Private security guards were the wrong choice to guard Victoria's returned travellers in the hotel quarantine scheme and no person or agency took responsibility for the decision to use them, an inquiry has found.
Retired judge Jennifer Coate said in her final report into the A$195 million programme that no one took ownership for the decision to use private guards and "all vigorously disputed the possibility they could have played a part in 'the decision'".
Coate said police would have been a better cohort than private guards.
"Consideration was not given to the appropriateness or implications of using a largely casualised workforce in an environment where staff had a high likelihood of being exposed to the highly infectious Covid-19," the report read.
"This, of course, had flow on impacts in terms of the spread of the virus."
Coronavirus outbreaks at Melbourne's Rydges on Swanston and Stamford Plaza Hotel, where returned travellers were being quarantined, led to 99 per cent of Victoria's second wave of Covid-19 cases.
Premier Daniel Andrews apologised for the failures.
"I want to apologise to the Victorian community for the very clear errors that were made in this programme," he said.
Finding that will 'shock the public'
Coate acknowledged decisions were being made with haste after the Prime Minister announced the mandatory 14-day programme for returned travellers on March 27, giving Victoria just 36 hours to create the programme.
But the six-month inquiry had failed to spell out why private security was the chosen workforce to guard the quarantine programme.
"The fact remains that not one of the more than 70,000 documents produced to the inquiry demonstrated a contemporaneous rationale for the decision to use private security as the first tier of enforcement, or an approval of that rationale in the upper levels of government," she said.
"Such a finding is likely to shock the public.
"It remained, as multiple submissions to the inquiry noted, an orphan, with no person or department claiming responsibility."
Army not even considered
Coate said there was no actual consideration of whether Australian Defence Force personnel would have been a better enforcement option at the hotels when the programme was set up.
"The assessment that ADF was not needed on the ground at the hotels was an assessment made without any proper consideration of... what would be the best enforcement option," she said.
Emergency management commissioner Andrew Crisp decided not to ask for ADF help as of March 27, because once it was agreed private security would be used, there was no longer a need.
Coate said the Government's decision-making process was at odds with the Westminster system principles of responsible government, made without proper analysis or clear rationale.
And given no one knew who made the decision, there was an obvious risk no one understood they were responsible for changing if it was wrong.
"That a decision of such significance for a government programme, which ultimately involved the expenditure of tens of millions of dollars and the employment of thousands of people, had neither a responsible minister nor a transparent rationale for why that course was adopted, plainly does not seem to accord with those principles," she said.
Dispute over who was in charge
Coate said there was an ongoing dispute between the Department of Health and Human Services (DHHS) and the Department of Jobs, Regions and Precincts (DJPR) over who was in charge of operating the quarantine programme.
She also found failures in the programme's establishment, given the state Government did not give proper consideration to the risks involved.
"It is beyond doubt that many people worked incredibly hard, in extraordinary time frames, to deal with an unprecedented set of circumstances," she said.
"But that is not a total justification for the deficiencies in some of the actions taken, and decisions made, in that first 36 hours, and it does not excuse the deficiencies found in the programme."