PUBLIC WATCH REPORT - Systemic Misconduct in NSW Health Care Complaints Commission

Public Watch Report: The New South Wales Health Care Complaints Commission – A Scandal of Incompetence, Overreach, and Unaccountability

Date: 26th September 2025

The New South Wales Health Care Complaints Commission (HCCC), established under the Health Care Complaints Act 1993 to safeguard public health through fair complaint resolution, stands accused of systemic incompetence, ethical violations, and a flagrant disregard for its legislative mandate. Far from protecting the public, the HCCC’s actions have been described as “absolutely shocking” by those caught in its crosshairs, including the complainant who inspired this report, who states:

“The HCCC’s threats and abuse against me mirror the horror stories of others—presumed guilt, dismissive processes, and no accountability.”

From the persecution of naturopath Barbara O’Neill to ongoing parliamentary and public outrage, the HCCC’s conduct reveals an organisation that is failing the people of NSW. This report, grounded in media reports, parliamentary findings, and public testimony, exposes the HCCC’s dangerous dysfunction and calls for urgent reform.

Systemic Incompetence and Failure to Investigate

The HCCC’s mandate, per Section 3 of the Health Care Complaints Act 1993, is to “promote and protect public health and safety” through thorough and impartial complaint investigations. Yet, media and parliamentary sources paint a picture of gross incompetence.

A 2014 Sydney Morning Herald article reported:

“The HCCC has seen a dramatic decline in investigations despite complaints from the public being at an all-time high.”
(Sydney Morning Herald, February 16, 2014)

In 2020–21, the HCCC discontinued 43% of complaints without investigation, and in 2022–23 only 427 of 9,159 complaints were finalized as investigations (HCCC Annual Report 2022–23). This reflects a systemic failure to probe serious allegations, prioritising bureaucratic efficiency over justice.

Public accounts on X amplify this criticism:

• “The HCCC is a bureaucratic black hole. My complaint about a doctor’s negligence was dismissed with no explanation after months of silence.” 
  
  
• “HCCC investigations are a joke—they assume guilt and ignore evidence. It’s a system designed to fail patients.” 
  
  

The complainant echoes this:

“The HCCC’s investigation into my case was a farce—assumptions of guilt, gaslighting, no transparency, and no regard for evidence. It’s not just incompetence; it’s malicious.”

Across public petitions and commentary, there’s a strong narrative framing HCCC actions as not purely safety‑driven, but ideologically motivated. Other public critiques further underline this pattern in varying contexts:

• Craig Kelly, former MP, reacting to the HCCC’s handling of a doctor who prescribed ivermectin:

“I was in court … to watch this abomination of injustice. The entire process was a joke… instead of the corrupt HCCC having to prove … she acted so negligently … the process is the reverse onus of proof, and … the doctor has to prove that she is not guilty.”
— Reflecting frustration at both the ideological framing and procedural unfairness of guilt before evidence in breach of democratic and constitutional rights.

• Dr My Le Trinh, from a personal account shared publicly, described her experience with the HCCC as follows:

“The relentless pursuit of evidence against me has taken a toll on my mental health … this unjust persecution is unwarranted … especially considering my long-standing record …”
— Depicting the experience as punitive rather than corrective

The Barbara O’Neill Case: Persecution Without Proof

The HCCC’s handling of naturopath Barbara O’Neill exemplifies its overreach and abusive practices. In September 2019, the HCCC banned O’Neill for life, alleging she provided “dangerous and unsubstantiated health advice,” (HCCC Public Statement, September 24, 2019).

The Commission cited breaches of five clauses of the Code of Conduct for Unregistered Health Practitioners under Clause 7 of the Health Care Complaints Regulation 2016. Yet, supporters—including NSW parliamentarian John Ruddick—decried the ban as “harassment.” Ruddick stated:

“Barbara O’Neill and Dr My Le Trinh have been harassed by the HCCC. Neither has ever had a complaint from their countless patients but are targeted for their views.”
(X Post, June 2025)

O’Neill’s son Michael O’Neill wrote:

“There’s a lack of concrete evidence that her advice caused any actual harm.”
(The Assassination of Barbara O’Neill, Nexus Newsfeed, October 2019)

A petition with 22,000 signatures declared:

“Barbara was unfairly persecuted by a medical establishment threatened by her influence.”
(Change.org Petition, 2019)

O’Neill herself described the process as torturous:

“The HCCC’s investigation was a nightmare—months of vague accusations, no clear communication, and a public shaming that felt like a witch hunt.”
(Nexus Newsfeed, October 2019)

The HCCC’s public warning, issued without conclusive evidence of harm, arguably breached Section 90B of the Health Care Complaints Act 1993, which mandates “fair and reasonable” decisions.

