The executive management review of the Emergency Services Agency did not name names. It didn't need to.
It's findings that there were examples of agency executives bullying, blaming, withholding information and undermining each other's decisions were scathing.
Commissioner Georgeina Whelan's position as the agency's leader had become essentially untenable. This had happened on her watch. The questions were when and how - not if - she would go.
Emergency Services Minister Mick Gentleman had expressed full confidence in the agency's executive team while the review was underway but has stayed quiet after its findings were made public.
In a budget estimates hearing on Tuesday, where Mr Gentleman sat alongside Ms Whelan, it seemed as if the minister intentionally stopped short of expressing confidence. Instead he made mention of thanks.
Ms Whelan's resignation offers the government a chance to reset the culture of the agency, take charge on the recommendations from the management review and ensure the same problems do not get identified in five years' time.
Justice and Community Safety Directorate head Richard Glenn, who the Emergency Services Agency reports to, said on Tuesday it was unhelpful to conflate findings from a 2017 staff survey with the findings of the executive leadership review he commissioned in March.
Mr Glenn would say that, but even if the two sets of findings did not offer a like-for-like comparison, it did point to festering cultural issues within the organisation. Both identified a culture of blame.
The Transport Workers' Union, which represents paramedics, suggested it would be a recipe for failure if the executives were tasked with fixing the organisation they had presided over when it was broken.
But while Ms Whelan was the figurehead of the agency, it will not be improved simply by virtue of her going.
The Emergency Services Agency has sought to expand its function, much to the frustration and anger of the firefighters' and paramedics' unions. The unions and agency have had competing visions on the difference between an operational and enabling service.
Resolving this conflict is the essential task of improving the agency. Repairing the relationships between the ACT Ambulance Service, ACT Fire and Rescue and the agency will be a challenge for the government and Ms Whelan's replacement.
Ms Whelan's resignation offers the government not a solution but an opportunity to consider what the Emergency Services Agency is really for and how best it can operate. It is now be up to the government to seize the moment.
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