Whistleblower Policy and Protocol



Policy Statement:


Epworth HealthCare (Epworth) is committed to best practice in corporate governance and compliance and consistent demonstration of behaviours consistent with our Values by those who represent Epworth.


Persons, including but not limited to employees, volunteers, contractors, suppliers or members of the public who detect or have reasonable grounds for suspecting Improper Conduct associated with Epworth can raise concerns in good faith under the protocol without being subject to victimisation, harassment or discriminatory treatment by Epworth or its staff, and may choose to raise concerns on an anonymous basis.



The Whistleblower who detects or has reasonable grounds for suspecting Improper Conduct is encouraged to raise any concerns with the Disclosure Officer.


Improper Conduct may involve:


  • corrupt conduct
  • substantial mismanagement of Epworth’s resources
  • conduct involving substantial risk to public health or safety, or
  • conduct involving substantial risk to the environment


Improper Conduct is not perceived unreasonable or unfair behaviours or poor work performance or practices that can be identified, raised and addressed through other mechanisms.


The Whistleblower




Epworth will take all reasonable steps to protect and respect the rights of a person who reports alleged Improper conduct in good faith.


Epworth will take all reasonable steps to protect the Whistleblower and will not tolerate any retaliatory action or threats of retaliatory action against any person who has made or who is believed to have made a report of Improper conduct in good faith. Any such retaliatory action or victimisation by any member of staff in reprisal for a report being made under this protocol will be treated as serious misconduct and will result in disciplinary action, which may include dismissal.


A Whistleblower is not automatically protected from the consequences of being a party to any Improper Conduct they report under this protocol.


Where it is established that a Whistleblower who is a member of staff  is not acting in good faith, or he/she has knowingly made a false disclosure of Improper Conduct, then he/she will be subjected to disciplinary proceedings, which may include summary dismissal.




A Whistleblower may elect to make a disclosure anonymously. As far as possible, Epworth will respect the Whistleblower’s request to not identify themselves.  However, Epworth may not be able to investigate certain disclosures without the identity of the Whistleblower becoming known, whether directly or by inference, to Epworth or to the person about whom the allegations are made.  Where criminal matters are involved, Epworth may be required to report certain allegations to the police (or other relevant agency) and to give the identity of the Whistleblower.


However, even if the identity of a Whistleblower is known or becomes known, Epworth will continue to ensure that all reasonable steps are taken to protect the Whistleblower from reprisal.


At the time of making a disclosure, the Whistleblower can request a meeting in a discreet location away from their workplace or from Epworth.


Others who know of or suspect that another person has made a disclosure under this protocol should protect and maintain the confidentiality of that person. Staff members who breach confidentiality in relation to a known or suspected disclosure will be subjected to disciplinary proceedings, which may include summary dismissal.




Where possible and assuming the identity of the Whistleblower is known, the Whistleblower will be kept informed of the progress and outcome of the investigation of his/her disclosure, subject to privacy and confidentiality considerations. All Whistleblowers must maintain confidentiality of any information provided to them by Epworth in relation to, or as a consequence or outcome of their disclosure.


Management of the person/s against whom the disclosure has been made


Epworth recognises that persons against whom disclosures are made and investigated under this protocol must also be supported during the handling and investigation of disclosures. Epworth will afford procedural fairness to the person against whom a disclosure has been made.




Disclosures may be made in the following ways:


By letter: Disclosure Officer, Epworth HealthCare, 89 Bridge Road, Richmond VIC 3121

By emailEC-DisclosureOfficer@epworth.org.au


Step 1:

The Disclosure Officer will determine if the disclosure is a Whistleblower Disclosure. They will deem the claim to be a Whistleblower Disclosure if they are satisfied that the claim made tends to show that Epworth, an employee, or officer or other person representing Epworth has engaged in Improper Conduct.  Matters involving potential criminal offending may be referred immediately to the police.


Step 2:

Where a disclosure is assessed not to be a Whistleblower Disclosure, the Disclosure Officer will decide how the matter should be responded to in consultation with the Group Chief Executive, the President of the Board of Management or the Executive Director Human Resources as appropriate. Even if a disclosure is not a Whistleblower Disclosure, there may be other Epworth policies and protocols that apply and the person who made the disclosure will be advised of the correct reporting avenue.


