The final report into Victoria's bungled hotel quarantine program has been released and unable to determine who made the decision to use private security.
Head of the inquiry, retired judge Jennifer Coate, said no single person had taken ownership of the disastrous call to use private security, describing the program as an "orphan".
She said the lack of accountability would "shock the public".
"No person or agency claimed any responsibility for the decision to use private security as the first tier of security," the report reads.
"All vigorously disputed the possibility they could have played a part in 'the decision'.
"The Premier and former Minister (Jenny) Mikakos said they played no part in the decision. Minister (Lisa) Neville was aware of the proposal but not responsible for it and Minister (Martin) Pakula appears not to have been told until after private security had been engaged.
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"Enforcement of quarantine was a crucial element of the Program that the Premier had committed Victoria to adopting, but neither he nor his Ministers had any active role in, or oversight of, the decision about how that enforcement would be achieved."
The former judge said the risks of the hotel quarantine program were known.
"The decision to embark on the Hotel Quarantine Program in Victoria was made by the Premier without any detailed consideration of the risks that such a program would entail," the report reads.
"The evidence was those risks were considerable."
In the report tabled today, Ms Coate said police would have been a better option than private security.
"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."
But Ms Coate did find that the then Chief Commissioner of Police Graham Ashton expressed a desire for police to be used as a secondary source of security.
"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."
Ms Coate was also scathing of the health department and cited a lack of funding.
"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," Ms Coate found.
"This left brewing the disaster that tragically came to be."
The report also confirms breaches in hotel quarantine directly led to the second wave of COVID-19 cases in Victoria.
"Despite the relatively low number of positive COVID-19 cases in the Hotel Quarantine Program, breaches of containment in the Program, in May and June 2020, were inextricably linked to the second wave of COVID-19 cases in Victoria, with devastating social and economic consequences for the State," the judge wrote.
"The expert evidence, based on genomic testing, was that 99 per cent of Victoria's second wave of COVID-19 cases in the community came from transmission events related to returned travellers infecting people working at the Rydges and the Stamford Plaza Hotel."
The inquiry ran for six months and saw more than 70,000 documents produced.
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