'The Rotten Core' Essay Read By Nick Feik

Teleraine, a town in Tasmania, may seem idyllic to visitors, but it hides a dark reality. The town is home to a cemetery where a notorious child sex abuser, James Griffin, is buried. The nearby Ashley Youth Detention Centre, a site of investigation for child sexual abuse, employs staff from the Teleraine Football Club. The region's major employers, including the Extractus Bioscience and its opium processing plant, contribute to both detaining children with drug and alcohol problems and producing drugs that can lead to addiction. The Commission of Inquiry recommended shutting down Ashley. Meanwhile, the Launceston General Hospital allowed Griffin, known for inappropriate behavior and boundary breaches with patients, to work in the pediatric ward despite prior warnings. Several reports of Griffin's crimes were ignored or dismissed by the police and hospital, and there was a lack of communication and action between different departments. The responsibility for these crimes and cover-ups e The Rotten Core, read by Nick Vyke. Teleraine, in the Meander Valley in Tasmania's central north, looks like a beautiful little town. Situated on the gorgeous Meander River, it's a natural and historical attraction for tourists and a gateway to Cradle Mountain and the Central Highlands. The main street, snaking up the hill, hosts old pubs, faux-Bohemian art and craft shops, cafes, charity run-up shops, trade stores and a library. For most visitors, staying a day or two, it's idyllic. It's not idyllic. A sculpture of a haunted-looking Indigenous girl watches the comings and goings on the roundabout in the centre of town. The inscription plate has disappeared. Next to the employment office, where good job vacancies are scarce, a community notice board advertises legal literacy volunteers, offering to help clients fill out all sorts of paperwork and online forms. Less than 40% of the locals have finished Year 12. Up over the hill, two kilometres past the visitor centre, and nestled among the picturesque poppy fields, is the Teleraine General Cemetery. Here, among the generations of local Griffins, lies the infamous James Geoffrey Griffin, former nurse and serial child sex abuser, who worked on the paediatric ward at Launceston General Hospital for 18 years. Born in Teleraine 1950, died in Lugana 2019. Befitting the secrecy that protected him throughout his life, his grave is unmarked. Back across the river, left at the police station, is the Teleraine Football Club. Names on the club lists are familiar from the staff rosters at the Ashley Youth Detention Centre, a few minutes out of town on Meander Valley Road. Ashley was one of the key sites of investigation in the recent Commission of Inquiry into the Tasmanian Government's responses to child sexual abuse in institutional settings, due to its continuous catastrophic failures to protect the children in its care. Ashley is one of the region's major employers, along with Extractus Bioscience, formerly Tasmanian Alkaloids, and its opium poppy processing plant. Extractus, not far down the road from Ashley, supplies around half of the world's legal opiates, morphine, codeine, oxycodone, etc. Some locals have worked at both. It's one of the sad ironies of Meander Valley life that these two facilities are tasked with alternately detaining children, up to 90% of whom suffer from illicit drug and alcohol problems, and producing licit drugs to relieve pain and suffering, but which also feed so much addiction. When the Commission of Inquiry's final report was handed to the Tasmanian Governor on August 31 last year, it outlined devastating failures in institutions across the state, including the Launceston Hospital. But the Commission has singled out Ashley. It should be shut down altogether, they said, as a matter of urgency. Its problems were intractable. The following day, the State Coroner's Office quietly released another report into the unrelated deaths of suicide by four Tasmanian police officers. One of the policemen, Senior Sergeant Paul Reynolds, who coincidentally also lived on Meander Valley Road and spent a lot of time at the Deloraine Football Club, had taken his own life after being informed that he was being investigated by Tasmania Police Professional Standards Command for sex offences involving children at the club. Reynolds was, quote, highly reputed in the Deloraine area to be a pedophile, unquote, one officer told the Coroner's Office. Other reports were starting to emerge of the horrendous scope of his crimes over decades. This small region may have been the epicentre of a statewide abuse crisis, but the responsibility for both crimes and cover-ups stretch all the way to the highest levels of Tasmanian government. Launceston General Hospital, where James Jim Griffin should never have been allowed to work, is half an hour east of Deloraine. A few months before he started there, a member of the public informed Tasmania Police that a laptop Griffin had recently owned contained child exploitation material, including links to child pornography sites. The complainant had bought the computer from Griffin in the late 1990s, realised that the previous owner was a registered nurse and reported their discovery to the police in September 2000, and yet Griffin started working at the hospital in February 2001. The complainant followed up with police in March that year, having heard nothing. The police didn't deem the complaint worthy of serious investigation or a forwarding to the health department or nursing board and didn't even enter the report into its database. By September, Griffin was looking after the children in Ward 4K. Griffin was already 50 years old, having worked mostly odd jobs before then, including as a volunteer paramedic and an accommodation manager at the University of Tasmania. He was married with kids and was regarded as outgoing, confident and friendly, if not great with paperwork, by some at the hospital, but too friendly by others, a bit sleazy and too close to the young female patients. To almost every one of his colleagues, this behaviour was just Jim. He was first warned verbally about inappropriate conduct and boundary breaches with patients in 2002 and 2003, then received a written warning in 2004. The warnings continued virtually every year for the next 15, for kissing and hugging patients, rubbing their backs and touching their thighs, sitting on their beds, exchanging private phone numbers and linking up on social media, carrying girls to and from their showers and making sexual innuendo. These reports often remained verbal or were sanitised in file notes to management and not followed up. James Griffin didn't just groom kids, wrote a fellow nurse later, he groomed everyone. Griffin also worked as a medic and masseur at the Northern Tasmanian Netball Association and occasionally did shifts as a nurse on the Trans Bass Strait Ferry, the Spirit of Tasmania. In 2009, he was reported to Tasmania Police by an interstate police agency for upskirting young girls, that is, taking sexually intrusive photos without their permission on the ferry. Police searched his house, found hundreds of images of young girls in bathing attire and noted that he cleared his internet search history daily, but there was no evidence of an offence in relation to this report. Ultimately, they didn't pursue the matter and didn't report it further to the hospital, the nursing board or