The final report from the inquiry into Victoria’s botched hotel quarantine program has been unable to determine who commissioned the use of private security and has slammed the Andrews Government for failing to do “proper analysis” of the plan.

The COVID-19 Hotel Quarantine Inquiry report, which was tabled to Parliament on Monday, found Victoria’s second wave was triggered by transmission of the virus from hotel quarantine into the community through poorly trained private security guards.

Hotels also had poor cleaning products and training and guards made poor use of personal protective equipment.

Former judge Jennifer Coate said in the report that none of the more than 70,000 documents provided to the inquiry demonstrated a “contemporaneous rationale” for the decision to use private security or an approval of that decision from the upper levels of government.

“Such a finding is likely to shock the public,” Ms Coate said.

“The decision as to the enforcement model for people detained in quarantine was a substantial part of an important public health initiative and it cost the Victorian community many millions of dollars.

“But it remained, as multiple submissions to the Inquiry noted, an orphan, with no person or department claiming responsibility.”

The police chief commissioner at the time, Graham Ashton, had been consulted about police providing security and enforcement in the quarantine program.

“While no request was made to Victoria Police to provide the ‘first tier’ of the enforcement model for hotel quarantine, the then Chief Commissioner of Police was consulted and expressed a preference that private security perform that role and Victoria Police provide the ‘back up’ for that model,” Ms Coate said.

The report notes a failure of the Department of Jobs, Precincts and Regions (DJPR) to conduct a proper and rigorous procurement process for hiring security firms.

In particular the engagement of Unified Security, who were not an approved firm, was concerning.

There was also a lack of oversight by the department of security guards and their subcontractors.

“Consideration was not given to the appropriateness or implications of using a largely casualised workforce in an environment where staff had a high likelihood of being exposed to the highly infectious COVID-19,” Ms Coate said in the report.

“This, of course, had flow on impacts in terms of the spread of the virus.”

Ms Coate released the inquiry’s interim report into the hotel quarantine scheme in November, with 69 recommendations about how to improve the system.

There were 1400 ADF personnel in Victoria, helping to fight the coronavirus outbreak. Photo: AAP

No consideration given to using ADF

The Andrews Government has been criticised for not using Australian Defence Force (ADF) personnel in hotel quarantine as some other states had.

Ms Coate found that at State Control Centre (SCC) meetings in late March discussing the establishment of the program, no consideration of using ADF for enforcement was made.

“Instead, an early mention of private security rather than police grew into a settled position, adopted by acquiescence at the SCC meeting. There was no actual consideration of whether ADF personnel would have been a better option,” she said.

“The assessment that ADF was not needed on the ground at the hotels was an assessment made without any proper consideration of the anterior question of what would be the best enforcement option.”

With more than 800 people dead as a result of the second wave, and billions of dollars lost in the Victorian economy due to the lockdown, there were many people hoping the report would provide answers to who was responsible for key decisions.

The report also found that the Department of Health and Human Services (DHHS) failed to accept its role as lead department for the running of the program.

Former health minister Jenny Mikakos has already quit her post over evidence before the inquiry.

Other failures identified in the report include the state requiring hotels to run the cleaning process, something they did not have the experience to manage.

“There was simply too much at stake for the State to have conferred such responsibilities on private service providers, whose ordinary roles were so far removed from infection prevention and control measures,” Ms Coate said.

In addition to recommendations made in her interim report in November, Ms Coate said there needed to be better pandemic preparedness and planning, including collaboration with outside medical experts.

She also called for the Public Sector Commissioner to refine the lines of accountability and responsibility between department heads and ministers.

A key piece of evidence was an admission from former DHHS secretary Kym Peake that she was not briefing Ms Mikakos on key issues in the program.

Ms Peake has since resigned.

Hotel quarantine was supposed to keep Victoria safe, not spawn hundreds of deaths and community infections. Photo: AAP

Lack of planning on state and federal levels ‘most unsatisfactory situation’

The report said while both State and Federal Governments were aware prior to 2020 of the possibility of a pandemic, none of the existing national or Victorian pandemic plans contained mandatory, mass quarantine.

“Indeed, the concept of hotel quarantine was considered problematic and, thus, no plans for mandatory quarantine existed in the Commonwealth’s overarching plans for dealing with pandemic influenza,” the report said.

“The lack of a plan for mandatory mass quarantine meant that Victoria’s Hotel Quarantine Program was conceived and implemented ‘from scratch’, to be operational within 36 hours, from concept to operation.

“This placed extraordinary strain on the resources of the State, and, more specifically, on those departments and people required to give effect to the decision made in the National Cabinet and agreed to by the Premier on behalf of Victoria.

“This lack of planning was a most unsatisfactory situation from which to develop such a complex and high-risk program.”

The report said while the inquiry did not have a remit to examine the actions of the Commonwealth, it would be “unfair” to judge Victoria’s lack of planning for a mandatory quarantine program, given the Commonwealth had neither recommended nor developed such a plan.

The program operated for three months from late March to late June, when it was shut down after genomic testing traced coronavirus infections in the community to infection control breaches in the state-run hotels.

During the time it operated, a total of 21,821 returned travellers went through the program, with a total of 236 (1.1 per cent) of those travellers testing positive for COVID-19 while in quarantine.

Victoria began receiving overseas arrivals again on December 6.

The inquiry held public hearings over 27 days, took evidence from 96 witnesses and received more than 350,000 pages of documents.

Victoria’s deadly second wave was sparked by leaks from hotel quarantine in Melbourne. Photo: AAP

Premier says lack of oversight the primary issue

Following the report’s release, Premier Daniel Andrews once again apologised for the failures in the program.

“I want to apologise to the Victorian community for the very clear errors that were made in this program,” Mr Andrews said.

He acknowledged that the escape of the virus from hotel quarantine had led to the state’s deadly second wave, which prompted the Government to introduce strict stage 4 restrictions in Melbourne, and stage 3 restrictions in regional Victoria.

“For that I am sorry, we are sorry,” he said.

He said the State Government’s “preference” and “intention” was to adopt all of the report’s recommendations.

“We’ll spend the summer to consider the report in more detail. Many of those recommendations have already occurred,” he said.

He also argued that the lack of oversight was the main problem with the quarantine program.

“The mere employment of private security is less the issue,” he said.

“It’s the failure to oversight them and others in the important work that they were doing that saw the virus get out and then saw all of us take too long to establish that fact.”

He added he would not be quitting as Premier and would contest the 2022 election.

-ABC