Lack of Trauma-Informed Care and Abusive Conduct

The HCCC’s processes are widely criticized for lacking trauma-informed care, exacerbating distress for complainants and practitioners.

The complainant in this report stated:

“The HCCC’s letters were cold, accusatory, and dehumanising. Gaslighting - considered abuse under NSW Health Law – is a standard tactic in their conduct. Their cruelty felt like they were trying to break me emotionally.”

Public sentiment mirrors this:

• “It appears the role of the HCCC is no longer about protecting the public or pursuing those who cause harm. Its role has become punishing dissenting doctors and silencing those who speak the truth.” (@myletrinh123, September 2025)
  
  
• “HCCC’s dismissive attitude and endless delays retraumatised me after a medical error. They don’t care about patients.” (@NSWPatientVoice, February 2025)

In O’Neill’s case, supporters noted:

“The HCCC’s prolonged scrutiny and public vilification caused Barbara immense distress, with no regard for the emotional toll.”
(Nexus Newsfeed, October 2019)

This contravenes Clause 3 of their own Code of Conduct for Unregistered Health Practitioners, which requires “respectful and courteous” treatment.

Aboriginal Reconciliation Failures: A Pattern of Neglect

The HCCC’s inadequate Aboriginal consultation policies have drawn sharp criticism, with no apparent action despite repeated calls for reform.

In 2020, the Joint Committee on the Health Care Complaints Commission noted:

“The HCCC lacks robust frameworks for consulting Aboriginal and Torres Strait Islander communities, undermining its commitment to cultural sensitivity.”
(Joint Committee Report, 2020)

This was reiterated in 2023:

“Ongoing deficiencies in cultural competence continue to alienate Indigenous complainants.”
(Joint Committee Report, 2023–24)

In June 2025, The Australian reported on the HCCC Commissioner’s appearance before the parliamentary oversight committee, where they faced scrutiny for:

“a persistent failure to implement meaningful Aboriginal reconciliation policies, despite years of recommendations.”
(The Australian, June 15, 2025)

The article quoted a committee member:

“The HCCC’s inaction on Indigenous consultation is unacceptable and risks further marginalizing vulnerable communities.”

Following the criticism, the HCCC  subsequently added faux-Aboriginal art on their website, not acknowledging the artist, demonstrating the exact disrespectful tokenism that is so harmful and insulting to communities.

A prominent Indigenous Australian author relayed: “Silence, self-loathing, and denial of my heritage were the inevitable result of the silencing of my people’s voices.”(Margo Neale – “Songlines” 2020). This trauma, echoed by countless Indigenous people, is a direct cause that leads to the deaths in custody, de-prioritised by the same legal and judicial system that claims to be investigating their cause.

The complainant’s experience reflects this neglect, he was even threatened with prison for performing an Indigenous acknowledgement of country at a public community event:

“My complaint involved cultural insensitivity through lack of interest and refusal to consult, but the HCCC dismissed it with no understanding of Aboriginal perspectives. It’s systemic neglect, whilst relapsing Aboriginal people previously stable under my care, were ignored .”

This pattern of inaction violates the HCCC’s Customer Engagement Framework, which promises “inclusive and accessible” services.

Broken Commitments and Continued Failures in My Case

In June 2025, the HCCC Commissioner publicly committed before Parliament to address repeated failures of Aboriginal consultation.

Yet immediately after this commitment, the HCCC published further prohibition orders against me—without consulting Aboriginal leaders or community members, despite two years of requests. The priority it seems was to put fake art on their website.

This contradiction is damning:

“Despite commitments by the Commissioner to consult with Aboriginal communities, the HCCC has issued fresh prohibition orders - riddled with falsities and omissions - without a single effort to speak with Indigenous leaders or community members directly affected.”

At the very moment they assured Parliament of reform, they continued the same exclusionary practices.

Legal Misconduct: Breaches of Orders, Concealment, and Trickery

The HCCC’s conduct in legal proceedings compounds these failures.

• In multiple NCAT hearings, the HCCC has been caught breaching court orders and misleading the Tribunal.
• They sought suppression orders over publicly available evidence, an attempt at concealment described by observers as “unsatisfactory and inconsistent with principles of open justice.” Evidence that clearly undermines their narrative.
• Their tactics—delaying disclosure, applying suppression orders improperly, and attempting to frame evidence in ways that limit scrutiny—have been described as deceptive legal manoeuvres bordering on trickery.

This breaches the NSW Model Litigant Policy, which requires agencies to act with “complete propriety, fairness, and the highest professional standards” and not to take advantage of technicalities or seek to obscure the truth.