the health department. In 2011, Kylie Pan, a social worker who had recently begun a secondment at the Launceston Hospital, realised that there was a child abuser working in the children's ward. How did she know? She'd been abused by Griffin as a child multiple times, as had friends of hers. Now, 20 years later, she was working on the same floor as him. When her own child had to spend a night on the ward, she was petrified. Pan spoke to her social work manager and together they went to the hospital's HR department. Pan explained Griffin's past offences and pressed upon the HR staff the obvious risk he posed to the children on 4K. She was told that they had looked into Jim, but there was nothing they could do unless there was a criminal conviction. Her allegations were historical, not current. They said Griffin would make too much of a fuss if they moved him because he'd been there for so long. There was no follow-up from the hospital and no records were kept of Pan's disclosure or they were subsequently destroyed. The burden of getting a conviction had been put back on Pan, so she went to the police. After a discussion with a criminal investigative branch officer, Pan concluded that the chance of conviction was low and the price of disclosure too high while she and Griffin were both working at the hospital, she felt abandoned but didn't press charges. What she didn't realise was that no record of her conversation with the officer was kept in any police files either. The police did have an information report from Child Protection Services, later known as Child Safety Service, which had most likely been filed by Pan's social work manager. But the police later advised that because the report didn't contain the names of the victims or identify the person who'd filed it, they couldn't follow it up. They asserted they'd requested further information from Child Protection Services but it wasn't provided on the grounds that the privacy of the notifier must be protected, so they let the matter drop. Neither the hospital, the police, nor the health department notified the nursing board or the Australian Health Practitioner Regulation Agency, APRA, of the risk, despite their professional obligation to do so. In 2013, the mother of a young girl at the Netball Association reported Griffin to the police for inappropriate behaviour and conduct towards her daughter, Tiffany Skeggs, then 15 years old. The woman didn't realise that Griffin had been grooming her daughter since 2008 and abusing her. But was seriously worried about what she'd seen and heard. Griffin had been reprimanded by the Netball Association for privately massaging young girls and was told to keep the treatment room door open in future. The police contacted Child Protection Services who called Tiffany on her mobile phone during school hours to follow up. After school, a Child Protection worker told Tiffany over the phone and in the presence of her mother that the complaint brought by her mother was in relation to her sitting on Griffin's knee during a netball competition. Tiffany was asked if any inappropriate conduct was occurring. She denied the allegation out of fear for the consequences. Child Protection Services told her it was inappropriate to sit on Griffin's knee then reported to the police that her mother had misconstrued the matter. It ceased investigating and took no further steps. This was part of the same overarching department Health and Human Services that had oversight of the hospital. Neither Griffin nor Tiffany were spoken to by police. No reports were made to either the nursing board or APRA. All of this took place in the context of the heated national discussion over institutional responses to child sexual abuse prompted by the Federal Royal Commission that ran for five years from November 2012. Tasmania Police was notified about Griffin's child pornography again in 2015. This time by the Australian Federal Police. Griffin and Tiffany, still a child, were returning from a trip to Gallipoli he had arranged for the two of them. They were stopped at the Melbourne Airport by Australian Border Force officials who searched their belongings and electronic devices. Tiffany later told the Commission of Inquiry that their phones contained sexual images of her from the trip and years earlier. Eventually, the officers quote, came back to us gave us our phones and our bags back and I never heard anything, another word about it. It was like it just never happened, unquote. The AFP had forwarded the evidence but Tasmania Police never investigated further and never notified the hospital, child protection services, the nursing board or APRA. An internal investigation conducted by Tasmania Police in 2020 stated that the package of images and information provided by the AFP was of a high evidentiary value and would have most likely resulted in a conviction. Griffin continued to abuse Tiffany for a further two years at netball venues, at Griffin's home and also regularly in the locked 4K ward of the hospital including in rooms for special patients that required around-the-clock care. Various complaints in relation to her presence at the hospital with Griffin were made by nursing staff to management but these were either not acknowledged or not acted upon. In 2016, Griffin was granted his registration to work with vulnerable people from the recently opened registrar's office. After another set of allegations against Griffin from inside the hospital in 2017 colleagues and a patient reporting him over lewd conversations with young female patients. He was seconded out of the hospital and sent for a stint at, of all places, the already notorious Ashley Youth Detention Centre. The secondment only lasted a few weeks and he was soon back in 4K. One colleague said he seemed even more touchy-feely and brazen upon his return. He was openly taking a lot of painkillers at work for back pain and his paperwork was even more lax than usual. Other colleagues noted inconsistencies in the way he handled various prescribed medicines on the ward, little knowing that he was using hospital-sourced opiates and benzodiazepines in his grooming and abuse of young victims. In 2018, a mother phoned the state government's child safety service not knowing who else to call over the treatment of her daughter in ward 4K. Angela's 11-year-old daughter Lillian not their real names had started acting distressed after being in the hospital overnight in the care of Griffin. One day, Angela told the commission, she turned up to find her daughter who had a disability and was non-verbal but able to communicate. Quote, Quote, She gave her daughter a cuddle and then took her to have a shower only noticing then that she had cream everywhere all over her vagina. It was plastered on there. It wasn't normal. It's not right. Angela said she noticed Lillian had an injury to her vagina and went to alert staff. I was running in and out of the hospital crying because I just could not understand what was going on with her. And the doctors would not listen to me. No one was listening to me. No nurse was telling me what was going on. Who was putting cream on her. Nothing like that. The head nurse told her she could make a complaint. She said she could give me a form to put in and she told me she was going to take complaints but whether or not it happened I have no idea. Angela took Lillian out of the hospital and never went back. Travelling instead to Hobart