Final Report – Volume 3: Military sexual violence, unacceptable behaviour and military justice

Recommendation 14: Understand the prevalence and effects of military sexual trauma and improve responses to support victims

The Australian Government should commission independent research on the prevalence of military sexual trauma among serving and ex-serving Australian Defence Force (ADF) members. This research should examine:

1. the link between sexual misconduct and suicide and suicidality, other impacts experienced during service, and specific needs of victims at the time of transition, and benchmark the ADF response with best practice approaches to inform recommendations for improvements
2. the terminology 'sexual misconduct' used by the ADF, compared to 'military sexual trauma and violence', and the impact of terminology on victims.

Recommendation 15: Clarify definitions and processes related to sexual offences

Defence should amend its Complaints and Resolutions Manual to:

1. include definitions of sexual offences aligned with the Crimes Act 1900 (ACT) sexual offence provisions, that clearly describe the types of behaviours and actions that constitute each offence
2. provide clear and explicit instructions that managers and commanders who receive a report of sexual misconduct should consult with the Joint Military Police Unit to determine whether the conduct constitutes an offence, before taking any further action.

Recommendation 16: Evaluate training on managing sexual misconduct and make it mandatory for all leaders

Defence should commission an independent evaluation of the Sexual Misconduct Incident Management Workshop as a matter of priority. Following any required improvements identified by this evaluation, sexual misconduct incident management training should be mandatory for all commanders and managers.

Recommendation 17: Prioritise the prevention of sexual misconduct in the Australian Defence Force

The Australian Defence Force should develop a comprehensive sexual misconduct prevention strategy that includes primary prevention and early intervention, as well as targeted behaviour change programs for perpetrators of sexual misconduct.

The strategy should be:

1. developed in partnership with the Australian Human Rights Commission and Our Watch, include specific actions for implementation, including timeframes, and be tailored to the ADF context
2. submitted to the Minister for Defence and the Minister for Defence Personnel for endorsement, and published on the Defence website.

Recommendation 18: Strengthen workplace protections during sexual misconduct investigations

The Australian Defence Force should develop a dedicated policy that applies when sexual misconduct incident investigations are underway in the administrative, disciplinary or civilian justice systems.

The policy should:

1. provide that the commanding officer must immediately apply one of the following interim actions to the alleged perpetrator, neither of which imply any finding of guilt or wrongdoing:
   1. amend their work arrangements to ensure no contact between the victim and the alleged perpetrator (depending on the nature of the work, this may require re-assignment to a different location), noting that the arrangement must not restrict the victim from accessing any common areas
   2. allow suspension with pay
2. ensure that the commanding officer's decision must be informed by a comprehensive risk assessment of the safety, health and wellbeing of the victim, the alleged perpetrator and the broader workplace, with the reasons for the decision being recorded
3. ensure that interim actions are reviewed on a regular basis until the matter has been resolved through both the disciplinary (or criminal) and administrative systems.

The policy should not preclude the commanding officer from:

4. suspending an alleged perpetrator without pay (either in full or part), in accordance with the Defence Force Discipline Act 1982 (Cth) and the Defence Force Regulation 2016
5. taking any additional interim actions as necessary.

Recommendation 19: Protect victims of sexual misconduct from disadvantage over the course of their careers

To ensure there are no inadvertent career consequences for victims of sexual misconduct and to support the safety of victims over the course of their careers, Defence should:

1. develop a neutral label to signify where a change in working hours, or a short-notice or out-of-cycle posting, has occurred to protect a member's health and wellbeing, in a way that protects individual privacy and clearly signals that no career penalty should apply. Similar amendments should be made to the military employment classification system and in guidance to promotions boards
2. report to the Minister for Defence Personnel by no later than 30 June 2025 on whether career management, human resources and Defence housing systems have been updated to ensure victims of sexual misconduct are not posted with their perpetrator/s over the course of their career.

Recommendation 20: Amend the legislation related to sentencing perpetrators of military sexual offences

The Australian Government should amend Section 70 of the Defence Force Discipline Act 1982 (Cth) to:

1. expressly require service tribunals to consider the impact of a sexual offence on the victim as a factor during sentencing, including a victim impact statement if one has been made, and allow the victim to read their statement aloud if they choose to do so, in a closed or open court
2. make it clear that if an offender is of higher rank than a victim, this should be considered an aggravating factor for the purpose of sentencing.

