Victoria’s response to the coronavirus pandemic is now the most examined and investigated of any jurisdiction in Australia. That is as it should be. In the overall success story of the nation’s response, Victoria’s second wave is the most significant failure. It led to great suffering and loss of life.
With NSW now on a knife-edge, we must hope that the Victorian experience remains the country’s worst.
On Monday, the Hotel Quarantine Inquiry, lead by Justice Jennifer Coate, released its report. It is detailed, dense, comprehensive and convincing – though constrained by Coate’s powers and her terms of reference.
This report adds to the interim report, which outlined how hotel quarantine should be run. Its recommendations are now reflected in Victoria’s rebooted system.
This final report focusses on how mistakes were made.
The context for the report’s release – and events in the days since the release – will influence how people see the report. Outbreaks from hotel quarantine have happened in South Australia and in NSW. At the time of writing there have apparently been four leaks in three weeks from hotel quarantine in NSW. We now know that even when hotel quarantine is well run, keeping the virus contained is extremely difficult.
We must also rely on constraining individual behaviour, and on contact tracing. We have had an inquiry into the problems with Victoria’s contact tracing, and also an Ombudsman’s inquiry into the public housing lockdown. I wrote about these last week. There are common themes between the findings of all these investigations – to which I will return.
But politically and in its firepower, the Hotel Quarantine inquiry was the big one. Victorians got good value from Coate and her team. The report is detailed, dense, comprehensive and convincing.
The most important picture that emerges is about failed systems, rather than culpable individuals. But Coate does mention individuals, and so will I.
Systems are built and maintained by people and when government systems go wrong, senior bureaucrats and politicians bear the greatest responsibility.
And the picture that emerges from all these inquiries is that there are serious problems with the public service in Victoria.
This impression is echoed by sources from top to bottom both within the public service and by experts observing from the outside.
Victoria was once rightly regarded as one of the best, if not the best public services in the country. It is now regarded as one of the most dysfunctional.
The Department of Health and Human Services, given its central role in the pandemic response, is the poster child for this but not the only example.
This is a blot on Premier Daniel Andrews’ leadership.
One of the unfortunate effects of Victoria’s recent trauma is that opinions on Andrews are polarised. He is depicted as either a hero or a scoundrel. He is neither. Or perhaps a bit of both. Partisanship on both sides makes it hard to tell a nuanced story.
It is perfectly possible, and I think appropriate, to be impressed with Andrews’ extraordinary courage and leadership through the second wave, and also mark him down on the systemic issues in the public service which, we now know, helped to cause it.
Does he have the capacity and willingness to acknowledge that the public service has been mismanaged under his watch, and to fix the resulting problems?
His strengths may also be his weaknesses. Andrews is a controlling leader. His private office has grown, and the public service is full of accounts of his staffers intervening in public service decision-making and even ordering senior public servants around.
Responsibility here is shared with the former head of the Department of Premier and Cabinet and Victoria’s top bureaucrat, Chris Eccles, who resigned after it was discovered he had failed to tell Coate about a crucial telephone call.
Eccles was Andrews’ pick and was a central and apparently trusted member of his team. He does not emerge well from the Coate inquiry.
I’ll return to all this. This is going to be a long piece.
But first let’s look at what we learned from Coate about what went wrong with hotel quarantine.
First, and arguably most important (though hardly reported in the media so far), there was a lack of planning.
Here the responsibility is shared with the federal government. In fact, as Coate indicates, the federal government is perhaps mostly to blame given it is in charge of border control, and in a leadership position.
A pandemic was not, or should not have been, a surprise. The experts had been warning of one, and we had SARS and bird flu to learn from. There were Commonwealth pandemic plans and Victorian counterpart documents, but none anticipated the need for a mass program of mandatory quarantine.
After the H1N1 (swine flu) pandemic in 2009, the Commonwealth plan was reviewed. That resulted in recommendations for quarantine policies to be developed - including which level of government should be responsible, and the possible use of hotels, with the latter regarded as “problematic” for reasons that were not spelt out.
No work was done, either nationally or in any of the states. Coate did not have the remit to examine the role of the Commonwealth, but she comments:
“It would be unfair to judge Victoria’s lack of planning for a mandatory quarantining program given the Commonwealth, itself had neither recommended nor developed such a plan…Had the work … been undertaken, there would likely have been, at least, a set of guiding principles and a framework to support the establishment of the Hotel Quarantine Program, thus avoiding the program needing to be set up in an ad hoc manner during a pandemic.”
Coate recommends that Victoria now do what it can to advocate for a national policy and guidelines on quarantine to be developed.
