Victoria’s hotel quarantine inquiry.

While Victoria’s hotel quarantine inquiry has been marked by the poor recall of some politicians and senior bureaucrats, the seeds of disaster were likely sown several governments ago.

Under the government of Jeff Kennett, Victoria embraced the theory of new public management (NPM), overhauling the way public institutions were run and giving preference to managers who were generalists over subject matter experts … “And the consequences years later were lethal.”

If the Victorian hotel quarantine inquiry has proved anything, it’s how fickle the memories of powerful people can be.

During the course of 25 hearings and 63 witness appearances, the work of nailing down who knew what and when has been complicated by slips of recollection – the state’s chief health officer, Brett Sutton, being the latest to falter.

On Tuesday, an extraordinary hearing of the inquiry was called after reporters dug up emails contradicting Professor Sutton’s previous account of events.

Last month, the CHO told the inquiry he was not aware private security was being used in the quarantine regime until the first Covid-19 outbreaks began to appear in late May. Yet the emails handed to the inquiry on Tuesday show that on March 27 a conversation took place between state and federal health officials over whether private security was to be used.

When federal officials asked for information on the arrangements, Professor Sutton asked a Department of Health and Human Services official to answer directly and to copy him into the response.

DHHS deputy director Braedan Hogan then answered a series of questions, including one regarding security arrangements. “Private security is being contracted to provide security at the hotels with escalation arrangements to Vic Pol [Victoria Police] as needed,” Hogan wrote.

The next email in the chain shows

Sutton confirming receipt: “Thanks so much, Braedan.”

The inquiry learnt of the existence of the emails when The Age reported they had been left out of an order to produce documents.

When asked why they had been excluded, Brett Sutton told reporters that, although he had seen and responded to the email chain, the content “had not registered” with him and he stood by his prior evidence given to the inquiry.

Asked why the email chain had been left out of an order to produce documents, lawyers for the DHHS said the department had been swamped by the request and was advised by Sutton that the emails were not “critically relevant”.

“Professor Sutton instructed us he had not read the detail of the email at the time and that the evidence that he gave to the board was truthful at the time and remains so. In other words, Professor Sutton stands by that evidence which was provided honestly,” the DHHS lawyers said.

“Professor Sutton further instructed us that he did not consider he needed to clarify his evidence and therefore the email did not need to be provided to the board for that reason.”

The inquiry has given Sutton a week to explain the new information.

The hearing followed an announcement on Monday by Victoria’s healthcare quality and safety agency, Safer Care Victoria, that it would screen 200 people from the hotel quarantine program for hepatitis B, C and

HIV after test devices for Covid-19 screening had been misused between March 29 and August 20, potentially exposing those tested to blood-borne diseases.

The tests work by pricking a person’s fingertip to take a sample of blood, but the devices, usually used to monitor blood glucose, are intended for repeated use by one person only. While the needle is changed between uses, traces of blood can remain inside the body of the device.

Adjunct Associate Professor Ann Maree Keenan, acting chief executive of Safer Care Victoria, said the risk of transmission was low and that testing was being done for “peace of mind”.

“The clinical risk is low. But if you are at all worried you had this test – and we have not contacted you yet – please call us,” she said in a statement.

“Right now, we won’t be able to answer the many questions people will have about how this happened. Be assured that Safer Care Victoria is conducting a full review into how and why this device came to be in use.”

Having watched these incidents unfold, Jan Carter, the former head of policy and research at the Brotherhood of St Laurence, who worked closely with DHHS as a consultant for many years, says what has happened to date in hotel quarantine is an outcome “locked in” by decisions made decades ago.

Under the government of Jeff Kennett, Victoria embraced the theory of new public management (NPM), overhauling the way public institutions were run and giving preference to managers who were generalists over subject matter experts. Contracting out to private companies became standard procedure, driven by a belief the private sector was more efficient and cost-effective. The shift also had the added benefit of shifting power away from unions within the public sector.

Labor governments never undid the changes and soon these ideas became the norm.