The Australian Defence Force Chief Judge Advocate should amend Practice Note 6 – Part IV Sentencing to require the prosecution counsel to invite victims to make a victim impact statement for consideration by the service tribunal during sentencing.

Recommendation 21: Implement a 'presumption' of discharge for Australian Defence Force members found to have engaged in certain forms of sexual misconduct

The Chief of the Defence Force should issue a directive providing for a presumption that anyone in the Australian Defence Force (ADF) who is found to have engaged in certain forms of sexual misconduct will be discharged.

1. The directive should apply to specified forms of sexual misconduct including, but not limited to, sexual harassment, sexual offences, related offences including intimate image abuse, stalking, and any other offence involving conduct of a sexual nature against an ADF member including prejudicial conduct, assault and obscene conduct.
2. The standard of proof is the balance of probabilities. For the directive to apply, there needs to be a finding, either by a criminal/disciplinary tribunal or administratively by command, substantiating that sexual misconduct has occurred. Where a sexual offence allegation has been made but has not proceeded to prosecution, or has been prosecuted but has not resulted in a conviction, the behaviour must be assessed on the balance of probabilities to determine whether the directive applies.
3. Procedural fairness should be afforded to the member before a decision on whether to retain or discharge them is made. The directive should provide guidance on factors to be taken into account by the decision-maker. The decision must be approved by the relevant service chief.
4. Discharge statistics related to decisions made under the directive should be provided annually to the Minister for Defence and the Minister for Defence Personnel. Statistics should be disaggregated by service and be accompanied by an analysis of common themes, lessons learnt, and actions taken in response.

Recommendation 22: Adopt a policy of mandatory discharge for Australian Defence Force members convicted of sexual and related offences

Defence should adopt a policy of mandatory discharge for Australian Defence Force members convicted of sexual and related offences (including stalking and intimate image abuse) in the military and civilian criminal justice systems, subject to further legal advice on the legislative barriers, if any.

Recommendation 23: Record convictions of sexual offences in Australian Defence Force records and civilian criminal records

As a matter of urgency, the Australian Government should:

1. ensure the Australian Defence Force has a complete and reliable record of all serving members who have been convicted of sexual offences and related offences (including stalking and intimate image abuse) in civilian courts
2. work with state and territory governments to ensure that civilian criminal records include convictions of sexual offences and related offences (including stalking and intimate image abuse) made under the Defence Force Discipline Act 1982 (Cth).

Recommendation 24: Annually publish anonymised data on outcomes of all incidents of sexual misconduct

Defence should publish data on administrative and disciplinary outcomes for all forms of sexual misconduct incidents. At a minimum, this data should:

1. be published on an annual basis, disaggregated by service
2. identify the nature and type of all sexual misconduct incidents, including:
   1. the nature and type of sexual offences and related offences, including intimate image abuse, stalking and relevant service offences that include sexual misconduct as an element
   2. other forms of sexual misconduct, including sexual harassment and sex discrimination
3. include demographic information of victims and perpetrators, including age, rank and gender.

Recommendation 25: Conduct a formal inquiry into military sexual violence in the Australian Defence Force

The Australian Government should commission an external, independent, expert inquiry into military sexual violence in the Australian Defence Force (ADF), with a report that includes recommendations provided to the Minister for Defence, the Minister for Defence Personnel and the Attorney General, and made public.

The terms of reference for this inquiry should be developed in consultation with victims of sexual violence in the ADF (serving and ex-serving), and at a minimum should include:

1. the effectiveness of the military justice system compared to the civilian justice system in receiving, investigating and adjudicating on sexual and related offences. This should include an examination of the Joint Military Police Unit's investigative powers and capability to conduct sexual offence investigations; the referral of matters to civilian police; any barriers faced by civilian police investigating sexual offences on ADF bases; sentencing outcomes; recidivism rates; decisions not to prosecute and conviction rates
2. the underlying reasons for the reduction in actions (including making a report, and agreeing to reported matters being investigated) taken by victims of sexual violence, including the role of alcohol and other barriers, and the adequacy of ADF policies in addressing these
3. the effectiveness of anonymous reporting options including awareness, uptake and impact compared to alternative approaches (including but not limited to the approach taken in the United States).