If we want to blame individuals, the Commonwealth Government Health Ministers since 2009 have been Nicola Roxon, Tanya Plibersek, Peter Dutton, Sussan Ley and, since 2017, Greg Hunt. Their Victorian state counterparts over the same period have been Daniel Andrews, David Davis, Jill Hennessy, Jenny Mikakos and since September this year, Martin Foley. Space does not permit listing of their counterparts in other states – but all surely share responsibility for this seminal failure.
The lack of a plan meant that when a National Cabinet decided on 27 March that returning travellers must be compulsorily detained, Victoria had to build its program “from scratch” with just 36 hours from concept to the arrival of the first travellers.
Says Coate:
“This placed incredible strain on the resources of the State and, more specifically, on those Departments and people required to give effect to the decision of the National Cabinet. This was a most unsatisfactory situation from which to develop such a complex and high-risk program.”
We will never know – and Coate did not have the power to inquire – what the discussion was in that National Cabinet meeting.
Was the possibility of the Commonwealth running the scheme discussed? We know that both the use of the Australian Defence Force and private security were discussed.
Andrews has several times gone out of his way to say, with what strikes me as curious emphasis, that he emerged from the meeting with the strong impression that the ADF would not be available for hotel quarantine in Victoria.
There is a missing part of the jigsaw puzzle here, and we may never get to see it.
Given the lack of planning, problems were probably inevitable, even if everything else had gone right.
But it did not go right.
There were fatal flaws in decision making, accountability and management.
First, the decision to use private security guards. Many people are frustrated by the amount of attention given to this. After all, private security has been used in other states.
As Andrews said in his press conference following the release of the Coate report, the issue was not so much that private security guards were used, but that they were not properly trained, managed and supervised.
He is right – although Coate also finds that private security was not a suitable workforce for such an important operation, and Andrews has effectively already acknowledged that by making sure it is not used in the rebooted scheme.
But the way this decision was made does matter. It was fundamental and foundational – both in principle and in practice.
The government had decided to deprive citizens of their liberty, in the interests of protecting the wider community. There could hardly be a more significant exercise of government power and responsibility.
The government then outsourced the exercise of the power, and the responsibility, to an industry which it knew had big problems.
In retrospect, the error is gobsmacking. But in the rush – and in the context of a government grown use to outsourcing what it too glibly describes as “services”, the decision was made without any proper process or consideration of alternatives. Responsibility for training in infection control was also largely outsourced.
Coate finds there was no articulation of how the private security guards would be used, but in fact their role grew from an assumed “static” job of keeping people in their rooms to handling luggage, accompanying detainees on fresh air breaks and even buying toys for children.
Private security guards ended up being stop gaps, a workforce used to do anything that needed to be done when the public sector employees were stretched.
Coate records how one provider, Unified Security, came to be preferred because its staff were prepared to pick up this extra work without comment or complaint, whereas Wilson Security “rightly” raised issues about the risks involved – and was effectively penalised as a result.
So who made the key decision to put private security guards at the centre of quarantine operations?
Coate concludes the decision emerged from a meeting of various agencies at the State Control Centre on the afternoon of 27 March. It was only after this meeting that the Department of Jobs Precincts and Regions began to contract the private security firms.
No single person or agency took responsibility for the decision – nor was Coate able to determine individual responsibility. She lays out a detailed evidentiary trail that has convinced me that if a particular individual made the decision, she would have found out about it.
Nor were any ministers involved. Nor was there any proper risk assessment process or consideration of alternatives.
This is, as Coate says, is “shocking”.
Coate does find, though, that two individual were the main “influencers” of the decision: the then Commissioner of Police, Graeme Ashton and Chris Eccles
It is clear there was some discussion of private security at the National Cabinet meeting – though not, apparently, a decision.
It is also clear that Victoria Police had a preference that police not be used as the main security workforce.
In the early afternoon of the 27th, Ashton was texting and ringing around trying to find out what was going on and whether police would be involved.
After taking a phone call from Eccles at 1.17pm , Ashton was then under the clear impression that a “deal” had been set up by the Department of Premier and Cabinet under which private security guards would be used.
Both Eccles and Ashton claim not to remember the contents of the phone call. Victoria Police claimed in their submission to Coate that the decision must already have been made before the phone call. Coate rejects this.
She finds that an assumption formed and was carried forward into the afternoon through various communications and meetings until the SCC meeting, where as Coate puts it “the die was cast … The meeting moved on to other topics, with the decision now made, though those at the meeting do not appear to have been aware that such a significant decision had been taken.”
