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 morning, found no request was made to Victoria Police to provide the “first tier” enforcement of hotel quarantine.

However, the chief commissioner of police at the time, Graham Ashton, was consulted and “expressed a preference that private security perform that role and Victoria Police provide the ‘back up’.”

• The full report is available here

Former judge Jennifer Coate said not one of the 70,000 documents before her inquiry “demonstrated a contemporaneous rationale for the decision to use private security as the first tier of enforcement, or an approval of that rationale in the upper levels of government”.

The report also found that decisions were made away from the Premier and senior ministers.

“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,” the report said.

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

The report found that Victoria’s second wave was triggered by transmission from hotel quarantine guests to staff and on into the community.

“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.”

Premier Daniel Andrews apologised to all Victorians as he fronted the hotel quarantine inquiry.

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.

A rebooted program started earlier this month.

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

More to come.

-ABC