The inquiry led by former Justice Jennifer Coates tabled its final report in Parliament this morning on Victoria’s catastrophic Hotel Quarantine Program COVID-19 Hotel Quarantine Inquiry report.

The report has been unable to clarify the “ownership” of the decision to use private security.

“The evidence was that the use of private security did not raise any particular concerns during the weekend setup of the Program or produce any considered discussion about how the enforcement model should work.”

The report criticises the Andrews Government for failing to do “proper analysis” of the plan and makes damming assessments of departmental heads, many now resigned because of the poor handing of the second wave.

The inquiry underscores the absence of responsibility over critical decisions. It recognises that what normally “would take months to organise” had to be done in 36hrs due to the nature of the pandemic.

Ms Coate wrote that none of the more than 70,000 documents provided to the inquiry established 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 added.

“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 hotel quarantine program, named Soteria after the Ancient Greek goddess of safety. Eight-hundred people lost their lives – (150 being Greek) – and the state’s economy took a battering due to the longest lockdown in the world.

The inquiry’s report makes a particularly damming assessment of Ms Kym Peake, the former Secretary of the Department of Health and Human Services (DHHS) who regardless of, “the direction from the Premier that she should divest herself of ongoing responsibilities as Secretary to DHHS” maintained her day-to-day role as Secretary of DHHS.”

A key piece of evidence was an admission from Ms Peake that she was not briefing the former Minister for Health, her boss, Ms Jenny Mikakos on key issues in the program. Ms Peake and Ms Mikakos resigned months before the report was due.

The initial responsibility for setting up the Program was given to the Department of Jobs, Precincts and Regions (DJPR) “in a telephone call made by the then Secretary of the Department of Premier and Cabinet (DPC) to the Secretary of DJPR on 27 March 2020.”

The inquiry concludes that “….DJPR had no preparation for, or relevant expertise to operate, an enforced quarantine program” and that  “it would need the assistance of DHHS for crafting the legal framework for the Program and arrangements for the health and wellbeing of the people in quarantine.”

The inquiry’s report underscores the “ongoing dispute between DHHS and DJPR as to who was in charge of the overall operation of the Program, which continued throughout the Inquiry.”

“If the secretary of the department was still here [Ms Peake], I’d expect that she’d be handing me her resignation today, and I would accept it,” Mr Andrews said to the ABC.

“And I think the same would go for the minister [Jenny Mikakos].”

Other failures underscored 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.

Mr Andrews said the State Government’s “preference” and “intention” was to adopt all of the report’s recommendations, but it would need to consider the report in more detail over the summer.

The Leader of the Opposition, Mr Michael O’Brien has called for a Royal Commission.

Talking to Neos Kosmos Mr O’Brien said; “If one avoidable death is a tragedy, then 801 avoidable deaths is a scandal,”

“This is the greatest government failure in this state’s history … it is untenable for Daniel Andrews to continue in that job.

“You don’t just get to shrug your shoulders and move on.