The inquiry should have regard to all lived-experience testimony, statements, exhibits and published submissions made to this Royal Commission that are related to sexual violence in the ADF.

Recommendation 26: Foster a strong culture of reporting unacceptable behaviour

Defence should foster a strong reporting culture to:

1. proactively identify at-risk locations, cohorts, ranks or roles where toxic subcultures are flourishing
2. implement risk mitigation strategies to address unacceptable behaviour directly in the locations, cohorts, ranks or roles identified
3. report publicly on identified hot spots of unacceptable behaviour and what actions have been taken to address unacceptable behaviour.

Recommendation 27: Evaluate outcomes to ensure that Defence has addressed the intent behind recommendations

Defence should evaluate the outcomes of actions taken to implement the recommendations made by the Commonwealth Ombudsman in its review Does Defence handle unacceptable behaviour complaints effectively? Defending Fairness, to ensure that the intent of the recommendations is achieved.

Recommendation 28: Coordinate governance, assurance and policy functions of the military justice system

Defence should establish a home for military justice governance, assurance and policy and provide sufficient resourcing to achieve the following functions:

1. monitor qualitative and quantitative data and analyse trends across the range of military justice processes and outcomes
2. prioritising strategies to improve military justice record-keeping and data input issues to remediate data quality and facilitate analysis
3. monitoring the effectiveness of implementation of recommendations from various military justice reviews (including Inspector-General of the Australian Defence Force), including activity and impact evaluation
4. continue to define military justice metrics and align them with health and wellbeing metrics, and in so doing, to:
   1. identify and monitor risks of misuse and abuse of military justice processes
   2. track complaints and trends related to termination, offence type and investigation outcomes
   3. identify members who are repeatedly subject to military justice processes
   4. identify officers who apply disproportionately high numbers of administrative sanctions
5. establish and implement effectiveness measures for military justice reforms / key actions on the Military Justice Steering Group action plan
6. review current-status reporting on initiatives in line with good-practice governance principles.

Recommendation 29: Establish a new role to improve training and communication on conducting inquiries

Defence should establish the Joint Workforce Capability Employment Manager as a priority, whose scope of work should include:

1. reviewing the effectiveness of training in how to conduct 'fact finds' and inquiries and ensuring that trauma-informed principles are embedded throughout the training
2. reviewing the effectiveness of policies and communication material related to 'fact finds' and inquiries.

Recommendation 30: Prioritise the Inspector-General's inquiry into the weaponisation of the administrative system

The Inspector-General of the Australian Defence Force should initiate an own-initiative inquiry into the weaponisation of the military justice administrative system by the end of 2024.

The inquiry should consider how to improve accountability of commanders who are found to misuse and abuse military justice processes. Measures to identify misuse and abuse may include monitoring trends in administrative sanctions and locations, cohorts, roles or ranks found to be associated with disproportionately high rates of sanctions.

Recommendation 31: Consider how mental health may contribute to poor conduct before recommending administrative termination

That it be mandatory for Defence, when recommending administrative termination of a member under Section 24 (1) (c) of the Defence Regulation 2016 (Cth) 'retention-not-in-service-interest', to consider the member's current mental health and/or the role that mental health may have played in the behaviour that attracted administrative action.

Recommendation 32: When requested, conduct a merits review when a member's service is terminated for the reason 'retention-not-in-service-interest'

Defence should implement a merits-review process for involuntary separation under Section 24 (1) (c) of the Defence Regulation 2016 (Cth) 'retention-not-in-service-interest' through consultation and collaboration with the Inspector-General of the Australian Defence Force (ADF) and the Administrative Appeals Tribunal/Administrative Review Tribunal.

1. Defence should introduce an enhanced merits-review process in the Redress of Grievance Directorate of the Inspector-General of the ADF.
2. The Australian Government should consider giving jurisdiction to a specialist division of the Administrative Appeals Tribunal/Administrative Review Tribunal to manage a fast-track method for conducting external merits reviews. It is proposed that an external merits review would only be considered after the independent merits review process of the Inspector-General of the ADF had been completed.

