Amanda Duncan's sister Zoe is never far from her mind, and what happened to her while she was a patient at the Launceston General Hospital (LGH) is something Amanda never wants to see repeated.
In 2001, 11-year-old Zoe went to the LGH suffering an asthma attack, but during her stay she was sexually assaulted by a male doctor.
When the assault was reported to authorities, the claims were dismissed.
Zoe died from epilepsy in 2017 aged 28. Even after she was diagnosed, she refused to go back to the LGH.
The Duncan family gave evidence earlier this year during the Commission of Inquiry into the Tasmanian Government's Responses to Child Sexual Abuse in Institutional Settings.
The harrowing stories and experiences of the family and many others prompted the Tasmanian government in July to call for an immediate review into management at all levels at the hospital.
Six months on, the Independent Child Safe Governance Review of the Launceston General Hospital and Human Resources has been released.
Ms Duncan welcomed the decision by the Tasmanian government to accept and implement all 92 recommendations from the report, describing it as a "positive step forward" — but she said there was "still a lot of work to do after the recommendations are passed down".
"It's absolutely critical that LGH staff, senior management and HR respect the recommendations that have been made," she said.
"Child safety is everyone's responsibility, and it's regardless of your role within a health service."
As a nurse and a midwife, Ms Duncan said it was challenging to share her lived experience as part of the review, but she was glad she did.
"It was important that I represented those who are working in the LGH currently, and also as the little sister of Zoe," she said.
"It was challenging but also empowering to represent the voice of Zoe and the family."
The Child Safe Governance Review looked into management of the hospital and human resources, with a particular focus on the handling of serious misconduct such as institutional child sexual abuse through the lens of child safety.
The report identified a raft of failures at the LGH, including:
"Ill-defined executive and clinician leadership accountabilities, lack of cohesion across the executive team, an imbalance within the executive leadership team which was weighted too heavily to longevity and status quo and insufficiently to renewal and change.
"Ineffective and unwieldy, internal communication and decision-making structures and ineffective performance management".
The report found while there were "well-established patient safety systems available at the LGH", the governance failures had "led to a lack of confidence in the effectiveness of those systems and the effectiveness of their practical application".
It also noted "complaints management at LGH was inconsistent and immature, and there was a lack of clarity in the escalation pathways for the handling of serious complaints, which the establishment of a centrally based complaints oversight system within the Department of
Health should help address".
Other issues included "confusion about the respective roles and accountabilities of the HR and clinical operational managers" as well as "no clearly designated executive [having] oversight responsibilities for the effective functioning of child safety at LGH".
The Australian Nursing and Midwifery Federation (ANMF) Tasmanian branch secretary Emily Shepherd said it would "take time" for the culture at the hospital to undergo meaningful change.
"As a member of the advisory panel, [the ANMF] very much support the recommendations, and we are hearing members are feeling more positive, but it will take a long time to rebuild the culture," she said.
Premier Jeremy Rockliff said he would work to ensure all recommendations from the review were implemented in full.
"We have already made changes since the commission of inquiry and indeed we will continue to do so," he said.
The review also outlined the need for LGH staff to undergo mandatory child-safety training by June 2023.