for her daughter's treatment from then on. No one ever followed up with her. The episode was not reported anywhere. Not internally, to the police or to regulators. From all available evidence Child Safety did nothing to investigate the allegation. It was only in May 2019 when Tiffany, now an adult went to the police that anything changed in this pattern of negligence. She had evidence including photos, dates and times and her case was taken up by police officers who finally treated the accusations against Griffin seriously. Even so it was almost three months before Griffin was pulled off the hospital ward. Police informed the Working with Vulnerable People Registrar of the allegations against him on July 28, 2019. When his registration was suspended three days later and a search of his house was conducted the Launceston General Hospital was advised of the police investigation and that Griffin had possession of child exploitation material. APRA received its one and only notification about Griffin and he was stood down from the hospital. In early September 2019 he was charged with multiple counts of child sexual abuse including sexual intercourse with a minor which was soon upgraded to a more serious charge of what is now referred to as persistent sexual abuse of a young person. Even though staff were expressly forbidden by management from speaking publicly about Griffin words spread quickly throughout the hospital community. Soon four other victim survivors came forward with allegations of abuse at the hands of Griffin and many more were to follow. He was charged again in early October with a raft of further serious charges. Astonishingly Griffin was granted bail after each set of charges and allowed back into the community. This was despite police having evidence from the five complainants across two generations each separately providing strikingly similar accounts of his offending along with corroborating statements from other witnesses. Griffin had also made admissions under caution to some of the offending including repeated instances of sexual penetration of a child complainant. During his second bail hearing the court also heard that Griffin had been continuing to meet with an eight year old girl with whom he had previously shared a bed and he was reportedly seen one evening at a state netball function. Police and prosecutors knew that Griffin had threatened suicide too, several times including in a text message I'll fucking kill myself before I go to prison. But they didn't raise this in the court. On October 18, 2019 Griffin died by suicide after taking a fatal dose of Oxycodone. The other nurses in Ward 4K were deeply distressed. They felt guilt over not having picked up warning signs but also outrage at the thought that hospital management had been covering up Griffin's behaviour for years. HR and hospital management tried to blame the nurses themselves for not doing anything about Griffin's grooming and forbade them from discussing details of the case, even internally. The nurses' calls for an investigation eventually led to the promise of an independent inquiry but they soon realised this was just a whitewashing exercise to be carried out by HR and management, the very people they suspected of ignoring warnings about Griffin in the first place. The hospital had made no effort to inform the victims of Griffin so a group of nurses contacted management offering to help identify children photographed on Griffin's phone. One nursing manager, a long-time friend of Griffin, replied that as the photos had been taken illegally, they couldn't be viewed. Management informed those volunteering to help that the grisly task of identifying victims would be undertaken by two senior managers, neither of whom had worked on the ward floor in 20 years. Griffin's phone was reportedly later destroyed and the hospital has never contacted the majority of Griffin's victims, nor have police or the department responsible for covering up his crimes. In November 2019, a complaint was lodged with Tasmania's Integrity Commission about the actions of senior hospital managers in relation to Griffin. The commission is the state's independent body for dealing with complaints about public sector misconduct and corruption. Yet it promptly referred the complaint to the Secretary of the Health Department. The secretary contacted hospital management, who outsourced the job to HR, which in turn conducted a desktop review with management of what the hospital knew about Griffin. Unsurprisingly, those responsible for minimising or not reporting Griffin's numerous infractions cleared themselves of serious blame. The Integrity Commission eventually found that there was no need for further investigation. Authorities, hospital management and the department were still trying to contain the damage in late 2020 when independent journalist Camille Bianchi released a podcast series, The Nurse, which exposed a whole horrible story to the broader public. The community response was overwhelming. Outrage, disgust, fear. It also led to more people coming forward with allegations against Griffin. Yet still, authorities held firm against further action. The exposure of child sexual abuse in Tasmania might have been limited to a podcast and a few news items about a nurse at Launceston Hospital, were it not for an equally deplorable institutional failure at Ashley Youth Detention Centre, less than 50 kilometres away. This had unfolded for the most part under the same department, formerly Health and Human Services. A statement to the Commission of Inquiry extract about Ashley Youth Detention Centre. I'd stopped regularly attending school. I had no money, no clothes and no food. I was too young to receive money from Centrelink so I started stealing. When I was 14 and a half I was caught stealing a bag of Doritos which I stole because I was hungry. My parents didn't want me and all of the shelters were full. I was too old for foster care. While I had some prior offences, I didn't think I was out of control in any way. They just didn't know what to do with me. As a result, they sent me to Ashley Youth Detention Centre on remand. I stayed there for three months. I was told that they hadn't had a girl in Ashley for about 18 months prior to me going in there and when I arrived I was the only girl. When the boys saw me they were thrilled. I instantly had the boys yelling things out to me and banging on my windows. On one occasion I was left in a room by myself with about 10 other male detainees and no worker supervising. In this time I was sexually assaulted. I shouldn't have been left alone with these boys. The staff had a duty of care to look after me. I'd describe the staff at Ashley as being like a pack of animals. Some of them had been working there for 30 years. They all went to school together. They were all from Deloraine which was a small country town. They all looked after each other. Erin was sent to Ashley four times in total and her experience during subsequent admissions was the same. She was put back into programs with boys who had been involved in her assaults. The guards knew of the risk but would often leave her unattended and the boys knew they could get away with things. Rather than transfer her or seek other solutions that would provide safety, centre managers put Erin on the contraceptive pill. Her complaint to Ombudsman Tasmania a cry for help was referred back to the centre then ignored. I