Ignoring the opposition’s calls for him to resign and claims of political deflection from former health minister Jenny Mikakos, the Premier apologised on Monday to the families of the 801 Victorians who died in the state’s second wave. He conceded that the scheme’s biggest problem was not to initially employ guards, but rather the government’s failure to properly oversee their work.

The inquiry found that the decision to employ private security guards for the program was an “orphan”, that neither Mr Andrews nor any of his ministers took responsibility for, unable to be traced back to any individual.

The Premier on Monday said it was “my preference” to adopt all 81 recommendations made by the inquiry’s chief, retired judge Jennifer Coate, which included that the Public Sector Commissioner should examine evidence given to the inquiry about lines of accountability between ministers and senior public servants.

“This will be an incredibly difficult week. There will be people missing from the Christmas dinner table on Friday and I am deeply sorry and saddened by that,” Mr Andrews said.

Former health minister Jenny Mikakos, who resigned in September after the Premier said in his evidence that ultimate responsibility for the program lay with her, was scathing of the report.

She said it failed to answer key questions about why police or Defence Force personnel were not used in hotel quarantine instead of security guards.

“I believe Victorians deserve to know the truth about an event that has so profoundly impacted them,” she wrote.

“They do not need another masterclass in political deflection from the Premier”.

She called on the inquiry to release the entirety of Mr Andrews’ phone records from March 27, the day the system was set up, which were not published in the final report.

Former judge Jennifer Coate has delivered her final report into Victoria's hotel quarantine program.

Former judge Jennifer Coate has delivered her final report into Victoria’s hotel quarantine program.Credit:Getty

Unified Security, one of three private security companies contracted by the government to monitor hotels, on Monday lashed the Andrews government and its “confused and ineffective government departmental structure that in turn led to inadequate infection-control protocols in the hotels”.

“It is pleasing to see our position has been vindicated by the report … for the past six months it has been convenient for bureaucrats to blame and hide behind security guards and security companies,” a Unified spokesman said.

“While this was deeply disappointing, we always had faith that the inquiry would get to the bottom of the multiple structural inadequacies that led to the outbreaks.”

When Mr Andrews announced on June 30 that Justice Coate would lead an inquiry into the hotels program, he told a press conference that “there have been some breaches of well known and well understood infection control protocols” by private security guards. He gave the example that guards had spread COVID-19 by sharing cigarette lighters.

The next day Mr Andrews fronted ABC’s 7.30 to tell a national audience: “We have some very clear suspicions about what’s gone on here. There’s a number of staff who despite knowing about infection control protocols have decided to make a number of errors.”

The final report on Monday found “the overwhelming majority” of security guards worked in the program “honestly and with goodwill”.

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

There have been some breaches of well known and well understood infection control protocol.

Premier Daniel Andrews, June 30

She concluded that a series of factors contributed to the program’s inadequacy, including confused governance structures, the failure of ministers including Mr Andrews to consider the health risks of a hotel quarantine program and the Department of Health and Human Services’ refusal to accept responsibility despite being the lead agency.

“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,” Justice Coate found. “This left brewing the disaster that tragically came to be.”

Under the contracts given to Unified Security, Wilson Security and MSS by the Department of Jobs, Precincts and Regions, the companies were asked to provide guards training on infection control and personal protective equipment. Justice Coate found in her report that DHHS should have managed the contracts and training for guards.

The Age revealed in July that Unified hastily recruited subcontractors to supply security guards, who were paid as little as $18 per hour in cash. Six subcontracted guards, along with a nurse and a hotel employee, caught COVID-19 while working at the Rydges on Swanston in late May.

Wilson Security chief executive Nick Frangoulis pointed to the final report’s conclusion that the company raised “valid safety concerns” as proof they went beyond the government’s infection-control standards.

“This also meant, at times, not performing some duties if it presented additional risk to our guards,” he said. “We’re confident Wilson Security demonstrated how private security could have been utilised appropriately for the program.”

Opposition Leader Michael O’Brien said the report failed in its goal of discovering who decided to employ private security and called for a royal commission that he said would have greater powers to examine the decision-making on March 27, when the hotels program was devised.

“We see the Premier digging in, we see the Premier saying sorry but not showing that he’s sorry,” he said.

Opposition Leader Michael O'Brien demanded that Premier Daniel Andrews resign on Monday.

Opposition Leader Michael O’Brien demanded that Premier Daniel Andrews resign on Monday.Credit:Joe Armao

“Andrews has blamed Victorian families, security guards and thrown a minister under the bus, yet refuses to take any personal responsibility for the worst public policy failure in the state’s history. No political leader should be able to survive this type of failure.”

Former health minister Jenny Mikakos resigned over the hotel quarantine program in September.

Former health minister Jenny Mikakos resigned over the hotel quarantine program in September.Credit:Getty

The report found poor communication between ministers and department heads and Mr Andrews pledged to adopt a recommendation for a further inquiry into accountability of the public service and government.

Associate Professor Aaron Martin, a lecturer at the University of Melbourne’s School of Social Political Sciences, said there was a “signal and noise” problem where it may not have been apparent to department secretaries which pieces of information should have been relayed to the minister.

“In hindsight it’s easy to say what went wrong and right, but with time decisions made with very little info in an unprecedented health crisis. I have some sympathy for some mistakes, though not all are excusable,” he said.

Despite concluding the private security decision was reached by “acquiescence” at a meeting at the State Control Centre on March 27, Justice Coate sheeted home a large portion of the responsibility for the security guard decision to the then police chief commissioner, Graham Ashton.

“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,” she found.

Justice Coate said the Victorian government failed to assess 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”.

The hotel inquiry’s budget swelled from $3 million to $5.7 million and it is understood government departments spent at least $4 million on lawyers.

With Paul Sakkal

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