During the pandemic, the state government was forced to set up hotel quarantine – a whole new public service – in a single weekend. In an environment shaped by NPM, private security stood as the natural answer to the question, who is the best choice to do this work?

“The pandemic concentrates all sorts of things in a very sharp fashion,” Carter said. “For example, it concentrates the importance of evidence and expertise, which is sort of ironic. The NPM was very dismissive of expertise and specialists. It preferred to have generalists running things who thought that running a factory was no different to running a health service.

“And the consequences years later were lethal.”

During final submissions at the end of September, the inquiry heard how Victoria’s “hastily assembled” quarantine program is “responsible” for 768 deaths and 18,418 cases since May.

That total stood at 20,323 cases and 817 deaths on Wednesday – although the daily rate of new cases has fallen into the single digits.

While the depth of Victoria’s lockdown has been sharply criticised by business interests, epidemiologist Professor Tony Blakely of the University of Melbourne says had more been done, sooner, restrictions would likely have already been lifted.

Blakely is the lead author of modelling published by The Medical Journal of Australia that first showed an “elimination strategy” was possible for the state. Since publication, the model has been shown to have accurately forecast events to date.

In particular, it predicted that stage 3 lockdown measures would not be enough to contain the spread of Covid-19 as new cases surged past 500 a day and that widespread mask-wearing significantly helped to slow the spread of the virus.

“There was equivocation at the start,” Blakely says. “Had we gone hard, gone early, Victoria could have been in a better place in the last six weeks. If we had only gone into stage 4 immediately early in July.

“The peak would have been much less; the tail would be over by now and we would be open again. There is a lesson here we have learnt not only in Australia, but elsewhere – hit it hard, quickly, if you are aiming for tight suppression or aggressive suppression – or even elimination.”

As the state transitions out of lockdown, Blakely says that if the situation is handled correctly Victoria may still be able to eliminate the virus entirely.

While the hotel quarantine inquiry was due to report on November 6, its chair, former judge Jennifer Coate, has warned the delivery date may need to be pushed back, in light of the new information provided on Tuesday.

Coate said she wasn’t sure how much of an extension was required, if any, and wouldn’t know until Brett Sutton’s explanation was received.

“I can assure all that as soon as I am in receipt of the outstanding material, if the report date … needs to be extended, I will advise the premier and seek any extension,” she said.

Since it began, the inquiry has heard from senior ministers, health officials, several departmental officials, current and former police commissioners, the emergency management commissioner and Premier Daniel Andrews.

Despite hours of testimony, no one has been able to pinpoint when the decision to rely on private security was made.

The inquiry’s report – when it arrives – will be expected to establish a time line of who knew what and when, and who made the decision to rely on private security. But many hope it will be able to highlight what systemic issues led to the breakdown of Victoria’s first line of defence against Covid-19.

There are also other questions about the circumstances under which security contracts were awarded to security companies Unified, MSS and Wilson in the rush to set up the quarantine program.

In late March, Victoria’s Department of Jobs, Precincts and Regions tapped the three security providers for the quarantine hotels without going through any tender process.

Unlike Wilson and MSS though, Unified was not on a government-approved list of security providers. The three companies in turn subcontracted out the work to contractors, who the inquiry has established were poorly paid and poorly trained. Witnesses told the inquiry of non-existent infection control, limited personal protective equipment, little training and poor behaviour by guards who allowed hotel guests to enter the community while under quarantine.

For its services, Unified was paid

$44 million by the government to post 1800 guards at 13 hotels – although it is unclear whether all of this money has been paid.

While the hotel quarantine inquiry has no prosecutorial power, its findings promise to trigger additional legal cases. Already there are several actions pending that target the state government and Unified Security and MSS Security for damages.

Elsewhere, Unified – which holds contracts to provide security for Metro Trains Melbourne – is set to appear before a separate Independent Broad-based Anti-corruption Commission investigation next week looking at how contracts were awarded within V/Line and Metro Trains.

Much like the pandemic itself, the effects of what happens next will linger long into the future.