Final summing up by Counsel assisting in the Judicial inquiry into Victoria's hotel quarantine program. It does not seem to be much of a surprise. As usual the "Swiss Cheese Model" seems to have applied.
Hotel quarantine became 'seeding ground', leading to 768 deaths and 18,000 infections, inquiry hears
The inquiry into Victoria's hotel quarantine program hears the program failed to meet its primary objective — to keep the community safe from the virus — with devastating consequences.