Recommendation 33: Seek to understand whether/how involvement in military justice processes contributes to adverse outcomes

Defence should undertake further research to better understand the stressors that are both associated with, and lead to, involvement in administrative and disciplinary processes, including:

1. identifying prevalence rates of suicide and suicidality for serving and ex-serving members who have been exposed to military justice administrative and disciplinary processes
2. exploring the connection between members' use of alcohol and other drugs as a numbing strategy to help them cope with trauma and service-related stressors, and involvement in administrative or disciplinary processes
3. identifying opportunities to intervene when members are engaging in maladaptive coping strategies before their behaviour leads to administrative or disciplinary action.

Based on the outcomes of this research, Defence should implement policies to support members involved with military justice processes and minimise the risk of adverse outcomes, including suicide and suicidality.

Recommendation 34: Prioritise the review into the regulations governing court martial panels

Defence should prioritise the review of current provisions relating to court martial panels not being required to provide reasons for punishments being imposed.

Defence should document this in the 2024/25 Military Justice Steering Group workplan.

Recommendation 35: Determine whether support mechanisms for members involved with military justice processes are effective

Defence should evaluate the effectiveness of the key support mechanisms for those involved in military justice proceedings, including but not limited to:

1. support officers
2. individual welfare boards.

In its evaluation, Defence should consider members' experiences of the supports provided.

Recommendation 36: Trial a model outside the chain of command for supporting members involved in military justice processes

The Australian Defence Force (ADF) should fund and pilot a model for automatic, opt-out referral to both legal and welfare support services for members engaged in certain military justice processes that is separate from the chain of command (for example, the Workplace Behaviour Adviser Network, the Sexual Misconduct Prevention and Response Office, and the Employee Assistance Program).

In developing the pilot, the ADF should:

1. consider the role of individual welfare boards in the process
2. make it clear that once the referral is received, the relevant service would be responsible for initiating contact
3. consider thresholds for referral, and focus on increasing support for members exposed to factors known to contribute to higher risk of psychosocial harm, suicide and suicidality for example:
   1. those involved (both as victims and accused) in unacceptable behaviour complaints, sexual misconduct incidents, and disciplinary proceedings for offences under the Defence Force Discipline Act 1982 (Cth)
   2. those who are being considered for administrative termination.

The ADF should evaluate the pilot at its conclusion to assess the demand impacts and benefits in order to inform the decision for a broader roll-out.

Recommendation 37: Develop a charter of minimum standards for all members involved in military justice processes

The Australian Defence Force (ADF) should develop a charter of minimum standards for all members involved with or subject to disciplinary processes, or involved in matters handled by the Inspector-General of the ADF. It should include commitments to:

1. treating members with courtesy, compassion, dignity and respect, and consideration of their welfare needs
2. providing members with information that is clear and understandable about:
   1. the relevant military justice processes
   2. the legal, welfare and victim-support services available to them
3. referring members to relevant support services
4. providing updates at key stages of the process, including explaining the outcomes at its conclusion
5. giving victims of unacceptable behaviour the opportunity to provide a victim impact statement to inform sentencing, where the accused has been found guilty.

The charter should also contain defined roles and responsibilities for meeting the minimum standards.

The charter should be publicly available and members may refer to these minimum standards via the existing appeals and complaints processes where they feel these standards have not been upheld.

Recommendation 38: Improve governance processes related to accountability and continuous improvement

To improve accountability and continuous improvement regarding mental health and wellbeing outcomes, Defence should:

1. continue to work towards including health, wellbeing and safety measures in its Budget Paper performance measure, and ensure these measures cascade into future corporate plans
2. prioritise the development of the Monitoring and Evaluation Framework in partnership with the Department of Veterans' Affairs, for the joint Mental Health and Wellbeing Strategy 2024‒2028, and set out what success would look like for that strategy in terms of outcomes in the short, medium and long term, against the wellbeing domains
3. continue to develop a clear performance logic, including the translation of performance measures from budget papers, the corporate plan, and the joint strategy into clear accountability measures for senior leaders in Defence
4. once the Enterprise Reform Program has been implemented, assess how improvements in the collection, sharing and use of data may better support performance measurement, in line with the Defence performance logic model.

