Hotel quarantine ‘to blame’ for 768 deaths
The Andrews Government's bungled hotel quarantine system is to blame for 768 deaths, an inquiry has heard.
Counsel assisting Ben Ihle said the evidence showed there were "critical and fundamental shortcomings" with the program.
"Those deficiencies were in its structure and focus, specifically in the areas of governance, infection control, outbreak management, healthcare, welfare and human services," he said.
"In light of the epidemiological, genomic sequencing, positive case data and mortality rates, the failure by the hotel quarantine program to contain this virus is, as at today's date, responsible for the deaths of 768 people and the infection of some 18,418 others.
"One only needs to pause and reflect on those figures to appreciate the full scope of devastation and despair occasioned as result of the outbreaks.
"The board will comfortably find the hotel quarantine program failed to meet its primary objectives."
NO SINGLE DECISION OR ACT TO BLAME, HOTEL INQUIRY TOLD
A "multitude" of decisions, actions and inactions led to the failure of the hotel quarantine program, the inquiry been told.
Counsel assisting the inquiry, Tony Neal QC, said that with 36 hours to create the program after it was announced on March 27 by the Prime Minister Scott Morrison, there was "simply not the time to undertake the ordinary activities of translating a policy into a plan and then realising that plan."
Mr Neal said an "extraordinary" ask was made of those who were tasked to develop the program.
"An enormous immediate unenviable burden was placed on those in public service to establish not one but two settings of infection control facilities in buildings clearly not designed for quarantine purposes," he said.
Hotels would need to be "stood up" quickly, staffed with security guards and other personnel often at "very short notice".
He dismissed any notion of corruption or bad faith by those involved in setting in up.
"There'll be no suggestion from those assisting you that those engaged in setting up this program worked other than to the best of intent and the best of their ability. Bad faith or corruption is not what the evidence shows," Mr Neal told board chair Jennifer Coate on Monday morning.
"Yet it is true that that hastily assembled program failed at two locations in approximately two and a half months and with disastrous consequences."
Mr Neal said it was no single decision or act that caused the program to fail. Rather, complex systems failed in complex ways.
"It would not be suggested a single decision or single act caused the hotel quarantine program to fail in its objective of stopping the spread of COVID-19 into the broader community," he said.
"What the board will hear in due course is that a multitude of decisions, actions and inactions, many of which compounded the effect of the other, ultimately expressed themself in the outbreaks which subverted the very reason for the existence of a hotel quarantine program."
QUARANTINE PROGRAM A 'SEEDING GROUND' FOR COVID SPREAD
The hotel quarantine program failed to achieve its primary objective, instead becoming "seeding ground" for the spread of COVID-19 into the community, the inquiry heard.
In concluding remarks, counsel assisting, Tony Neal QC said a 'multitude' of decisions, actions and inactions" led to the failure of the hotel quarantine program.
He said it was not seen first and foremost as a public health program and "mischaracterised" as a mainly logistic and compliance operation.
He said the program failed to meet its primary objective to stop the virus spread.
"The program that was intended to contain the disease was instead a seeding ground for the spread of COVID-19 into the broader community. Infection prevention and control measures were ad hoc and inadequate, not only at the Rydges Hotel in Carlton but across the entire hotel quarantine program, until the establishment of the health hotel model with the standing up of the Brady Hotel in mid-June," he said.
He said failure to appoint people without health expertise to the position of state controller for the pandemic response limited the program's focus on infection prevention.
Mr Neal also reiterated that no one turned their mind as to whether the security industry was the appropriate workforce, "because no one understood themselves to be the original decision maker".
It was also a "matter of great concern" that the DJPR placed the responsibility for PPC and infection control education on private security providers - a decision he said was made by "mid ranking" officials rather than a considered decision made at a secretarial or ministerial level.
Mr Neal also referred to failures by departmental secretaries Chris Eccles, Kym Peake and Simon Phemister to pass on important information to their respective ministers.
"There is a spectrum of seriousness as to these admissions," he said.
"The evidence before the board shows that these were indeed significant issues which should have been brought to the relevant Minister's attention.
"For serious government to work, secretaries must be accountable to their ministers and that involves keeping ministers informed."
Mr Neal said this also likely contributed to lost opportunities to address issues that could have led to "better, fuller and more timely action".
"In our submission, these matters tend to demonstrate attitude to transparency and accountability that likely manifest in its practices that contributed to problems within the hotel q uarantine program."
EARLY APPROACH TO DETAINEE TESTING UNDERMINED PROGRAM
While testing of hotel quarantine detainees evolved over time, early approaches to how detainees were tested for COVID-19 undermined the program, the inquiry heard.
Many detainees were not tested before leaving the 14-day program.
And those who tested and had positive results were still permitted to leave after day 14 if they undertook to self isolate.
Professor Sutton told the inquiry this could have led to people being released while infectious.
"The initial approach to testing risked undermining at least to some degree the efficacy and intention of hotel quarantine program," counsel assisting, Ben Ihle said.
"In doing so it risked transmission of COVID-19 from those detained in the program into the community."