was pretty lucky when it came to physical assaults, she said. I was never physically assaulted by the guards but I witnessed them assault the boys really badly. They'd break arms and legs. I knew what they could do. I knew that they could do this to me so I was neither violent or aggressive. They'd just do more manipulative things to me. The guards would constantly make comments about her body including her breasts. They refused to provide her with a bra. She wasn't even allowed tampons. They told me that the girls had abused the privilege of having tampons in the past so we weren't allowed them. That was it. We were allowed to have pads but we were only allowed to have so many at a time. Sometimes when she was searched there would be two or three male guards conducting the search. They would tell her they were watching for her protection because she was a female. They'd tell me to remove one item of clothing at a time until I was completely naked. Coming out of Ashley, Erin went into a severe downward spiral. She started drinking and using ice, speed, marijuana to cope with her post-traumatic stress disorder, her anxiety and depression. Years later she still struggles to trust males in particular which impacts all of her relationships. I've got really slow self-esteem. It's embarrassing and not something that other people my age can relate to. Constantly being sexualised has really impacted who I am today. Erin's account of her time at Ashley Youth Detention Centre, extreme as it is, was not even unusual among the former detainees who spoke to the commission. The conditions she described, the treatment meted out and the culture of the institution were portrayed in similarly horrific ways by everyone, male or female, who'd been detained there. Recent accounts barely varied from those made in the 1990s and early 2000s. Ashley is Tasmania's only place of youth detention. The government has promised to close it down, but it remains open and conditions are as bad as ever. Children as young as 10 are placed there, mostly on remand for petty crime, meaning they haven't yet faced trial or been found guilty of any charges. Most have been held without having seen a lawyer and come from troubled families or foster care. Across four units, the centre holds up to 51 young people at a time, although the average number is between 10 and 20, with around three males for every female. Aboriginal children are over-represented. Most residents are traumatised and already suffer from developmental disorders, mental health problems and drug or alcohol abuse. Most are also returning. The recidivism rate is around 75% within a year. It's a cohort of children with complex behaviours and needs, who are often a risk to themselves or others and are challenging to manage. They require a trauma-informed and rehabilitation-focused response and are not in any way receiving it. On the contrary, Ashley is where many children are upskilled in crime, as one former Children's Commissioner put it, and introduced to networks of criminals and a life of violence and incarceration that many will never escape. Every single detainee I met in Ashley I now know in Risdon, the adult prison, one witness told the commission. Staff are generally unqualified and ill-equipped. Over the years, most have been drawn from the local Deloraine community, recruited not for skill or experience but through a social or sporting connection. Apart from a few under-resourced counsellors and support workers, staff are uninterested in restorative justice or therapeutic models of care. Many are functionally illiterate and incapable of reading the applicable policies and regulations, let alone making detailed written reports. This is not unusual in Tasmania. The state's adult literacy rate is 50%. The youth workers are essentially prison guards with no training to look after children. A recent advertisement for youth workers at the centre required no qualifications, listing only a preference for people with life skills. Until recently, there was a core of centre managers who had known and worked with each other for years who protected one another and intimidated anyone who stepped out of line. They rarely reported even serious incidents of violence or sexual assault to the department or police and had no hesitation falsifying or destroying incident reports if allegations were made by residents to external parties. The centre has a memorandum of understanding with the local police, once represented by Officer Paul Reynolds, making Ashley the lead agency in investigating and reporting events involving detainees, staff and management within the confines of the centre. This essentially leaves it up to the discretion of the senior staff and at Ashley, many senior staff were abusers themselves. The facility's records, entirely paper-based until 2021, were of a poor standard and the archive of incident reports was maintained by one of the worst alleged sex offenders on site, long after allegations were made against him to the department. Police told the commission they have since sought to improve information sharing processes within the centre and child protection. For decades, there was virtually no practical operational oversight of the centre by any external authority, despite the legal requirement around the mandatory reporting of crimes involving children. Basic human rights were ignored. Former detainees told the commission they were regularly strip-searched, including upon arrival, completely naked in a room with several male guards and often digitally penetrated. One former resident recently alleged that they were routinely photographed while this happened. To this day, residents are regularly locked down 23 hours a day, for days at a time, a practice that fits the United Nations definition of torture. Visits by family are restricted arbitrarily, schooling is badly disrupted, welfare and counselling services are minimal and the conditions are described as being worse than Risdon Prison, near Hobart. Young detainees have been known to request transfer to Risdon instead of Ashley. It's impossible to do justice to the scope and horror of crimes committed at Ashley over the years. Every Ashley witness at the commission spoke of the terrible abuse they suffered and witnessed, and in some cases perpetrated. The commission called it widespread, at times methodical and systematic. Centre management encouraged a hierarchy among the young residents, in which the older and more experienced ones were supported for keeping the younger ones in line. 11 and 12 year olds would be placed in units with the worst offenders, enabling vicious sexual and physical assaults and psychological intimidation. Children were taken on excursions, then sexually abused by staff off-site. More often, it happened on-site. Medication, food and bedding were withheld, solitary confinement closed, and the threat of violence, rape and sexualised strip searches was ever-present. The gradual normalisation of callous brutality among the staff operated to erode normal human reactions, said the commission. The Tasmanian authorities responsible for these children's safety knew this was happening. They knew that staff members had facilitated the abuse, and that some had been abusing children themselves for years. They had records of which staff members were doing it. The government's response over decades amounted to a sophisticated protection scheme for the