Department of Health

Reporting checklist and procedure for sexual incidents on acute inpatient units

In order to simplify the reporting process for mental health services and ensure that reports are consistent, the Office of the Chief Psychiatrist is implementing a new reporting checklist in the form of a fillable PDF. Effective from 1 March 2018, mental health services are required to report all known occurrences or allegations of sexual activity, including sexual activity between patients or staff, sexual harassment or assault on an acute psychiatric inpatient unit. This is consistent with the Chief Psychiatrist Guideline that sexual activity is not appropriate in acute mental health treatment settings.

Standard Operating Procedure for Victorian Designated Mental Health Services


Sexual assault and harassment are serious matters and a consistent approach must be applied to ensure that all allegations are followed up immediately with an effective and caring response. Staff are not responsible for determining the veracity of the allegations.

This Standard Operating Procedure (SoP) is intended to inform use of the Sexual Safety Notification to the Chief Psychiatrist and is not intended to guide clinical practice. The response to an incident of sexual activity, sexual assault or sexual assault should align with local policies informed by the Chief Psychiatrist's Guideline Promoting sexual safety, responding to sexual activity, and managing allegations of sexual assault in adult acute inpatient units.

Scope and applicability

Designated Mental Health Services have an obligation to report to the Chief Psychiatrist sexual safety incidents that occur within Victorian Mental Health Inpatient Facilities.

This Standard Operating Procedure (SoP) should be used by staff of Designated Mental Health Services to ensure a consistent response to sexual safety incidents through the use of the Sexual Safety Notification to the Chief Psychiatrist.

This SoP does not alter the key principles for service managers in assessing, managing and reporting allegations, including:

  • Clear procedures for reporting and investigating allegations of sexual assault and harassment must be established and staff trained in their application.
  • Paramount consideration should be given to the safety, the physical and psychological needs of the patient, and their preferences for managing the allegation.
  • The authorised psychiatrist and senior management must be informed of all allegations of sexual assault or harassment.
  • The legal and advocacy needs of both parties must be promoted by the service.
  • Any investigation feedback should be provided to both parties, (and where appropriate, their families and carers), and any learnings from a review should be used to inform and improve the unit's practices.

What conduct is reportable?

Any incident that:

a) involves a person who is receiving mental health treatment; and
b) occurs during an admitted period of inpatient care; and
c) involves sexual incidents which includes:

I. Sexual assault - any behaviour of a sexual nature which is unwanted, making the victim feel uncomfortable or afraid. This includes rape, abuse, harassment and indecent assault. This behaviour can take various forms including unwelcome kissing or touching in the areas of a person's breasts, buttocks or genitals. Indecent assault can also include behaviour that does not involve actual touching such as forcing somebody to watch pornography or masturbation.
II. Sexual harassment - unwelcome sexual advance, unwelcome request for sexual favours or other unwelcome conduct of a sexual nature in relation to another person.
III. Sexual activity - an act of a sexual nature involving more than one party.

d) Irrespective of whether:

I. the act is:

i. alleged
ii. suspected
iii. unwitnessed, or
iv. witnessed.

II. a harm:

i. was intended
ii. has occurred

III. either party reports the act was:

i. consensual
ii. mistakenly believed to be consensual


1. Administration

The Sexual Safety Notification will be completed by:

  • the Senior Nurse on Duty or
  • a medical practitioner.

The Sexual Safety Notification can be completed using either:

  • hardcopy
  • fillable PDF.

2. Initiating a Sexual Safety Notification

  • When a staff member suspects, becomes aware of, or receives a report of sexual activity or sexual misconduct occurring on a mental health inpatient unit they will notify the Senior Nurse on Duty immediately.
  • The Senior Nurse on Duty or a medical practitioner will initiate the Sexual Safety Notification.
  • The Sexual Safety Notification will be used alongside the Chief Psychiatrist's Guideline Promoting sexual safety, responding to sexual activity, and managing allegations of sexual assault in adult acute inpatient units which establishes minimum standards to assist mental health service managers and clinical staff to protect consumers within their services, and to guide the appropriate staff response to incidents of sexual activity.

3. What Detail to Submit Via the Sexual Safety Notification

  • The details recorded on the Sexual Safety Notification will reflect the correct information during the response occurring in the first 24 hours.
  • When providing information in the notification, do not anticipate an action or response. Only confirmed actions should be recorded. If an action has been delayed or missed for a reason please provide this detail.

4. Submission

  • The form should be submitted no later than 24 hours following the incident (or the service being alerted to an incident).
  • Forms are to be submitted to the Chief Psychiatrist by:

5. Allied Procedures

  • This procedure does not alter any other reporting procedure, including RiskMan and local incident reporting procedures.
  • Incident Severity Rating 1 and Incident Severity Rating 2 category incidents must be reported to notify the Office of the Chief Psychiatrist by telephone as soon as practicable, at least by next business day on 03 9096 7571.

6. Confirmation

  • The Office of the Chief Psychiatrist (OCP) will provide a confirmation of receipt of the Sexual Safety Notification.
  • This confirmation may include requests for additional information that may include:
    • Written responses to specific questions from the OCP
    • Copy of the patient file note
    • Copy of an incident report (RiskMan)
    • Completion of a Clinical Report (a detailed summary completed by a Psychiatrist).

Reviewed 21 February 2018


Contact details

Office of the Chief Psychiatrist

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