In my case, NCAT itself has directly criticised the HCCC for such conduct.

Under pressure and Ombudsman scrutiny, after weeks of gaslighting and stone-walling, they were forced to concede attempts to coerce me to destroy damning evidence, obscuring their admitted breach of court orders: “In the letter dated 6^th December, 2024, the Commission requested that you destroy, return or delete the document. I confirm that the Commission has not compelled you by law to do so.” – HCCC Paralegal, 14/1/2025

Counsel for the commission is forced to admit breaching court order at NCAT: “it is an error, as the applicant has said. It's an error on behalf, made by the respondent in breach of orders made by the tribunal.”

NCAT transcripts show shocking admissions of concealment of critical documents and the tribunals Principal Member admitting she was negligent in not being aware of it, despite submissions clearly stating and emphasising its concealment as a key document and the clear errors in its content:

HCCC Barrister Case: And it is the autopsy report?
NCAT Member Balla: Yes.
Case: Um, and that is a matter which has been of some concern to the applicant
Balla: Has it been provided to him or are you waiting on me
Case: yes
Balla: to make the order?
Case: Uh, I, no, it has not been provided because of the non-publication orders
Balla: Yes.
Case: However, we do know that the applicant has a copy of that document.
Balla: How do you know that?
Case: Um,
Case: Because he has served it in these proceedings,
Balla: oh I see

Furthermore, the HCCC has admitted in writing that it undertook no independent research. Instead, the entirety of its “investigation” was effectively outsourced to the original complainant and their advisors, including the Coroners Court and the Crown Solicitor’s Office. This not only undermines fairness but raises serious questions about collusion and narrative control.

The evidence from the CSO, deriving from the coronial inquiry that the HCCC completely relies upon, is sourced from a biased process - legal counsel in formal correspondence to Counsel Assisting raised the alarm by expressing: “grave concern regarding prosecutorial overreach and breach of neutrality by Counsel Assisting” (May 2024). She mislead legal counsel by denying it and then brazenly marched forward doubling down on the prosecution narrative, obvious to all.

No members of the public or anyone under my care or within my spiritual community made complaints to the HCCC. Testimonials, witness statements and mitigation plans endorsed by doctors in support of my work, were dismissed or completely disregarded.

Systemic Abuse and Toxic Culture

The dysfunction is not abstract. It is systemic, deliberate, and ongoing.

• Staff whistleblowers told ABC News in 2019 that the agency’s conduct warranted a public inquest, describing leadership as “ignoring concerns” and creating a toxic environment.
• Over two years, my case has been handled by 14 different operatives, none with healthcare, spiritual, or cultural expertise, areas that they claim authority over.
• Instead, uninformed bureaucrats produced prejudicial judgments in clear violation of their own Clause 6 of the Code of Conduct for Unregistered Health Practitioners, which requires practitioners to work within their competence.

“A revolving door of staff without expertise has resulted in arbitrary, hostile decisions, driven not by evidence or cultural understanding but by assumptions, discrimination, and narrative control. Many of the false statements and invented claims published by the HCCC are frankly, shocking.”

Questions have been raised as to the HCCCs ability to adjudicate and prosecute practitioners over regulations that they do not practice or seem to understand themselves. The hypocrisy demonstrated by their over-reach, vilification and smear campaigns that label people as dangers to the public, and yet in the case inspiring this report, they presided over multiple mental health relapses, hospitalisations and suicide attempts, ignoring all warnings and responding with silence and stone-walling once they were presented evidence of the severe harm they have caused, making themselves a far greater danger to the public.

Multiple blog posts and x complaints refer to the same misconduct and corruption, naming the same key figures in the HCCC: "The HCCC has become extrajudicial, operates with impunity and needs to be abolished" - Professor David Kaye MBPsS MAPA ACS (https://blindjusticensw.blogspot.com/2021/?m=1)

Jurisdictional Overreach and Unsatisfactory Orders

Legal expert Michael Eburn has publicly criticized the HCCC’s interpretation of its powers, calling it regulatory overreach:

“There is no general legal duty that every practitioner must provide access to equipment such as a defibrillator. The Commission’s interpretation risks creating obligations that are not found in the legislation itself.”
(Australian Emergency Law, Dec 2024)

He warned that the HCCC is imposing hospital-style rules on spiritual and community events:

“This decision illustrates the difficulty of applying modern medical standards and assumptions into community or spiritual contexts, where the Code of Conduct does not explicitly demand the level of equipment or procedural safeguards that the Commission is now insisting upon.”
(Australian Emergency Law, Dec 2024)