The lack of a proper decision-making process was another foundational error. It meant that nobody saw themselves as responsible for reviewing the decision, or even for making sure the system was working.
This was complicated by the transfer of control agency from DJPR, which had hired the guards and contracted with the hotels, to DHHS as control agency.
And this led to the next big problem. All the departments and agencies involved believed that from this point on, DHHS was in charge and taking responsibility for the operation.
But, incredibly, DHHS thought differently. The State Controller – Health, Jason Helps, the Department Secretary, Kym Peake and Minister Jenny Mikakos all argued vigorously to the inquiry that the DHHS role was limited and its responsibility shared.
Coate devotes a long and detailed chapter to DHHS, and Peake and Mikakos do not emerge well.
Andrews might have dropped Mikakos in the poo when he described her as the responsible minister for hotel quarantine – a statement that lead to her resignation – but it is hard to see what else he could have said.
A welter of evidence, from the documentation and all the other agencies involved leads inescapably to that conclusion.
The on-the-ground result of this confusion about control and responsibility was that in the hotels, nobody was in charge. Coate says:
“This left brewing the disaster that tragically came to be. This complex and high-risk environment was left without on-site supervision and management, which should have been seen as essential to an inherently dangerous environment. That such a situation developed and was not apparent as a danger until after the two outbreaks was the ultimate evidence of the perils of the lack of proper leadership and oversight.”
Coate adds detail to the picture that has emerged from the other inquiries – of a dysfunctional DHHS. It is a huge department, created as one of several “uber” bureaucracies when the Andrews Government came to power.
The pandemic offers two lessons. First, that governments should think more carefully before outsourcing key responsibilities. Second, that when it comes to government departments, bigger is not necessarily better. Hotel quarantine in Victoria is now lead by a single, small agency.
Within the dysfunctional DHHS, Victoria’s high-quality public health leaders – Chief Health Officer Brett Sutton chief amongst them – struggled to be heard.
Sutton had sought the role of State Controller – Health, with oversight of the pandemic response. The pandemic plans assumed that the CHO would have this role – but Peake denied it to him. This is even though it was Sutton’s legal powers as CHO that were being used to detain people.
Both Sutton and his deputies thought they should be able to see how those powers were being exercised on the ground.
Coate comments “This is a position that, in my view, is unarguably correct.”
Mikakos has put out a statement regretting that Peake didn’t adequately brief her, and that Sutton didn’t raise his concerns directly with her.
Perhaps Sutton should have spoken to Mikakos – but given his position in middle management (itself part of the pathology of Victoria’s pandemic management) it would have been a huge thing for him to do.
He would have had to go over the head of his immediate boss, and of Peake.
For Sutton to have gone to Mikakos would hardly have helped his ability to operate in what was clearly already a toxic environment. Nor is there anything in the evidence to suggest that Mikakos would have over-ruled Peake.
There is another factor in Peake’s failure to brief Mikakos. In April, Eccles had introduced a new “Mission Coordination Unit” to manage the pandemic. Every public servant I have spoken to says this caused great confusion at an already difficult time. It made Peake and other department heads part of the “mission” with responsibility direct to Daniel Andrews as Premier.
One well highly regarded expert in public administration with detailed knowledge of the Victorian public service described this arrangement to me as having been “like acid on our conventions of government in Australia, because it eroded the doctrine of ministerial responsibility.”
Having said that, Peake didn’t brief Andrews on Sutton’s concerns, either. And, although Andrews had told her to appoint a deputy to run the department while she was engaged in the “mission” she didn’t do so – and didn’t tell Andrews that she had gone against his direction.
A theme emerging from all the recent inquiries is that Victoria has done worst when the public health team’s advice was not sought, or not listened to. This was a factor in the public housing lockdown as well, as I wrote last week.
There is hope here. Andrews has already announced that the DHHS will be split into two, with a new dedicated Department of Health. The new secretary of the Department, Euan Wallace, has a clinical and operational background, and the new Minister, Martin Foley, is reportedly already considering a structure that will give the CHO more seniority and voice.
This leads us back to the problems with the public service.
Coate, constrained by her terms of reference, nevertheless comments on the ways in which the public servants involved in hotel quarantine made big decisions without ministerial sign off, or even proper briefings to the ministers.
Peake kept Mikakos in the dark. The head of DJPR, Simon Phemister, failed to brief Minister Martin Pakula. At the same time, Mikakos and Pakula also seem to have been strangely incurious.
Eccles failed to inform Andrews when, in April, the federal government indicated that Australian Defence Forces might now be available to help with quarantine.