It wasn't until July that detainees who refused tests were directed to do a further 10 days in quarantine, Mr Ihle said.
Even under this direction, detainees awaiting test results were still allowed to leave hotel quarantine if they had a place to quarantine safely in Victoria.
SUTTON SHOULD HAVE BEEN STATE CONTROLLER
Victorian Chief Health Officer Brett Sutton should have been given the job of state controller, the inquiry heard.
The inquiry has been told Professor Sutton was overlooked by government officials for the role of state controller in charge of the emergency response to the pandemic, despite wanting the job.
Under the State Health Emergency Response Plan, the chief health officer would ordinarily be the state controller.
But DHHS deputy secretary Melissa Skilbeck recommended that someone else be appointed because Prof Sutton would be too busy with his role as CHO and it should go someone with more time and expertise to look after the logistics of the hotel quarantine program.
Prof Sutton disagreed, telling the inquiry that if he was appointed, he'd be able to have a "line of sight" over the operational elements of the pandemic response.
Counsel assisting, Ben Ihle, said the failure to appoint Prof Sutton deprived him of that visibility.
"This was clearly a health emergency. The board should agree that it was preferable, if not necessary, that he be appointed or someone with sufficient and equal qualifications," he said.
The role ultimately was given to two people, Andrea Spiteri and Jason Helps, from the DHHS.
However, days after their appointment, Prof Sutton was also appointed the role in February, but never told of that fact.
Mr Ihle said the board must grapple with an "unsatisfactory" explanation as to why that was the case.
The inquiry has heard Prof Sutton and Victoria's senior medical Adviser, Dr Finn Romanes, had expressed concerns that those in the leadership roles of the hotel quarantine program were people without significant public health experience.
QUARANTINE SET-UP CONTRIBUTED TO VIRUS RISKS
Counsel assisting the inquiry, Ben Ihle, says the prior to the announcement on March 27 that returned overseas travellers would be placed in 14-day hotel quarantine, Victoria had no plan for large scale quarantine.
The lack of a plan meant the hotel quarantine program had to start from scratch and be set up quickly, placing "incredible" strain on the state.
Given the program established was 'untested', it should have been accompanied by intensive ongoing monitoring and auditing, he said.
"The board should find these failures contributed along with others, the difficulties of the implementation and operation of the hotel quarantine program in this state and overall contributed to an increased risk or at least to a failure to adequately mitigate risks the virus would be transmitted from returned travellers," he said.
ARMY DECISION 'APPROPRIATE'
The decision to not use the ADF to guard at quarantine hotels was appropriate, the inquiry has heard.
The use of private security guards, over police and army personnel, in the quarantine program has been a controversial issue in the inquiry.
However, council assisting, Rachel Ellyard, said an early decision by Emergency Management Commissioner Andrew Crisp not to seek ADF help for frontline work was sound.
"He knew that he could ask for it if he needed it," she said.
"But it appears that in that first meeting, understanding that private security was going to be engaged after the expression of Victoria Police's preference … he thought the matter would be handled within Victoria and ADF boots on the ground weren't required.
"It was a reasonable conclusion for Mr Crisp to come to on that day that resourcing was available for the various aspects of the program so that there wasn't a need to request boots on the ground from the ADF."
Ms Ellyard said Mr Crisp's request on June 24 for 850 army personnel that was made, then rescinded, after the health department believed the private security workforce had to be replaced, was also appropriate.
"Again, it appears that those decisions about the use or non-use of ADF were reasonable and open and no criticism we say should be directed to those who made those operational decisions about whether frontline ADF were needed in the hotels."
However, Ms Ellyard said Victoria's top public servant Chris Eccles, should have told Premier Dan Andrews about an offer made to Victoria by his federal counterpart in early April for ADF personnel.
"The evidence is that that was not brought to the attention of the Premier," she said.
Mr Eccles cannot recall whether he told Mr Andrews.
Mr Andrews told the inquiry on Friday that had he known that the secretary of Prime Minister and Cabinet Phil Gaetjens told Mr Eccles that troops were available for the quarantine scheme in April, it may have influenced his decision-making.
"It would have been appropriate for the Premier to have been made aware of that, although it is not possible to speculate on what the outcome would have been," Ms Ellyard said.
DEPARTMENT FAILED ON PRIVATE SECURITY CONTRACTS
The Department of Jobs, Regions and Precincts didn't adequately manage private security contracts, the inquiry has heard.
Counsel assisting, Rachel Ellyard, also said the onus for infection control should not have been placed on those companies.
The three contractors selected by the Department of Jobs, Regions and Precincts to guard returned travellers in quarantine hotels had responsibility to ensure their workers complied with PPE use and COVID-19 training requirements.
"The risks of those matters were placed on the security companies and the same was true for hotels, and that in our submission, ought not to have occurred," counsel assisting, Rachel Ellyard, said.
Ms Ellyard invited the board to conclude the DJPR failed to have adequate oversight of the use of subcontractors in the program.
From day one, Unified security was almost entirely reliant on subcontractors, in turn drawing on small subcontracting companies.
One of the small subcontractors was providing hundreds of guards a day across six hotels.