Eburn also criticized the Commission’s practice of endlessly renewing interim prohibition orders:

“The Commission remade the orders as each expired. This sort of repetition appears unsatisfactory and risks defeating the purpose of the legislation.”
(Australian Emergency Law, Dec 2024)

This demonstrates that the HCCC is not enforcing law, but stretching it beyond Parliament’s intent — undermining the rule of law. This done whilst admitting no independent investigation, no experts engaged and no community members or clients consulted. They formally admitted reliance on the complainants (NSW Police) for information:

Attempting to divert blame for published falsehoods they admitted: “The commission relied on information provided by Police…” Mark Henney, HCCC (5/12/2024). Despite the buck-passing, they refused to account for their gross lack of scrutiny in publishing their false claims and lack of questioning the complainants reliability and integrity, despite over 16 identified falsities published, some enduring for over a year.

They further admitted “The commission has not engaged the services of expert practitioners…” going on to admit they solely relied on information provided by the complainant. This, while genuine complaints from patients and members of the public, are discarded or mis-handled.

Regarding 18 months of published defamatory, false and misleading claims and denial of my right to reply, they admitted: “the commission was still in the process of obtaining further information from the Coroner’s Court and the police (complainant),” – Mark Henney, HCCC, (7/2/2025).

The handling of Aboriginal voices in my matter is deeply troubling. A senior Elder, placed under oath, was misled and then silenced — his cultural reasoning disregarded, his testimony diminished, and his voice suppressed. This is not an isolated error but a clear reflection of systemic prejudice.

It is a dangerous signal that the HCCC has refused to consult Aboriginal witnesses, community members, or cultural leaders, instead choosing to align itself blindly with the Crown Solicitor’s narrative. This is not only negligent; it reinforces the very patterns of silencing, colonisation, and cultural erasure that Aboriginal people have endured for generations.

Extensive evidence and submissions on these abuses — including testimony, correspondence, and records of misconduct — have already been prepared and are awaiting public disclosure. Despite two years of raising alarms regarding this, the HCCC neglect goes beyond its refusal to consult, it demonstrates no awareness of these issues and no interest to enquire.

A Danger to Public Trust

The pattern is now undeniable:

• Parliament has condemned the HCCC’s failures (2020, 2023–24, 2025).
• Media has exposed incompetence and opacity (SMH 2014, Daily Telegraph 2019, The Guardian 2023, The Australian 2025).
• Legal experts have warned of overreach (Australian Emergency Law, 2024).
• Complainants and practitioners describe its actions as abusive and shocking.

As The Australian warned in June 2025:

“The HCCC’s systemic dysfunction is a public health risk.”

Parliamentary Oversight and Unaddressed Criticisms

Parliamentary reports show repeated warnings ignored. In 2020, the Joint Committee reported:

“Inefficiencies in complaint handling persist despite a 7.6% increase in complaints from 2018–19 to 2019–20.”

By 2023–24, the committee noted:

“Systemic issues in transparency and follow-through on serious allegations remain unresolved.”

The 2025 review, as reported by The Australian, stated:

“The HCCC’s ongoing systemic dysfunction and failure to act on prior recommendations demonstrate a troubling lack of accountability.”

Internal staff complaints in 2019 further exposed dysfunction. A former employee told The Daily Telegraph:

“The HCCC’s leadership ignores staff concerns, creating a toxic environment that impacts how complaints are handled.”
(The Daily Telegraph, August 12, 2019)

Despite these criticisms, no significant reforms have followed—breaching Section 12 of the Health Care Complaints Act 1993, which requires the HCCC to “review and improve” its processes.

Abuse of Power, Democratic Failure, and Constitutional Breach

The HCCC’s structure and conduct represent not only an abuse of power but a fundamental breach of democratic and constitutional principles. It is highly unusual, undemocratic, and a violation of human rights that an agency such as the HCCC can simultaneously investigate, prosecute, and adjudicate complaints — while colluding with complainant and Crown Solicitors in secret. This conduct is the domain of authoritarian dictatorships, not of democratic nations governed by the rule of law. When a single agency is permitted to investigate, prosecute, and adjudicate in secret, it abandons constitutional principle and enters the realm of arbitrary power — the very abuse that separation of powers was designed to prevent.

This is not simply “unfair process.” It is unconstitutional.

The Australian Constitution makes it clear:

“The judicial power of the Commonwealth shall be vested in a Federal Supreme Court, to be called the High Court of Australia, and in such other federal courts as the Parliament creates, and in such other courts as it invests with federal jurisdiction.” — Section 71, Australian Constitution

Judicial power is reserved for courts. The HCCC is not a court. Yet it has arrogated to itself the combined roles of judge, jury, and prosecutor — wielding powers that were never constitutionally granted.