abusers. In July 2003, ABC TV Stateline featured an interview with a former ward of the state alleging he was sexually abused by a foster parent who had already been convicted of child sex crimes. The ensuing controversy prompted the government to call an inquiry and set up a redress scheme for child victims of abuse in institutional care across Tasmania. It was to be administered by the then Department of Health and Human Services with the Ombudsman's Office. Former victims were invited to lodge claims and, if accepted, compensation was offered. There were four rounds of the abuse in state care scheme and between 2004 and 2014 the state paid out nearly $55 million to almost 2,000 victim survivors from more than 50 state care institutions in amounts capped at $60,000. By far the largest number of claims were from the Ashley Youth Detention Centre or its former incarnation the Ashley Home for Boys. In just the final round of the scheme 2011 to 2013 there were 172 claims from those who had suffered abuse at Ashley. Across all rounds there were likely more than 500. Some data is no longer available. This from a cohort generally fearful of speaking out against authorities, psychologically damaged and often illiterate. Yet what seems a well-meaning attempt at correcting past wrongs looks, in retrospect, more like the locus of a statewide cover-up. When the then Acting Secretary of DHHS Michael Pervan signed off on the scheme's final report in 2014, he may have thought he'd seen the last of these claims. Victims, often without legal representation, signed documents waiving their rights to future civil claims. And the Department held legal advice from the State's Office of the Solicitor General advising that information contained in the claims, details of perpetrators, dates and places, couldn't be used as evidence in criminal proceedings. The files weren't even cross-checked with the list of current employees. These testimonies should have alerted the Department, Police and Child Protection Services to alleged abusers still employed at Ashley. Staff who'd remained there offending for years to come despite the serious allegations against them, including multiple counts of rape, which the Government had accepted as true. It had paid out on them. Facing the Commission of Inquiry in August 2022, Pavan confirmed that he'd been advised as DHHS Secretary that the only way to achieve a successful disciplinary outcome or criminal prosecution in relation to the Centre's staff would be to have sworn statements that proved an allegation beyond a reasonable doubt. The information had been collected as part of the redress scheme for a particular purpose, healing, acknowledgement, compensating victims, and not in sworn statements. So, on the grounds of procedural fairness, went the argument, it couldn't be used for any other purpose. Furthermore, the privacy of those accused must be protected. The details of these allegations were not to be exposed to anyone. Mystifyingly, this included other Government agencies until or unless they were subsequently proven. This was interpreted as meaning in a court of law. It didn't matter, apparently, that few of the complainants had been told to follow up their allegations with the police or been encouraged to testify in disciplinary actions against the accused. The files were simply filed away. A different set of victim-survivors' abuse claims, handed to the State Government under the National Redress Scheme by the Federal Government from 2018, was treated the same way. Cases submitted, then closed by the thousand. For a while, anyway. The DHHS did make occasional limp efforts to change the culture at Ashley, but these mostly consisted of commissioning reviews and reports 17 of them since 2003 and then ignoring them. It would periodically embark on change management processes at Ashley, such as the review promised in 2016 of staffing and leadership structures, staff capability, safety, risk management, training requirements, trauma-informed care models and culture. But these amounted to little. The Department of Communities, established in July 2018 with Michael Pavan as Secretary, took over the administration of children and youth services, including Ashley. But the most significant change regarding the Centre in these years was the arrival in 2019 of a new clinical practice consultant, Alicia, surname withheld. She was hired by the Department ostensibly to introduce a more therapeutic model of care for residents, but her biggest impact would be as a whistleblower, exposing the wider community to the internal horrors of the Centre. The mainlanders' arrival into this insular world brought a shock that would reverberate eventually to then Premier Peter Gutwin's announcement of the Tasmanian Government's responses to the Commission of Inquiry into the child sexual abuse in institutional settings, which was established in March 2021. Alicia wasn't the only person drawing attention to problems at Ashley, but the State had managed, mostly, to suppress uncomfortable truths. Ashley management kept the majority of issues from leaving the walls of the Centre. New staff, external counsellors and government appointees such as the Commissioner for Children and Young People, occasionally filed complaints or incident reports with the Department but these were rarely acted upon. Disciplinary action against staff was almost never pursued unless there was corroborating evidence given under oath by fellow staffers or residents, an opportunity they either weren't offered or weren't brave or foolhardy enough to provide. Department staff, including senior management, believed disciplinary actions were matters for the head of the Department, the Secretary, and the Secretary Pavan believed he was bound by advice from the Solicitor General, barring exceptional circumstances that effectively prevented disciplinary action in the absence of sworn statements or criminal charges. Pavan told the Commission that his hands were tied. In late 2017, the Government had established the Serious Events Review Team, SERT, a permanent task force to review deaths and serious injuries across child and youth services. Its story symbolises the Government's tokenistic attempts to fix its own failings and its common response when anyone threatens to expose its dirty laundry. Veronica Burton's role as a SERT reviewer was to investigate serious incidents, and several of her reviews involved Ashley. Her task was to look at every factor that might have caused or exacerbated an incident, analysing and understanding why it occurred and making findings about its causes. Then advise what policies, practices and training to put in place to avoid similar incidents from reoccurring. Burton's investigations were fraught, to say the least. As she later described to the Commission, the accuracy of the reports was an issue, just whether or not the records were there or not. Often they weren't. They were missing, or they couldn't be found when I requested them. Sometimes they'd been altered. She was generally denied the opportunity to speak to the detainees whose case she was investigating. Managers would try to dictate what findings she would make, while junior staff would take the rare opportunity to speak to an independent observer by quietly unloading on their senior colleagues, describing bullying, intimidation and physical violence. Even so, Burton managed to file detailed reports. As Alicia also