Coate makes what might, if we are lucky, turn out to be her most significant recommendation (given that hotel quarantine has already been reformed and rebooted).
She refers the evidence regarding the way senior public servants behaved, and the lack of ministerial accountability, to the Public Sector Commissioner – who has a statutory responsibility for reviewing and strengthening the public sector.
And Victoria has a new Public Sector Commissioner, appointed just months ago. Adam Fennessy formerly Secretary of the Department of Environment and Water and more recently with Ernst and Young, is universally highly regarded.
Coate has a reputation for being politically savvy. With this recommendation, she bolsters that reputation.
So how did the public service arrive in its current state?
Coate does not delve into this, but other people with close knowledge do not hold back.
Some of the damage dates back to the Kennett years, but a lot of it has happened on Andrews’ watch. He created the giant departments. He continued the history of under-investment in public health.
And, under Eccles, a lot of experienced senior public servants were pushed out in favour of younger, very talented but relatively inexperienced people, who became part of a close and trusted circle around Eccles. Others had trouble penetrating.
Kym Peake was one of these – enormously talented, but without the kind of experience that might fit her for the massive job of managing DHHS.
She was highly regarded by her peers and by Mikakos, but less well-liked by her subordinates. She drove herself and her team hard.
DHHS employees have told me stories of being woken by her in the middle of the night with a demand that a briefing paper be on her desk early the following morning. People often worked through the night – including when there was no crisis.
Good people in senior management left. The department grew toxic. Meanwhile, cost cutting meant the department was increasingly contracting out “services” – such as managing public housing – while losing the connections with the community that would have allowed it to know how the contractors were performing.
In the various DHHS submissions to the inquiries of the last few months, there is a demonstrated unwillingness or inability to admit error, express regret or in any way step back from vigorous self-defence. Peake’s evidence before Coate demonstrated, at the very least, an inability to “read the room”.
Peake had already resigned before Coate reported but would surely have had to go in any case. It’s a personal and a public tragedy – a career that might well have turned out differently with better management at the top.
And so to Daniel Andrews, the man who will probably be Victorian Premier for years to come.
He, too, bears responsibility for the systemic failures.
He is universally regarded as a man of great capacity and strength. He also runs a centralised system.
One observer says that Andrews can take criticism but “he doesn’t like it”. He can also freeze people out and drop them fast.
It is easy to see that this might have lead to upward management. Ambitious public servants struggling with enormous management jobs might not have easily admitted to problems and errors.
It also seems, on the evidence before Coate, that they felt able to make enormous decisions without any reference to a minister.
As one observer said to me: “If you run a highly centralised power structure with an interventionist approach, then you will end up developing capacity issues. Something like DHHS is what you end up with.”
So now the issue will be the extent to which Daniel Andrews is willing and able to reflect, review and correct – perhaps with the intervention of Public Sector Commissioner Fennessy.
This will be key to his record – and to the future of Victoria, given that the Opposition shows no signs of being able to deny him another term.
Finally, a couple of observations about the media. Coate thanks them for the reporting of her inquiry, but she surely can’t be entirely happy.
For all the fuss about the emails that leaked to The Age, in the end they did not fundamentally change the picture before her.
The emails were clearly leaked to the media by someone in DHHS who was trying to spread the blame on to Sutton and his team – but the resulting extra work of discovery had the reverse effect, unearthing the email in which Sutton most explicitly protested how his team was being shut out, with resulting moral and legal risk.
As for the allegation that Sutton tried to cover up key evidence, which was reported by nearly all media outlets as front page news, Coate doesn’t even mention it – and it is not borne out by the evidence.
Coate says she found no evidence that any public servant behaved with a lack of integrity.
As for the allegations, published by News Corporation outlets, that hotel security guards had sex with people in quarantine, Coate mentions some instances of inappropriate behaviour, but nothing of this sort.
She says:
“There was no basis to find anything other than that the overwhelming majority of security guards who worked in the hotel quarantine program did so honestly and with goodwill. None of those workers went to work to get infected with COVID-19.”
Systems are built by people, and we all bear some responsibility for those of which we are part.
In this case, it would behove the media to correct the public record.
Margaret Simons is an award-winning freelance journalist and the author of many books and numerous articles and essays. She is also a journalism academic and Honorary Principal Fellow at the Centre for Advancing Journalism, University of Melbourne. She has won the Walkley Award for Social Equity Journalism, a Foreign Press Association Award and a number of Quill Awards, including for her reporting from the Philippines with photojournalist Dave Tacon.
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