Acknowledging the challenges in improving performance measurement, and the risk of unintended consequences, the Australian Government should assist Defence to build performance management experience and expertise at the unit, service and enterprise level by:

5. prioritising Defence in the broader Australian Public Service performance management capability uplift
6. prioritising Defence in the Australian Public Service Commission Capability Review program
7. supporting a coaching and mentoring program in areas (identified by Defence) that have responsibility for developing and implementing reforms in performance measurement.

Recommendation 39: Address risk factors for suicide and suicidality and report on progress as part of enterprise-level risk management

Defence should address in-service risk factors for suicide and suicidality as part of the reporting processes related to enterprise risk management and the development of mental health and wellbeing strategy by:

1. identifying in-service risk factors to be reported (including, but not limited to, the risk factors for suicide and suicidality related to Australian Defence Force service identified in Chapter 1, Understanding suicide)
2. developing outcomes-based measures against these risk factors
3. developing risk controls and measures of control effectiveness.

Enterprise risk management must be informed by a contemporary assessment of hazards related to the health and wellbeing of Defence personnel and should inform delivery of the joint Mental Health and Wellbeing Strategy 2024‒2028.

Recommendation 40: Improve governance mechanisms from the unit level to the enterprise level

In order to identify and address barriers to effective governance from the unit level to the enterprise level, Defence should:

1. review all internal and external governance reporting mechanisms
2. identify root causes of non-compliance with required reporting
3. identify duplicative reporting information and processes
4. draw on process-improvement methodologies (for example, Lean Thinking) to reduce the administrative burden of reporting and governance compliance across Defence
5. improve governance, performance-reporting and data literacy at the unit, service and enterprise level via training and/or embedding coaching.

Recommendation 41: Build project-management capability so that reform initiatives are successful

To build sustained capability to implement lasting policy changes, Defence should:

1. engage independent expertise to undertake a project management maturity assessment of the areas in Defence that will be responsible for implementing the recommendations of this Royal Commission
2. upon completion of the maturity assessment, develop a blueprint and implementation plan to deliver the improvements to those areas of project management capability that require an uplift
3. monitor the implementation of the capability uplift through to completion via a Tier 1 Committee.

Recommendation 42: Ensure that future Inspectors-General of the Australian Defence Force will not have served in the ADF

The Australian Government should amend Part VIIIB Division 2, sections 110E to 110P of the Defence Act 1903 so that:

1. a person appointed as the Inspector-General of the ADF must not have served in the ADF
2. the Inspector-General should be supported by two Deputy Inspectors-General with appropriate skills and experience, for example, having served in the ADF or having experience and understanding of the justice system, including military justice
3. the Deputy Inspector-General positions are to be statutory appointments.

Recommendation 43: Allow the Inspector-General of the Australian Defence Force to make recruitment decisions for the staffing of their office

The Inspector-General of the Australian Defence Force (ADF) should have the responsibility and authority for the selection of staff in their office, including as to whether staff are drawn from the ADF, the Australian Public Service, or from other sources.

The Inspector-General should have the power to select and recruit freely from the ADF without being constrained by whom the Chief of the Defence Force, the service chiefs or the Director of Military Legal Capability select or recommend.

Recommendation 44: Ensure that staff of the office of the Inspector-General of the Australian Defence Force have the necessary skills, expertise and qualifications

The Inspector-General of the Australian Defence Force (ADF) should develop a workforce plan that includes:

1. a review of the skills, expertise and professional qualifications required to discharge effectively the Inspector-General's complete functions
2. an assessment of the current workforce in the office of the Inspector-General in which any competency gaps are identified
3. a strategic plan to attract and deliver the required capability profile to the office of the Inspector-General.

Recommendation 45: Improve transparency and accountability of the Inspector-General of the Australian Defence Force by increasing their reporting requirements

The Inspector-General of the Australian Defence Force (ADF) should improve the transparency and accountability of their office by:

1. updating and publishing comprehensive guidance or other standard operating procedures on its website, including quality-assurance measures, related to the discharge of the Inspector-General's functions in each directorate of the office of the Inspector-General
2. establishing and including in this guidance specific performance measures related to timeliness in the completion of assessments and inquiries and the consideration of redress of grievance complaints, and reporting annually on performance against these measures.