found out, though, trying to get the Department of Communities to understand the issues at Ashley was, as Burton put it, like banging my head against a brick wall. I felt like no one wanted to hear about the issues or do anything about them. I was identifying similar or identical issues every time, making the same findings, making the same recommendations, and sending them to where they were supposed to go for action, and then nothing would change. And then I would go back, and they'd do the same issues, and I really did just feel like management, my management, the executive management of Child and Youth Services, were just not interested, or not able. I don't know, I never got any feedback. In mid-2020, without warning, CERT was shut down. Burton and other staff were given no explanation for the decision, although the timing corresponded with the increasingly urgent memos Burton sent to her manager about Ashley. She believed CERT was dissolved because department managers wanted to stop identifying failures around the protection of children. While she was out of the office on leave, all of my files and reports in relation to Ashley Youth Detention Centre went missing, all of my hard copies that I was filing in my office. And with CERT shut down, so too did the electronic versions. The evidence she gathered of crimes committed, including eyewitness statements and CCTV footage, and of reports altered and requests ignored, had all disappeared. It shouldn't rest on individual staff members or freelance podcasters to draw attention to the comprehensive failures of police, regulators, government departments and oversight bodies, especially in cases of mass child abuse. Yet it's difficult to pin the blame on any particular individuals or organisations when so many failed and so many were complicit. Where do you start? Where does responsibility ultimately lie? The only reasonable conclusion is that these failures are the result of systems built by the state to protect itself. The mechanisms that would ordinarily ensure transparency and integrity or protect citizens did the opposite. They were built to fail. Sometimes this was due to a lack of funding and resources. More insidiously, it was due to legal and structural features that inhibit proper functioning. A case in point is a registration to work with vulnerable people scheme established in Tasmania as a result of a recommendation from the National Royal Commission. The registrar is responsible for screening and monitoring those who engage with vulnerable people including children and is supposed to undertake risk assessments on the basis of information reported to it by Tasmania Police and State Service agencies. From its inception in 2015 until late 2020 the registrar received just a single report relating to staff at Ashley Youth Detention Centre. As outlined many staff at Ashley were the subject of multiple allegations of abuse of children both historical and contemporary but reports haven't been made to the registrar on the grounds of fair process. Again, the department claims it was acting on advice from the Office of the Solicitor General. If an allegation of serious sexual assault was made against a staff member the Working with Vulnerable People registrar wouldn't receive a report until after an investigation was completed by the department if that ever happened and only if the department secretary reached a verdict of guilt beyond reasonable doubt. This was the same registrar's office that had okayed Nurse James Griffin in 2016 and didn't receive any reports about him until he was formally discharged in 2019 18 years after he was first reported to police. In December 2020 as a result of the growing furor around Ashley a change in the government's interpretation of what constituted reportable employee conduct led to the release of relevant historical records. The Working with Vulnerable People registrar was inundated with more than 300 reports of allegations in relation to 69 current and former Ashley staff. In time partly as a result of these notifications the entire management team would either resign or be stood down. The Tasmanian Integrity Commission and the Ombudsman's Office are also nominally responsible for ensuring the proper operations of the public sector. They are so ineffectual it's laughable. The Integrity Commission tasked with preventing and investigating misconduct in the public sector has the worst record of any state integrity body in the country. In its 14 years of operations it has never held a public hearing and has only ever made adverse findings against two public servants. It completes less than 10% of the number of investigations done by mainland integrity bodies. In 2018, then Greens leader Cassie O'Connor criticised the government over the Integrity Commission's poor design and lack of funding. The fact that it is having to refer complaints back to the department that the complaint is made about will send a shudder down the spine of public servants she said, and nothing has changed since. An independent review of the Integrity Commission was set up in 2016, but at the time of writing only six of its 55 recommendations have been implemented. Tasmania's Ombudsman Richard Connick is also simultaneously its Health Complaints Commissioner, Custodial Inspector and Energy Ombudsman. He's in charge of the state's official visitor programs and adjudicates on complaints about the right to information office. As if that weren't enough, Connick was last year also appointed to fulfil Tasmania's obligations pursuant to the OPCAT Implementation Act 2021, following Australia's ratification of the UN's optional protocol to the Convention Against Torture and Other Cruel, Inhumane and Degrading Treatment or Punishment. The effect of this awesome load of responsibilities, combined with the level of underfunding that was noted by the Ombudsman himself in seven consecutive annual reports, is a lack of capacity to investigate and resolve many complaints at all. Connick's key observation in relation to Ashley, for example, in the 2020-21 Custodial Inspection Report was simply this, I hold few concerns about the operations of Ashley Youth Detention Centre and if I do have any queries these are resolved promptly through liaisons between my office and the Director, Youth and Family Services or the Centre Manager. He later admitted to the Commission of Inquiry that in the absence of a culture of reporting amongst Ashley's staff, his capacity to oversee the conditions in the Centre was largely reliant on information and complaints provided by the children themselves. The system was entirely dependent, noted Council Assisting Rachel Elliard, on this cohort of very traumatised and troubled residents asserting themselves while being under the control of the very people they might complain about. Unsurprisingly, the Custodial Inspector's Office receives only a small number of complaints from detainees each year and doesn't have the capacity to investigate individual complaints which are passed on to the Ombudsman, adding to Connock's overloaded responsibilities. In his role of Health Complaints Commissioner, Connock observed to the Commission that his office had not received any complaints at all in relation to child sexual abuse in Tasmanian institutional settings, nor conducted any investigations. There had been no referrals from the Health Department and his office did not monitor systemic risks in