'Disaster': Calls for external audit of health department after scathing hotel quarantine assessment

The Coate inquiry into hotel quarantine identified deep cultural problems in the Victorian government which were "at odds" with the principles of the Westminster system, prompting calls from experts for an external review of the state's troubled Health Department.

Former judge Jennifer Coate, in her final report into the hotel quarantine debacle, delivered a brutal assessment of the department, which she said had refused to accept accountability for the program's operation and had maintained a dispute with the Jobs Department over who was running it.

Daniel Andrews approaches the media after the release of the Coate report.Credit: Wayne Taylor

“This was the source of considerable and significant problems with the way in which the program operated,” Ms Coate found.

Premier Daniel Andrews has already split the Health Department in two and accepted the resignations of the former minister, Jenny Mikakos, and the secretary Kym Peake. He said on Monday that if they had not already resigned, he would have expected them to do so in the wake of the report.

Melbourne University infectious disease expert Dr Lindsay Grayson said the inquiry raised "crucially important" questions about whether the Health Department was fit-for-purpose to protect public health.

"The government should be asking if it's reasonable the department be left to restructure itself or if there should be an external review given the seriousness of the findings," he said.

DHHS ... did not see itself as 'in charge' on-site. This left brewing the disaster that tragically came to be.

Jennifer Coate, from her hotel inquiry final report

And Australian Medical Association Victorian president Julian Rait supported the call for an external audit, saying a panel of experts including governance experts, health experts and people from interstate, should probe the agency's structure.

"Given the scope and depth of the problems, you'd have to ask why would you not do a root-and-branch review of the department and its failings to ensure Victorians were better served in future by a properly functioning department," he said.

The Coate inquiry found the Health Department suffered from a "significant lack of much-needed" public health expertise following years of government under-funding under both political parties.

It had been the control agency of the hotel quarantine program, Ms Coate found, but had not accepted responsibility for that fact, or for ensuring infection control protocols were enforced.

"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 said. "This left brewing the disaster that tragically came to be."

Jennifer Coate found a lack of appreciation of the high risks of infection breaches led to the second wave.Credit: Jamie Brown

The report found an "ongoing dispute" between the former DHHS and the Jobs Department about who was in charge had caused "significant problems" and created "complex and, at times, inexplicable internal governance structures that served to complicate and obfuscate reporting lines and accountabilities rather than create clarity”.

Neither Health Minister Jenny Mikakos nor Jobs Minister Martin Pakula received briefings from their department secretaries on the day-to-day operation of the program or the contracts to hire security companies, Ms Coate found.

"On its face, this was at odds with any normal application of the principles of the Westminster system of responsible government," Ms Coate found.

She recommended the Victorian Public Sector Commissioner investigate lines of accountability between ministers and department secretaries and provide guidance across the public service about proper obligations. Mr Andrews said he intended to adopt the recommendation.

The Premier, speaking in the hours after the report was tabled, also admitted to "some cultural problems and failures in oversight and structural integrity".

"That is why we had this process to determine exactly the points at which the system broke down, the origins of the errors and the mistakes that have been tragic and that have caused us pain and done so much damage.

"We understand those weaknesses, those errors, and we have a steely resolve and commitment to remedy those errors, those cultural problems, administrative problems, to ensure that this can never ... happen again."

Dr Rait said the Health Department had a culture of not admitting failure that was illustrated by the department's decision not to appoint Chief Health Officer Brett Sutton to the position of state controller for health.

The decision, which Professor Sutton disagreed with, meant the hotel quarantine program was run as a logistics exercise "rather than a public health program" with public health expertise and its core, Ms Coate found.

Dr Rait said the Health Department did not properly monitor the health protocols within the hotel program.

"The key failing was the lack of humility to accept and acknowledge errors and take responsibility. An important part of creating a safety culture in any organisation is about trying to make people aware of mistakes and learn from them," he said.

"If you instead become proficient in denying problems or obfuscating the truth, you can dodge that. That's been the culture there for some years … making errors and moving on.

"Imagine if an airline did that?"