However, Ms Coate sheeted home a large portion of the responsibility to the police chief commissioner at the time, Graham Ashton.

Mr Andrews commissioned Ms Coate to head an inquiry into the program after several private security guards and workers in quarantine hotels contracted COVID-19 then spread it into the community in May and June.

This sparked Victoria’s second wave of COVID-19, which claimed over 800 lives and caused four months of tough restrictions that included a night-time curfew, widespread commercial shutdown and a ban on leaving the home for anything but limited exercise and essential supplies.

Ms Coate’s report found that on March 27, when the hotel quarantine program was devised following an agreement at National Cabinet, the Victorian government failed to consider the merits of using private security, police or the Australian Defence Force on the frontline of the hotels.

The assessment that the military was not needed was made “without any proper consideration of … what would be the best enforcement option”.

“Instead, an early mention of private security rather than police grew into a settled position, adopted by acquiescence at the State Control Centre meeting.” That meeting at 4.30pm on March 27 involved Emergency Management Commissioner Andrew Crisp, Victoria Police and senior public servants.

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“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 found.

That position “was clearly persuasive” to others at the crucial meetings on March 27.

“There being no particular discussion or dissent, this set in motion the actions, that evening, by [the Department of jobs Precincts and Regions] to commence contractual engagement with three security firms,” Ms Coate found.

“The decision was made without proper analysis or even a clear articulation that it was being made at all.

“On its face, this was at odds with any normal application of the principles of the Westminster system of responsible government. That a decision of such significance for a government program, which ultimately involved the expenditure of tens of millions of dollars and the employment of thousands of people, had neither a responsible Minister nor a transparent rationale for why that course was adopted, plainly does not seem to accord with those principles.”

The report was scathing of the Department of Health and Human Services. It found the department suffered from a “significant lack of much-needed” public health expertise following years of government under-funding. Also, it was the lead agency but did not accept that responsibility.

“Just as DHHS did not see itself as the control agency responsible for the program, it did not see itself as ‘in charge’ on-site,” Ms Coate found.

“This left brewing the disaster that tragically came to be.”

The inquiry was initially due to report in September but was delayed first by working at home constraints then by new documents, primarily from the Department of Health and Human Services, that were only provided to the inquiry in late October. 

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Its budget of $3 million swelled to a cost of $5.7 million.

The report criticised the decision by former Health Department secretary Kym Peake, who resigned from the role last month after coming under fire during the inquiry, not to appoint Chief Health Officer Brett Sutton as state controller – the most senior supervisory role – for the public health emergency.

The exclusion of Professor Sutton, against his wishes, contributed to the view of hotel quarantine as a logistics and compliance exercise, rather than a public health program.

“It meant that those in leadership roles for the program were not people with public health expertise,” Ms Coate concluded.

Of the guards themselves the report found that “the overwhelming majority … did so honestly and with goodwill”.

It was not their fault they got sick and spread the disease, Ms Coate ruled: “None of those workers went to work to get infected with COVID-19. However, systemic governmental failings led to problems.”

Former Health Minister Jenny Mikakos was the first senior figure to resign over the inquiry in September after Mr Andrews used his evidence to lay ultimate responsibility for the program on her.

Mr Andrews’ top public servant, Department of Premier and Cabinet secretary Chris Eccles, resigned next over new evidence showing a phone call with former police Chief Commissioner Graham Ashton on March 27, which Mr Eccles did not mention in his original testimony.

The inquiry released an interim report at the start of December detailing recommendations for a reset hotel quarantine program, which two weeks ago began hosting international arrivals for the first time since July.

Hotel quarantine is also currently mandatory for any people arriving in Victoria from Sydney’s northern beaches and will extend to all of greater Sydney and the NSW Central Coast due to an escalating coronavirus outbreak.

More to come.