Victoria’s second wave of coronavirus was caused by a mix of bad luck and bad management
We have learned a lot from the judicial inquiry into hotel quarantine in Victoria, and the lessons should not be obscured by the fact that the failures were systemic and cultural, rather than the result of people acting corruptly or in bad faith.
Ministers, public servants and statutory officers have all minimised their own responsibility and some have had failures of memory we might see as convenient. But pinning guilt on individuals is of limited use.
The broad outline of what went wrong – the systemic failures – are clear from the evidence and were summed up yesterday in the closing addresses from counsel assisting the inquiry.
National cabinet made the decision to set up compulsory quarantine on 27 March. The first returning travellers were accepted into the program on 29 March. Between those two events, multiple agencies were involved in emergency meetings, and the decision to use private security emerged, because the police made it clear they didn’t want to “babysit” the people in hotel quarantine.
There were three other conceivable options – defence forces, corrections officers or private security. The reluctance to use corrections staff is understandable. The detainees were not criminals.
Andrews believed that defence force personnel were not available. He attributes this to the national cabinet meeting, the details of which we will probably never know, although he has gone out of his way to lay emphasis on it a few times. Counsel assisting the inquiry, Rachel Ellyard, suggested no finding should be made against the government for failing to consider ADF at this time.
In his opening address, Neal said that in these frantic three days: “Decisions were made very quickly and in the absence, it seems, of precise lines of responsibility, control, supervision and management.”
Understandable and forgivable, perhaps, given the speed. But part of the problem was a lack of useful planning. There were state and federal pandemic plans but they weren’t very helpful documents. They did not include detailed plans for mass quarantine. They weren’t adequately reviewed and updated and when it came to it, they were largely ignored.
A key question is why the reluctance of the police to get involved wasn’t challenged. Did anyone consider a middle course of having a small number of police to supervise private security? Did anyone push back or offer alternatives? It seems not. -Then, in what will surely be the subject of a stiff adverse finding from the inquiry, the contracts for security were drawn up to delegate responsibility for PPE, infection control and training to the private companies.
As counsel assisting made clear in questioning the premier, Daniel Andrews, last Friday, this is extraordinary. The government was well aware of the problems in the private security industry. Yet having deprived Victorians of their liberty, making them entirely dependent on government for their safety, the key infection control function that justified the operation was outsourced.
We now know that training, recruitment and the use of personal protective equipment was completely inadequate.
The responsibility for supervising the hotel spaces rested with the Department of Health and Human Services – the secretary, Kym Peake, and minister, Jenny Mikakos. For all the fudging in the evidence of those two people, that responsibility emerges clearly from the documentary and verbal evidence.
I am told an air of chaos and possible confusion was imported in early April, when the Department of Premier and Cabinet secretary, Chris Eccles, circulated by email news of a “significant reorientation of the public service” in response to the pandemic, including establishing a Missions Coordination Committee. This further centralised decision making while also, paradoxically, making it harder to tell who was in charge of aspects of the Covid response.
It was regarded by many senior public servants as not fit for purpose. Nevertheless, the core responsibility of DHHS for managing the quarantine program from early April is indisputable. When Andrews told the inquiry that Mikakos was responsible, he may have been throwing her under the bus but he was also stating a fact. It is hard to see how he could have given any other answer without being contradicted by the documents emerging from his own cabinet.
The management by DHHS was clearly inadequate. First, the quarantine program was lead and managed as a logistical exercise, rather than one of infection control. The chief health officer was sidelined.
When early reports of problems emerged, the first response seems to have been to deny they existed.
According to the evidence of Peake and Mikakos, the minister was not informed of problems in early May. This is so extraordinary it might stretch credulity, but I find it easy to believe.
There is a pattern which was also visible in DHHS’s management of the public housing tower lockdown in early July, which I reported for the Guardian. I saw how hard it was to get the agency to acknowledge problems and fix them. The arrogance and stubbornness was extraordinary. We are lucky nobody died as a result.
The agency has, thanks to outsourcing and under-resourcing, become a manager of contracts, while losing the operational knowledge and relationships with community that would allow it to judge whether the contractors are performing well. A toxic internal culture has seen good middle managers leave.
Covid comes along, and the cracks become chasms.
The hotel quarantine scandal has revealed deeper problems with the public service and the culture of the government. Counsel assisting the inquiry Ben Ihle said yesterday that senior public servants made deliberate decisions not to inform ministers, or were simply not across their brief.
Ministers should not be let off the hook here. It is their job to be alert for upward managers and take their own soundings. Nevertheless, something is clearly very wrong with how the public service is being managed.
On 15 May, a Covid-positive family of four arrived at Rydges Hotel. Ten days later, three members of staff were diagnosed with Covid.
Then Victoria had some bad luck.
Infected security guards attended large family functions, meaning case numbers boomed rather than trickled upwards. The contact tracing system was overwhelmed, the virus spread to aged care, and we know the rest.
From mid-June, Andrews seems to have taken charge after the scale of the leakage from hotels became clear.
Responsibility was transferred away from DHHS to the Department of Justice, corrections officers and infection control people from Alfred Health were brought in. But it was too late.
One issue not much examined by the inquiry is the role of ministerial advisors and staff. When a minister claims not to be have been told something, were their staffers told?
When they say they were not briefed, are they being conveniently literal minded – as in, there was no written brief – or do they include the numerous text messages, including on Signal and Whispr, that today form part of the way governments run?
There are some extraordinary lapses of memory, including in the evidence of Eccles regarding an 8 April email in which ADF support was offered by the commonwealth. Eccles apparently did not inform Andrews about this key change. He says he does not recall whether he told anyone else.
This is a point at which the story could have taken a different and better turn. What on earth was Eccles thinking?
But the systemic issues are more important than a quest for individual guilt.
We will probably never know what difference it would have made if any one of the elements of hotel quarantine had been better managed. Quarantine outbreaks have happened elsewhere, and been successfully contained.
And while the Victorian quarantine program clearly failed, it also partly worked. The vast majority of Covid-positive returned travellers did not infect anyone else.
Things are almost certainly better now than they would have been if travellers had been sent home to self-isolate. The bigger picture is that, by world standards, Australia and Victoria have done well.
Nevertheless, Victoria’s second wave was devastating, deathly and subjected a whole state to sustained low-level trauma.
The lessons are about better planning for predictable crises, and attention to the culture of government in Victoria; the need for ministers who are prepared to ask hard questions and public servants with the self-awareness and courage to be frank about problems.
Even in the teeth of an emergency, there should be questions asked and alternatives considered, and nimbleness in acknowledging and responding to problems and errors. In the short term, senior public servants are likely to pay the price. Departments will likely be reorganised.