relation to child sexual abuse for children and young people in health contexts. There had been one inquiry from a member of the public however. We did receive one inquiry which related to allegations of child sexual abuse at Launceston General Hospital involving Mr James Griffin. The mother of a child contacted the office by telephone in October 2020 to complain about the lack of action on a complaint she had submitted to the LGH in approximately 2018. The mother was concerned about the lack of follow-up from the LGH of her complaints about a nurse's behaviour with her daughter at the hospital in 2018. She advised that it had been confirmed that the person she complained about is a pedophile. The mother was referred back to the hospital. The matter was not pursued by the Health Complaints Commissioner because the government that month announced an independent investigation into the LGH relating to Mr Griffin. This was conducted, as we know, by the hospital's own management. Sitting quietly among the mess of compromised Tasmanian government departments and authorities is one small office that has even more to answer for. It is a little known and poorly understood fact that in Tasmania, every government agency, every department, every statutory authority must get its legal advice from the state's unelected office of the Solicitor General, the OSG. The Solicitor General is required to act as counsel for the Crown and government must accept legal advice provided by the Solicitor General's office as accurately stating the law. This is justified on the grounds of financial management and accountability for public funds but its effects go well beyond the financial. Where there's uncertainty about any legal matter, government bodies are bound to seek and accept the OSG's advice about the legal powers, functions and responsibilities of the Crown or the lawfulness of any action or proposed action. This applies not only to every single department including the Department of Premier and Cabinet but also the Ombudsman's Office, the Environment Protection Authority, the Audit Office, the Director of Public Prosecutions, even Tourism Tasmania. Most startlingly, this directive also applies to the Integrity Commission meaning the body whose sole task is to prevent and investigate public sector misconduct must get its legal advice from the government it's overseeing. Our role is independent of state and local government and operates outside the control of ministers or government departments the Integrity Commission states but plainly it isn't. Some long-time observers of Tasmanian politics believe the OSG to be more powerful than any elected political office including that of the Attorney-General to which it reports and that of the Premier. The relationship between the OSG and the rest of the government is not a traditional lawyer-client one. In this case the client must accept the OSG's advice and there's no recusing in cases of conflict of interest. In summing up this relationship as it pertains to the Commission of Inquiry the counsel assisting asserted that the office of the Solicitor-General both advises and decides on the conduct of civil litigation involving child sex abuse matters including the amount of compensation that might be paid despite what might be the contrary views of a secretary or department head. Even though the office both advises and decides it appears from the evidence that it only considers legal and financial considerations and not other matters like the state's reputation or values, morality the public interest. In one notorious case the OSG advised the Education Department to defend the litigation claim in court by arguing based on a judge's previous outrageous ruling that a child who'd been abused by her teacher had consented to it. The Attorney-General recently forbade the OSG from running such a defence in the future. It was the OSG that advised departments they weren't able to remove or discipline abusive staff without sworn evidence establishing criminal action beyond reasonable doubt. It was the OSG that conducted heavy-handed adversarial negotiations with victim survivors re-traumatising those who'd been abused in institutional care in an effort to mitigate or discourage their claims. The OSG also took control of workers' compensation cases involving whistleblowers such as Alicia, who suffered reprisals and workplace harassment for performing her legal duties. Alicia was a key witness to the commission, yet the OSG conducted what can only be described as lawfare over three years to intimidate and punish her for whistleblowing. She was forced to sit excessive and unnecessary psychiatric evaluations to prove she deserved workers' compensation and pressured unsuccessfully to surrender critical evidence and sign non-disclosure agreements while her own reports and complaints, later substantiated and corroborated by the commission, were ignored and dismissed. The campaign sent her close to financial, physical and psychological ruin. It was the OSG that dictated which notifications could or couldn't be sent to bodies such as the Working with Vulnerable People Registrar or APRA and what information should be provided by departments in civil litigation suits or indeed what information about abuse allegations in public institutions should be made public at all. It advised departments, too, that state employees could only face disciplinary action for misconduct that occurred in the course of employment, which was interpreted as meaning for example, only abuse that occurred at the school where an abusive teacher worked or the actual hospital where James Griffin was employed. Disciplinary investigations were not to consider previous allegations, either. In general, the OSG's advice favoured the rights of alleged perpetrators over the safety of children was not trauma-informed and set the threshold for further investigation or disciplinary action far too high. Counsel assisting Rachel Elliard sought to highlight the problem of OSG autonomy by raising the case of a child abuse claim in which the OSG was both advising the department and deciding the outcome where the victim was also a ward of the state. Who, in this case, was the OSG representing? Didn't it represent a conflict if the office is pleading for the state and the plaintiff? No, I don't think it does, replied then Assistant Solicitor General Paul Turner. In his mind, it was just a matter of balancing the state's various interests. You've got to remember, he said, we are the state. We're all in this as one thing. I know it sounds, or it seems to sound, a little difficult for you to understand, but you're in a different milieu. The Tasmanian government avoids accountability in many and varied ways. It constantly restructures departments without notice or explanation and regularly shifts senior executives when the political heat rises. The ministerial cabinet has been subject to five major reshuffles in the past three years so ministers can rarely be held accountable for any portfolio. It's easy to understand in this context why victim survivors and their communities bear bone-weary cynicism and disillusionment about the possibility of real reform and redress. The whole system is rotten. But the decades of cover-ups have also birthed an alternative economy of community explanations for the unexpurgated evil in their midst. A constant undercurrent of fearful whispers and factoids, often based