This section provides a concrete, statute-grounded compliance checklist and operational recommendations for the primary duty-bearers named in the Act: the Council, health establishments and their licensees, midwives and medical practitioners, the Registrar of Births, Deaths and Marriages, researchers, and ministerial/departmental officers.
Compliance steps for establishments, clinicians and attendants (s 16, s 17)
- Map roles to statutory definitions
- Determine, for each birth and relevant death scenario, who meets the definition of “attendant” under s 16(1). That requires reviewing whether the event occurred in an “establishment” (as defined under the Health Service Establishments Act 2006), a public hospital, or elsewhere, and who was in attendance (midwife, medically-qualified practitioner, licensee).
- Adopt approved Council forms and processes
- The Act requires attendants to provide “required information” in a form provided or approved by the Council (s 16). Establishments should request copies of the Council’s approved forms and embed them into medical record workflows. Where the Council updates forms, implement version control and change management.
- Meet the seven-day deadline for required information
- Put in place procedures to collect, validate and transmit the Council’s forms within seven days of the event (s 16(2)). For multi-disciplinary care, designate a named role (e.g. clinical coordinator or records officer) responsible for ensuring compliance.
- Maintain confidentiality and restrict external disclosure
- Attendants must not disclose the required information beyond what is necessary for attendant functions (s 16(3)). Ensure staff receive training on the confidentiality obligations in s 15 and s 15A. If disclosure beyond immediate care is requested, seek Council approval or legal advice.
- Responding to s 17 written requests
- Treat any written request from the Council under s 17 as statutory. Log receipt, identify the custodian(s) of the requested information, assess whether the information is in the person’s control and is within the scope of the request, and provide the specified materials promptly. Although s 17 does not prescribe a timeframe, compliance should be as soon as practicable to mitigate the risk of a fine (s 17).
Registrar of Births, Deaths and Marriages (s 16(4))
- BDM Registrar pipeline
- Ensure mechanisms are in place to transmit required information relating to maternal or perinatal deaths to the Council within 30 days of notification under the BDM Act (s 16(4)). Coordinate data flows between registration staff and Council liaison officers.
Council operations and governance (s 5, s 6, s 7, ss 8-12)
- Formulate data governance, access and disclosure policies
- The Council should develop written policies on classification of material, de-identification standards for research releases (s 15(5)), procedures for issuing confidentiality declarations under s 15A, and criteria for approving disclosures to clinicians and researchers (s 15(4)). These policies should be published internally and shared with partner institutions subject to confidentiality rules.
- Implement strict access controls and audit trails
- Given the inadmissibility and confidentiality regime (s 15, s 15A), maintain secure IT systems, role-based access controls, and audit logs showing who accessed what information and why. These technical measures will support compliance with legal prohibitions on unauthorised disclosure (s 15(1), s 15A(3)).
- Prepare standard operating procedures for coronial and police interactions
- The Council may provide recommendations and information to coroners (s 6A(1)) and must notify police when it reasonably suspects an indictable offence involving a child or woman (s 15(9)). Draft SOPs to determine thresholds for reporting, roles for Council staff, documentation required, and protocols for liaising with coroners and police while preserving confidentiality to the extent possible.
- Reporting and non-identifying public communication
- Produce the annual report by 31 October on the previous financial year (s 12(1)). Ensure that public reports do not contain any information enabling identification of persons in registers (s 12(7)). Coordinate with the Department to append or lay reports before Parliament as required (s 12(2)-(3), (6)).
Researchers and external parties (s 15(4)-(6), s 15A)
- Requesting research data
- Researchers must apply to the Council for access, state the research purpose, and accept that identifiable data will not be provided without written consent of the person or their parent/guardian (s 15(5)). Prepare ethical approvals, data management plans and consent forms for Council review.
- Contractual and confidentiality obligations
- When the Council discloses information to third parties or enters into contracts/joint ventures (s 11), ensure contracts include confidentiality clauses mirroring the statutory obligations, provisions for return or destruction of data, obligation to comply with s 15A where declarations are made, and indemnity clauses where appropriate and lawful.
Ministerial and departmental compliance (ss 10, 11, 22)
- Staffing and service provisions
- The Secretary must make available staff to the Council as necessary (s 10(a)). Departments should nominate staff with appropriate clinical, statistical or legal expertise and ensure secondments are supported by clear terms of reference documenting duties and confidentiality obligations.
- Approving arrangements with the University or others
- The Council may arrange with the University of Tasmania for services with Secretary approval (s 10(b)) and may enter contracts with Secretary approval (s 11). Ensure formal Memoranda of Understanding or service-level agreements are in place and governance responsibilities are recorded.
Practical recordkeeping and audit measures
- Keep contemporaneous logs of requests and disclosures
- Maintain a central register of s 17 requests, s 15A confidentiality declarations, disclosures under s 15(4), and any reports to police or coroners. This supports transparency, audit and risk management.
- Training and induction
- Provide tailored training for clinicians, records staff, registrars and Council employees on obligations under ss 15, 15A, 16 and 17, including practical case examples of permitted disclosures and obligations to report suspected indictable offences.
- Legal oversight and escalation
- Establish a legal escalation pathway for ambiguous requests, potential conflicts between confidentiality and statutory reporting obligations, and complex coronial or police interactions.
- Review and continuous improvement
- Regularly review the Council’s forms, data definitions and reporting timelines in consultation with health services to reduce reporting burden, clarify responsibilities, and ensure data quality for trend identification and planning (s 6(b)(iii)-(iv)).
By following these steps, duty-bearers align operational practice with the Act’s statutory structure: timely data flows to the Council to support perinatal and paediatric oversight (s 6, s 14), while enforcing the confidentiality protections, limited disclosure routes and reporting obligations that the Act prescribes (ss 15, 15A, 6A, 15(9)).