The catalyst for this report was the criticism of the Department of Health and Families (DHF) in the Health and Community Services Complaints Commission (HCSCC) report on their investigation of a sexual assualt on an infant in Ward 5B of the Royal Darwin Hospital (RDH) in 2006. ****** Terms of reference: 1: The findings in relation to the governance of complaints and prioritised recommendations to support system improvement. 2: The findings in relation to open disclosure principles at RDH and prioritised recommendations to support progression. 3: RDH compliance with Australian standard 4269, complaints handling.