Recommendation 46: Ensure staff of the Inspector-General of the Australian Defence Force are trained in trauma-informed practice

The Inspector-General of the Australian Defence Force should ensure that all staff in the office of the Inspector-General (including consultants) who engage with members' next of kin and family members; are communicating with complainants, respondents or witnesses for the purpose of an inquiry; or who are charged with considering a redress-of-grievance complaint have completed the Compassionate Foundations course or equivalent training in trauma-informed practice before doing so, and complete refresher training every two years.

Recommendation 47: The Inspector-General to inquire into all deaths of serving members unless suicide can be excluded as the cause of death

The Inspector-General of the Australian Defence Force (ADF) should ensure that where suicide cannot be categorically excluded as the cause of death of an ADF member, a formal inquiry under written directions is conducted.

When undertaking such an inquiry, the Inspector-General should obtain input from a qualified mental health expert, such as a psychologist, when determining:

1. whether suicide may have been the cause of death
2. where suicide cannot be excluded, what the contributing factors may have been and whether there was a 'service nexus'
3. what recommendations should be made.

Recommendation 48: When a member dies by suicide, appoint a legal officer to represent the interests of the deceased and support the next of kin

When a serving member dies by suicide, or is suspected to have died by suicide, the Inspector-General of the Australian Defence Force should ensure that a legal officer from Defence Counsel Services has been appointed to represent the interests of the deceased upon written directions for a formal inquiry being issued.

The Inspector-General should ensure that interviews with the member's next of kin are conducted after the legal officer has been appointed and made contact with them.

Recommendation 49: Minimise disclosure restrictions of Inspector-General inquiry reports and ensure they are fair and understood by the next of kin

In relation to non-disclosure directions made pursuant to section 21 of the Inspector General of the Australian Defence Force Regulations 2016:

1. staff from the office of the Inspector-General must explain the scope of the directions to next of kin and family members before they are made
2. the directions should not apply to information that next of kin themselves provide to an inquiry, and which next of kin may know independently of anything contained in a draft, unredacted or redacted report
3. next of kin should be consulted directly about the persons that are to be included in the carve-outs to the directions permitting disclosure, and persons nominated by the next of kin should be included unless there is a good reason not to include them
4. restrictions on disclosure in respect of unredacted and redacted final reports should only extend to those parts of the reports that need to have disclosure restricted in the interests of the defence of the Commonwealth, or for reasons of fairness to a person who the Inspector-General considers may be affected by the inquiry
5. the Inspector-General should establish a mechanism by which next of kin may have the directions that are made reviewed by a legal officer of the office of the Inspector-General who was not involved in the relevant inquiry or in the decision to make the directions. The Inspector-General must have regard to the issues or concerns raised by the legal officer
6. there should be comprehensive guidance in relation to the making and terms of Section 21 directions included in the updated comprehensive guidance on the Inspector-General's website.

Recommendation 50: Amend the scope of the Inspector-General's role to inquire into suicide deaths of former Australian Defence Force members

The Inspector-General should be required and empowered to inquire into the death of a former Australian Defence Force (ADF) member where the death may have been by suicide, and where:

1. the death occurs:
   1. after 30 September 2024; and
   2. within two years of the former member ceasing to be an ADF member; and
2. the Inspector-General is notified or otherwise learns of the death within three months of the date of death.

Recommendation 51: The Inspector-General to regularly review inquiries into suicide deaths to determine common themes

The Inspector-General of the Australian Defence Force should conduct a review of all inquiries and reports into suicide or suspected suicide every three years to determine whether there are any common themes and contributing factors, and report the findings to the Chief of the Defence Force, the Minister for Defence and the Minister for Defence Personnel.

Recommendation 52: Conduct a merits review when a member's service is involuntarily terminated and they submit a redress of grievance complaint

When a member makes a redress of grievance complaint concerning a decision to terminate their service, the Inspector-General of the Australian Defence Force should:

1. (in addition to Recommendation 32) conduct a review in the nature of a merits review and determine, in their view, the correct or preferable decision
2. conclude their consideration of the complaint within 60 days of referral
3. give the member the opportunity to provide any further information or submissions prior to concluding their consideration of the complaint, in person, if practicable to do so, when the proposed outcome will not be favourable to the member.