Step 3:

The Disclosure Officer will refer a Whistleblower Disclosure to the Disclosure Committee to commission an investigation which will be conducted as follows:


  • review all claims made, in conjunction with any evidence provided by the Whistleblower
  • investigate and locate any evidence that may substantiate or refute the claims of the Whistleblower (this may include interviewing other parties)
  • the person/s against which the allegation has been made will have the opportunity to respond and explain their behaviour and to provide any material in support of their response and explanation
  • a conclusion shall not be reached and a recommendation will not be made until reasonable and appropriate enquires have been made and submitted material considered, and
  • the Disclosure Committee may also refer the matter for investigation to an external body or the police if criminal conduct appears to have occurred, and the Board of Management will be advised of any such referral


Step 4:

At the conclusion of an investigation a report will be prepared by the Disclosure Committee. The report will broadly outline the following:


  • the details of the Whistleblower Disclosure
  • the information and evidence collected during the investigation that either supports or refutes the allegation of Improper Conduct
  • the conclusions reached by the Disclosure Committee and the reasoning behind each conclusion, and
  • the recommendation of the Disclosure Committee as to any action to be taken and as to who should be the appropriate decision maker in respect of any such action


Step 5:

Authority as to taking any action in response to a recommendation made by the Disclosure Committee shall be determined by the seriousness of any substantiated allegations.


Step 6:

The level of reporting to the Board as to Whistleblower Disclosures will be determined by the seriousness of any allegations made in relation to Improper Conduct. At a minimum, the Disclosure Officer will prepare a general report on Whistleblower Disclosures to the Audit and Risk Committee of the Board of Management on an annual basis.


Step 7:

The Disclosure Officer will maintain a register of Whistleblower Disclosures, a copy of the report of the Disclosure Committee and actions taken in response to the report.


Disclosure Committee

The Disclosure Committee will ensure that, unless the circumstances require otherwise, the person who is subject of any Whistleblower Disclosure investigated by or on behalf of Epworth is:


  • informed in writing as to the substance of the allegations
  • given the opportunity (and sufficient time) to respond to the allegations, be afforded the opportunity to bring a representative of their choosing to any meeting and be heard in relation to the matter under investigation
  • informed as to the substance of any adverse finding against them included in any report arising from the investigation, and
  • offered the opportunity to utilise the employee assistance program where they are an employee of Epworth




Any person, including but not limited to, employees, volunteers, contractors or any member of the public that has concerns regarding Epworth in relation to any Improper Conduct affecting Epworth can raise these concerns without being subject to victimisation, harassment or discriminatory treatment by Epworth or its staff, and may choose to raise concerns on an anonymous basis.




Improper Conduct means recklessly negligent, dishonest, unethical or illegal conduct including: 


  • corrupt conduct
  • substantial mismanagement of Epworth’s resources
  • conduct involving substantial risk to public health or safety, or
  • conduct involving substantial risk to the environment


Corrupt conduct:


  • conduct of a person (whether or not a representative of Epworth) that adversely affects, or could adversely affect, either directly or indirectly, the honest performance of Epworth’s functions, or
  • conduct of a representative of Epworth that amounts to the performance of any of his or her functions on behalf of Epworth dishonestly or with inappropriate partiality, or
  • conduct of a representative of Epworth, a former representative of Epworth that amounts to a breach of public trust, or
  • conduct of a representative of Epworth or, a representative of Epworth that amounts to the misuse of information or material acquired in the course of the performance of their functions as such (whether for the benefit of that person or body or otherwise), or 
  • a conspiracy or attempt to engage in conduct referred to above.


Disclosure Committee: At least any two of the Group Chief Executive, President of the Board of Management, the Executive Director Human Resources and the Executive Director having responsibility for the department in which the alleged Improper Conduct arose.

Disclosure Officer: The General Counsel and Company Secretary of Epworth or their appointed nominee.


Reasonable grounds: An objective test and relates to whether a reasonable person in possession of the information would form the belief that the Improper Conduct occurred. It is important that there is evidence to support a person’s beliefs, other than their concerns. This may include documentation, witnesses or other direct evidence.


Values: Epworth’s values published on www.epworth.org.au.


Whistleblower: any person who makes a disclosure in connection with Improper Conduct under this protocol.


Whistleblower Disclosure: disclosure by a Whistleblower under this protocol based on reasonable grounds that discloses or demonstrates an intention in good faith to disclose.


Current as at 24 April 2018