Formal investigation – information for complainants

What you need to know if your complaint is under formal investigation

This page is for people who have made a complaint to HDC that is being formally investigated. We will let you know if we are formally investigating your complaint. On this page you can learn about the investigation process and what to expect.

About formal investigation of complaints

In a small number of cases, our Commissioner formally investigates a complaint. This is a serious step. The Commissioner identifies the issues to be investigated. These may be different from the issues raised in your complaint. For example, the focus may be on specific issue/s within the complaint, or may take a broader view of the issues raised.

If we decide to investigate your complaint, we will let you and the provider know. Most of the time, the decision to investigate formally is made after a detailed assessment of a complaint. That means we may have already asked the provider to respond to the complaint, and may have asked for clinical advice on the care provided. If we haven’t already, we give the provider the details of the complaint and the chance to respond in writing.

The investigation process is impartial. The Commissioner is like a judge, conducting an investigation that is independent and fair to you and to the provider. The Commissioner does not act solely to protect your interests.

How long will the investigation process take?

This depends on how complicated your complaint is. While many investigations take around 12 months to complete, some more straightforward investigations can be completed in a shorter timeframe. Other investigations are very complex, involving many providers and wide-ranging issues, and can therefore take longer. We will keep you updated on progress at least every 10 weeks.

Please note that these timelines are in addition to the time taken to complete an initial assessment of your complaint before a decision is made to investigate formally.


For an investigation, your complaint is assigned to an Investigator. The Investigator becomes your main contact. If you have any questions, please contact your Investigator.

The Investigator:

  • Identifies the facts (what happened, when, where, and more)
  • Uses evidence from the first stage of your complaint
  • Collects further evidence
  • Presents evidence to the Commissioner or Deputy Commissioner who is making decisions on the investigation.

During an investigation, we may consider any of these types of evidence:

  • Documents such as statements from providers and complainants, clinical notes, policy and practice manuals
  • Verbal evidence from interviews with witnesses and other parties
  • Any other relevant evidence such as labelled medication containers.

Where the standard of care is an issue, HDC seeks clinical advice from a person who works in the same field as the provider. This independent person will have knowledge and experience in the area.

Once the evidence has been gathered:

  1. Our Commissioner or Deputy Commissioner forms an opinion on whether the provider has breached the Code of Rights.
  2. We summarise the opinion in a report. Usually, we ask you to review and comment on the “information gathered” part of the report. This is an important step in reaching a final decision.
  3. If we find that a provider has breached the Code, or we make an adverse comment about a provider, the provider will have an opportunity to respond. 
  4. After considering responses to the provisional opinion, our Commissioner or Deputy Commissioner makes a final decision.

Outcome of an investigation

After an investigation, we usually recommend that the provider makes changes and improvements. Because each complaint is unique, these are different every time. Recommendations may include:

  • A written apology to the person complaining
  • Specific training for a provider
  • The creation, use, and review of systems to prevent further breaches of the Code.

When we make recommendations, we follow up to confirm that they have been actioned appropriately.

If an investigation raises concerns about a registered health practitioner’s competence, HDC may recommend to the practitioner’s registration authority (for example, the Medical Council) that it consider reviewing the practitioner’s competence.

Not all complaints lead to a decision that there has been a breach of the Code. In these cases, we may still make recommendations to the provider.

Applying what we learn

When HDC provides a final report, that is the end of the investigation. However, we do further work with what we have learned from the complaint. We encourage changes to providers’ and organisations’ practice, and to wider health and disability systems.

HDC can make recommendations to:

  • The provider
  • The appropriate authority (for example, a registration body)
  • The Ministry of Health
  • Any other person or organisation, such as professional colleges, district health boards, ACC, and consumer and provider groups.

HDC can also refer or notify other agencies or authorities about the outcome of the investigation. If the Commissioner has found a breach of the Code, usually the report is published on our website. This educates and informs providers and the public. We remove names and other identifying features before publication.

Director of Proceedings

Very rarely, when a provider has been found in breach of the Code, the Commissioner or Deputy Commissioner may refer the matter to the Director of Proceedings. This is a step reserved for the most serious breaches of the Code, and the purpose is to protect public interest through holding practitioners to account.

The Director of Proceedings will decide whether to take action against the provider, before a disciplinary tribunal and/or before the Human Rights Review Tribunal. If this happens, you may be asked to be a witness in any court proceedings. That is something the Director of Proceedings will discuss with you if the need arises.

If the Director of Proceedings declines to take proceedings before the Human Rights Review Tribunal, you may be entitled to bring proceedings in your own right. Find information on how to file a claim in the Human Rights Review Tribunal.