The company was not on a government panel of preferred businesses to use, like the other larger two companies, MSS and Wilson, yet got a lot of the work, including at the Rydges on Swanston, where the first outbreak occurred in May.
"DJPR placed more than half the hotels in this program with a company which was using nearly entirely subcontracted labour, which wasn't on the panel and which was using that labour without active knowledge and oversight by DJPR," Ms Ellyard said.
"That's a particular risk for the success of this program, occasioned by so much responsibility ending up on the shoulders of a small subcontracting firm for the identification and supply of hundreds of staff who had to be appropriately trained and resourced at a time when there were other larger companies who were not being called upon in the same way.
"The board should conclude DJPR didn't have adequate oversight of the use of subcontractors in the program and didn't consider, when apportioning work between the three contractors, the extent to which those contractors had access to appropriately trained staff.
"This was, we submit, a failure of contract management on the part of DJPR and it ignored a mechanism designed to ensure the safety of subcontractors and returned travellers alike."
Ms Ellyard said this became a real issue, because a separate decision had contracted out the responsibility for infection prevention education and PPE usage to the security companies.
She said Unified was more reliant on advice from the Department of Health and Human Services about infection control issues and less self sufficient than larger companies yet getting more of the work, including in that 'crucial' hotel, Rydges, which housed COVID-19 guests.
Ms Ellyard said those entering into contracts on behalf of DJPR, didn't understand how common subcontracting was.
It also didn't appear Unified gave formal notice that it was using subcontractors and when DJPR found out, it did nothing to approve them.
"One is left with the impression that although they were relying so heavily on Unified in the program, DJPR didn't really understand the extent to which Unified in turn was relying on contractors," Ms Ellyard said.
USE OF PRIVATE SECURITY WAS 'PREFERENCE THAT BECAME OUTCOME'
The decision to use private security to guard at hotels for returning travellers was a "creeping assumption that became the reality", the inquiry has heard.
Counsel assisting Rachel Ellyard, said the question of who decided to use private security "astonishingly" remains unanswered following 25 days of evidence.
"No accountability has been accepted by ministers secretaries or any other official for that decision being made," she said.
"It is a question of critical importance we submit to you, because of the impact that decision ended up having.
"This decision ended up employing thousands of people and costing tens of millions of dollars. As a matter of proper governance we ought to be able to say who's accountable for that decision."
However, Ms Ellyard said there wasn't any specific decision by any individual or group to use that workforce.
"It was a creeping assumption that became the reality," she said.
She said the board should not take the view a final decision was made any time before a State Control Centre meeting around 4pm on March 27 chaired by Emergency Management Commissioner Andrew Crisp - the day the program was announced.
"It seems that if the decision was made in that State Control Centre meeting, no one knew they were making it and no one wanted to own it. It is for that reason that we submit to you the use of private security is not really a decision at all.
"While no one person made a decision, by the end of that State Control Centre meeting it was understood by all present that that was what was going to happen.
"It is a conclusion that was arrived at by way of a creeping assumption, that took hold over a period perhaps of a couple of hours, and that wasn't questioned by anyone."
Ms Ellyard said it was "strongly influenced" by everyone at that meeting understanding that Victoria Police's preference was for private security to be the front line of security.
"Their preference became the outcome."
PROGRAM CANNOT BE VIEWED WITH HINDSIGHT ALONE
The hotel quarantine program cannot be assessed with the benefit of hindsight alone, the inquiry has heard.
Counsel assisting, Tony Neal QC, has begun addressing the board on the conclusions it will invite it to draw about the hotel quarantine program.
He says the context in which the program came to be created needs to be acknowledged.
"That context was a new disease that quickly became a serious global pandemic with disastrous consequences," he said.
"In coming to the task of assessing what happened and what went wrong, it behoves all to remember the particular circumstances in which the decision to set up the (hotel quarantine program) was made.
"Whilst necessarily there must be critiquing of the program and analysis of its shortcomings, the decision to enter into the hotel quarantine program cannot be fairly assessed merely with the wisdom of hindsight."
The board is hearing closing submissions today until 4pm.
INQUIRY HEARS CLOSING SUBMISSIONS
The hotel inquiry will resume today to hear closing submissions on what findings the board should make over the flawed scheme.
It comes after Health Minister Jenny Mikakos resigned from parliament on Saturday after 20 years of service, in the wake of Premier Daniel Andrews' evidence to the inquiry.
In his appearance on Friday, Mr Andrews told the inquiry he considered Ms Mikakos and her department accountable for the bungled scheme, which is blamed for triggering the second COVID-19 wave that has claimed more than 750 lives and infected over 18,000 people.
"I have never wanted to leave a job unfinished, but in the light of the Premier's statement to the board of inquiry and the fact that there are elements in that I strongly disagree with, I believe that I cannot continue to serve in his cabinet," Ms Mikakos said in a statement on Twitter.
The inquiry has heard 25 days of evidence, with retired judge Jennifer Coate AO due to deliver her report to the Governor by November 6.
Originally published as Hotel quarantine 'to blame' for 768 deaths