This principle was clarified in the landmark High Court ruling in the Boilermakers’ Case (R v Kirby; Ex parte Boilermakers’ Society of Australia (1956)):

“The judicial power of the Commonwealth cannot be vested in a tribunal that also exercises non-judicial functions.” — High Court of Australia

The HCCC does exactly this — exercising investigative powers, prosecutorial powers, and quasi-judicial determinations all at once. This is an affront to the constitutional separation of powers, which is foundational to democracy and the rule of law.

Some may attempt to argue that the availability of an appeal to NCAT is sufficient to safeguard against abuse. It is not. This defence fails for multiple reasons:

• Appeals are time-consuming, costly, and often prohibitive for ordinary practitioners.
  
  
• Appeals do not undo the immediate reputational, financial, and community damage caused by HCCC prohibition orders and public statements.
  
  
• Most critically, as my case demonstrates, the HCCC’s conduct before NCAT has itself been unconscionable — breaching court orders, manipulating and omitting evidence, submitting fabricated narratives, and engaging in repeated, gross breaches of the NSW Model Litigant Policy.

An appeal mechanism cannot excuse or legitimise unconstitutional power. It is no defence to say, “you may challenge our misconduct later.” Independent legal review and the Deputy President of NCAT have each questioned the HCCCs misuse of its prosecutorial powers by issuing endless “interim” orders. In my NCAT appeal, whilst under questioning by the Deputy President, HCCC barrister declared they were considered “rolling” orders, demonstrating intent to abuse their legislated powers. Regarding my complaint about abuses of process and lack of procedural fairness, under questioning by the Deputy President they went on to claim that I could request an adjournment, exposing their legal tactics of obstruction and breaches of model litigancy, even after over two years of this farce.

By acting as investigator, colluder, judge, and prosecutor, the HCCC operates outside both the spirit and the letter of Australian law. It is a structural corruption of justice.

The question must therefore be asked: How has such an agency been permitted to wield unconstitutional power, unchecked, despite repeated parliamentary and public criticisms? These separations were outlined in the constitution to prevent the very moral decay, abuse of power and incoherence, demonstrated by the collapse into farce of the HCCC’s credibility as a legitimate authority.

This abuse and structural rot demands decisive action. The Commission must be stripped of prosecutorial and adjudicative powers, which should rightly rest with independent judicial bodies such as NCAT or the courts. Until this occurs, the HCCC remains a rogue body — a law unto itself — contrary to constitutional principle and the most basic requirements of fairness.

Staff within the HCCC are urged to recognise that compliance with unlawful or unethical directions does not absolve personal responsibility. Journal notes, copies of correspondence, records of collusion or improper instructions, and witnessing unethical conduct may become crucial evidence. There is a moral obligation to report such wrongdoing to the NSW Ombudsman, ICAC, and the Parliamentary Oversight Committee. Negotiations with state MPs for safe harbours for whistleblowers are underway, and it is expected that protections will be extended to those who come forward.

Reform is Non-Negotiable

This structural rot demands decisive action. The HCCC must be stripped of its prosecutorial and adjudicative authority, restoring those powers to courts or independent tribunals such as NCAT, where the separation of powers can be upheld, and due process truly respected.

Urgent Oversight Committee Action Required.

It is urgent that those operatives who have endured within the HCCC for years, sustaining and protecting this toxic culture, are identified and held accountable. The public deserves to know: who are the enduring bureaucrats behind these decisions? Where does this pattern of abuse originate? And who continues to shield it from reform?

It is recommended that staff at all levels be independently consulted, with guarantees of privacy and immunity from internal backlash, so that the truth of this culture can emerge without fear.

This is not abstract — it is urgent. The failure to act has already resulted in documented consequences: three suicide attempts, multiple hospitalisations, and widespread destabilisation of a community under direct impact of HCCC conduct. Despite repeated warnings and clear evidence, the Commission’s response has been nothing but evasion, gaslighting, and continued abuse.

This must stop. This is an emergency.

Conclusion

The New South Wales Health Care Complaints Commission is a failing, unconstitutional institution—marked by incompetence, bias, legal misconduct, regulatory overreach, and a refusal to heed years of criticism. From Barbara O’Neill’s persecution to my own case, its actions violate legislation, human rights, and public trust.

As The Australian warned in June 2025:

“The HCCC’s systemic dysfunction is a public health risk.”

Unless urgent reform or dismantling of this illegitimate agency is undertaken, this Commission will continue to harm the very people it is mandated to protect.