Recommendation 53: Give members 21 days to make a complaint after being notified of a decision to terminate their service

Defence should amend Section 41(2) of the Defence Regulations 2016 to allow a member to make a complaint up to 21 days after they are notified of a decision to terminate their service.

Recommendation 54: Improve the frequency of military justice-related audits conducted by the Inspector-General of the Australian Defence Force

The Inspector-General of the Australian Defence Force (ADF) should:

1. conduct a routine military justice performance audit of every major ADF unit every three years, and of every ab initio training establishment every two years
2. conduct a longitudinal study of all audit reports every two years to determine trends, themes and issues of concern, and provide the outcomes of this analysis to the Chief of the Defence Force, the Minister for Defence and the Minister for Defence Personnel
3. audit at least three non-major units each year that are not part of the Directorate of Military Justice Performance Audit routine audit cycle.

Recommendation 55: Conduct an audit into Defence workplace health and safety risk management

The Defence Audit and Risk Committee should commission an audit into Defence workplace health and safety (WHS) risk management within the next 12 months. The audit should include, but not be limited to:

1. reviewing WHS hazard trends with a focus on psychosocial health and compliance with requirements of the Work Health and Safety Act 2011 (Cth)
2. reviewing the accuracy of existing WHS enterprise risk reporting, including the WHS dashboard
3. assessing WHS risk-assessment methodology, and the accuracy of categorisations of 'likelihood' and 'impact' of hazards within the 'WHS' enterprise risk category
4. assessing the suitability and effectiveness of WHS hazard controls, including their ability to be measured for impact.

The findings of the audit must be reflected in the delivery of the Defence WHS Strategy and WHS risk reporting going forward.

Recommendation 56: Improve guidance and understanding of Defence's 'if in doubt, notify' policy

Comcare and Defence should work together to improve guidance and understanding of the 'if in doubt, notify' policy in relation to determinations about when to report notifiable incidents to Comcare.

Recommendation 57: Comcare to regularly review Australian Defence Force determinations of 'service nexus' for suicide attempts and suspected deaths by suicide

Comcare should improve its quality assurance of Australian Defence Force (ADF) 'service nexus' determinations made by the ADF by:

1. undertaking a periodic review of service nexus determinations made by the ADF for incidents of suicide, suspected suicide, attempted suicide, and non-fatal self-harm by ADF members, where the ADF has concluded that the incident did not arise out of the conduct of the ADF's business or undertaking, under section 38(1) of the Work Health and Safety Act 2011 (Cth)
2. evaluating the results of these periodic reviews after three years to determine whether there is a continued need for them. The timeframe of three years will enable Comcare to test a sufficient sample size to inform a decision about whether to continue periodic reviews.

Defence should fund any additional resourcing required by Comcare to undertake these periodic reviews over the three-year period and conduct its evaluation at the end of that period.

Recommendation 58: Give Comcare access to the National Veterans' Data Asset

Comcare should have access to the National Veterans' Data Asset (Recommendation 107), to inform Comcare's regulatory approach to preventing psychosocial harm including latent harm.

Recommendation 59: Defence to participate in Comcare's Psychosocial Proactive Inspection Program

Defence should participate in Comcare's Psychosocial Proactive Inspection Program, once the evaluation has established that it is effective.

Either:

1. Defence should fund its participation in that program, or
2. a Commonwealth appropriation should be made to Comcare for the purpose of Defence's participation in the program.

Recommendation 60: Improve strategies for harm prevention and early intervention by sharing quality data with Comcare

To improve Comcare's ability to inform prevention and early intervention strategies for suicide and latent harm arising from Australian Defence Force service, Defence should:

1. share with Comcare on a quarterly basis through the Suicide and Self-Harm Working Group meeting:
   1. data on psychosocial harm (including data related to notifiable and non-notifiable incidents)
   2. Defence's analysis of this data to identify systemic issues related to psychosocial harm
2. share with Comcare through the Defence-Liaison Forum meeting what actions it has taken to document and implement controls to address systemic hazards, risks and issues relating to psychosocial harm.