of significant disciplinary action imposed by the QAS. In addition to being formerly reprimanded and made the subject of a pay cut for a period of time. She was also issued a final warning and was required to complete the following administrative actions:

(a) training on the Code of Conduct and Public Sector Ethics;

(b) a full review of all QAS operating procedures as they relate to the work of paramedics within 4 weeks of her resumption of duty;

(c) participate in, and successfully, complete a Return to Clinical Practice Program; and

(d) be placed at a suitable location within the Gold Coast region.

[11] Before proceeding further, a number of observations can be made and conclusions reached in respect of the allegations concerning the failure to notify of movement. There is some controversy as to whether three of those occasions identified were in fact, failures to notify. However, it is not necessary to dispose of this matter to resolve that controversy. The second matter is that while the failures to notify of movement has the potential to disrupt the allocation of resources to address callouts that did not occur in this case.

[12] In respect of the first of the allegations of delay in responding to the Code 1B incident, the actual period of delay was more likely to have been less than five minutes and in the order of two to three minutes. In the respondent's response to this allegation, she stated:

I cannot recall the specifics of this incident, but I did not intentionally delay responding. It is possible I was using facilities at the time. I now recognise that if this was the case I should have notified IPCEN by radio immediately.

[13] The second thing to note in respect of the delay concerning the Code 2B incident is that there was no suggestion of any adverse consequences arising from that delay.

[14] In respect of the second allegation of delay in responding, it is clearly a serious example of a failure to respond. The respondent fully accepts the seriousness of her failure in this regard, and in her response said:

I acknowledge the specifics outlined are correct. On that day I was emotionally fragile and made poor decisions. I proceeded to Espresso Moto for coffee after signing on and was dispatched a Code 1B while awaiting my order. I did not appreciate how much time had passed until contacted by OPCEN. This decision undoubtedly demonstrated poor decision-making and is something I have grappled with since the incident.

[15] While more will be said about what the respondent described as being "contextual" background" below, the first thing to observe is that those matters raised in no way excuse the conduct of the respondent, a matter she readily accepts. The second matter is that thankfully no adverse consequences followed as a result of that delay, and in this regard, it is not an entirely irrelevant feature that the respondent was aware at the time that the patient was situated in a nursing home and was more likely than not under at least some degree of care.

[16] In her written submissions, the respondent said:

The respondent accepts full responsibility for the conduct in question and recognises that it represented a lapse of professional judgement. However, the respondent submits that the applicant's characterisation of the conduct as professional misconduct is disproportionate to the facts and the legal thresholds under section 5 of the National Law.

[17] The respondent went on to say in those submissions under the heading "contextual factors" the following:

The respondent acknowledges the seriousness of the decision of delay responding to a Code one case and accepts that it represented a lapse in professional judgement. However, proper contextual consideration is essential in determining the appropriate classification of this conduct under the National law.

Due to increasing operational pressures faced by paramedics is not uncommon to observe colleagues attempting to create opportunities to meet basic physiological needs such as eating, hydrating or using the bathroom during demanding shifts. The respondent does not condone or agree with such self-servicing practices and acknowledges that they fall short of the professional standard expected. However, they occur in the broader context of a uniquely high-pressure environment characterised by expenditures, unpredictable workplace and sustained physical and cognitive stress, often without structured or reliable opportunities for rest breaks.

[18] Most if not all the submissions made by the respondent, while no doubt relevant in going to matters of mitigation do not alter the appropriate objective nature and identification of the conduct involved.[1] On balance, the Tribunal is of the view that the conduct of the respondent in respect of the allegations concerning the failure to notify of movement might be seen as more in the nature of administrative failures rather than examples of conduct falling materially below that expected of a paramedic. Thus, the finding of unsatisfactory professional performance.

[19] In respect of the first of the allegations of failing to respond, it should be seen as a minor example of conduct falling below that expected of a paramedic by the public. It is not conduct that warranted a finding of professional misconduct but a finding of unprofessional conduct. In this regard, it may also be noted that but for the second incident of delay in responding on its own this allegation may only have warranted a finding of unsatisfactory professional performance.

[20] In respect of the second allegation of delay in responding there can be no room for doubt that when looked at objectively it clearly falls within the description of what constitutes professional misconduct.

[21] Turning then to the question of sanctions it is always necessary to have at the forefront of any consideration that the objective of the Tribunal is not to impose a punitive outcome but to deliver an outcome that as far as is practicable promotes the health and safety of the public.

[22] While the Tribunal has some sympathy for the global approach advocated for on behalf of the applicant it nonetheless considers that the allegations are sufficiently distinguishable one from the other to justify separate findings and consequential orders. Bearing in mind the level of seriousness of the conduct involved and the mitigating factors in favour of the respondent, which will be dealt with in detail in a moment. The Tribunal is of the opinion that, in respect of the first two allegations against the respondent, the safety and welfare of the public would be sufficiently addressed by the issuing of a caution.

[23] In cases where there is a finding of professional misconduct it is almost inevitable that a formal reprimand would follow and often even more serious consequences. In this regard, the concept of deterrence typically looms large. Quite properly the applicant here accepts that there is little if any need to impose an outcome designed to act as a form of personal deterrence. That said, in respect of the second example of delay, the Tribunal accepts that a reprimand is warranted for the purposes of sending a message of general deterrence.

[24] However, in reaching an appropriate outcome it is necessary to bear in mind not only the seriousness of the subject conduct but also the mitigating factors in favour of the respondent. There is no suggestion of any untoward conduct on the part of the respondent prior to the subject conduct, nor of any untoward conduct since. Further, the respondent has already been dealt with in a quite comprehensive manner via internal disciplinary action.

[25] There also can be no doubt that the respondent has full insight into the nature and seriousness of her conduct and is deeply remorseful and ashamed. In this regard her conduct and these resultant proceedings have affected her both emotionally and physically. Also, not only has the respondent readily admitted to her conduct, but has cooperated fully in these proceedings. Finally, the respondent of her own volition has undertaken further education, including steps designed to prevent such conduct occurring in the future.

[26] On balance, the Tribunal is of the view that the respondent is a person who is a dedicated paramedic and one who takes pride in doing the best she can professionally. The Tribunal is readily satisfied that the conduct of the respondent that brought her before the Tribunal occurred at a particularly stressful time in her life[2] and was clearly out of character . It was for those reasons, the Tribunal made the recommendation that it did concerning the reprimand.

[1] Health Ombudsman v Esposo [2025] QCAT 166 [19].

[2] E.g. see paragraph 7 of the Statement of Agreed and Disputed Facts.