on true reports that appear in the local papers one day but are gone the next. Or episodes from the past that were never properly exposed. They are pieces from an irresolvable puzzle and may or may not be relevant to any specific crimes but sure look strange in the light of everything else. A former police minister resigned in haste after being accused of child sex offences. His son was later imprisoned over child exploitation materials. A current government MP was a family friend of nurse James Griffin. The Launceston Mayor had his working with children registration revoked. Two key witnesses to the commission of inquiry were viciously physically attacked after testifying and others were threatened. The missing CERC documents including CCTV footage and other evidence of crimes were found in a department manager's garage. A man who defamed now Deputy Premier Michael Ferguson and was subsequently sent to prison for contempt disappeared the day before the closing session of the commission. When he turned up again he was taken to hospital but no details were available. The government announced an independent review into allegations involving former police officer Paul Reynolds but limited the terms of reference so it couldn't compel evidence from other cops. Nevertheless there are likely to be hundreds of allegations against him. Several serious offenders from Ashley Youth Detention Centre including alleged serial rapists are still on the government payroll and still working around children. There was another alleged pedophile nurse at Launceston hospital for two decades and he's now facing charges. It just goes on and on. The commission of inquiry was a shining light. Established amid a groundswell of public concern called by a Premier who had himself suffered sexual abuse as a child and run by three eminent and highly respected commissioners, its task was immense. It examined Launceston General Hospital and Ashley Youth Detention Centre as well as public schools and children's out of home care digging into events dating back to 2000 as well as exploring the witnesses in systems, organisations and facilities. It interviewed witnesses by the hundred and examined documents by the thousand and in August last year the commission produced its magisterial 3000 page final report making 75 findings and 191 recommendations. It also referred more than 100 people to police and child protection authorities. Given that the departments under inquiry employ around 25,000 people, this is one in every 250 employees. At the commission's closing address in Hobart, tissues were handed out to attendees in advance. Commissioners dabbed their own tears as they read their conclusions. As witnesses and victim survivors clutched on to one another, their bodies shuddering with grief and relief. And Premier Jeremy Rockleff and then Attorney General Elise Archer sat looking ashen up the back. Rockleff sacked Archer a month later amid bullying allegations and a leaked WhatsApp message of hers saying she was quote sick of victim survivors. The commission reported massive failures across the government. While we saw pockets of good practice, this was often a result of the initiative and good judgement of individuals rather than something encouraged and enforced by a broader system. More commonly, institutions did not recognise child sexual abuse for what it was and failed to act decisively to manage risks and investigate complaints. While encouraged by the increasing understanding of the nature and harm of child sexual abuse and noting that some safeguards and improvements had already been implemented, the commission found that the government still doesn't have the right systems in place to address the threat of abuse in institutions and doesn't have a culture that encourages feedback, reporting, monitoring and reflection when responding to incidents of abuse. The final report singled out youth justice and out of home care as requiring the most immediate reform and again called for Ashley Youth Detention Centre to be shut down as a matter of urgency. In his initial response in Parliament, Rockleff expressed due contrition and sorrow and committed to implement all 191 recommendations but he refused to put a date on the closure of Ashley and spent the next two days of question time defending his government's continuing failures. It only became obvious when the final report was released to the public after the commission's work was complete that the government had rigged the game all along. The commission, despite its sterling work examining events across the state over 20 years, made only a single finding of misconduct. One. This was levelled at the former Executive Director of Medical Services at Launceston General Hospital, Dr Peter Renshaw and even this was merely for misleading the commission. There was a handful of negative findings against him and other hospital staff in relation to James Griffin but there was none against any individuals at Ashley Youth Detention Centre. The legislation governing the commission of inquiry had always been understood to be somewhat restrictive but few had realised just how much protection it would afford those who enabled and covered up thousands of crimes against children over two decades. It's still unclear how, if at all, the commission's work will lead to justice for the victim survivors or the perpetrators. Sure, the commission made more than 100 referrals but for what crimes, against which victims, from which institutions, under which departments? So far, further details have been kept from the public. Will these referrals be treated with the same negligence as previous accusations against state servants? All commissions of inquiry and royal commissions are inquisitorial rather than prosecutorial in nature and governed by special laws that reflect this. These pertain to the gathering and use of evidence, requirements for procedural fairness when making findings and so on. The Tasmanian Commissions of Inquiry Act 1995 however, takes them to extremes. It reads like the paperwork for organised criminal negligence. Before making a finding of misconduct, a commission must give a person 10 days notice of this finding and provide them with an opportunity to respond. In response, the person may make submissions, give their own evidence, cross examine the person making the allegation and call witnesses. They also have a right to be represented by legal counsel. As the commissioners of the recent inquiry stated in their final report, this effectively hands controls of commission proceedings over to the accused. Even a lesser adverse finding comes with onerous procedural fairness obligations for the commission and the state argued that these were tantamount to misconduct findings anyway as they carried the same potential disciplinary threat for employees. In this case, the commission simply didn't have the time or resources to manage such processes, hence the extreme reluctance to issue such findings. The commission indicated it believed misconduct findings should be made against 22 people but these findings were not ultimately made apart from that against Peter Renshaw. Misconduct was defined as actions that could reasonably be considered to result in a criminal charge, civil liability, disciplinary proceedings or other legal proceedings. This isn't the worst of it. Public servants called before the commission were given the opportunity by the government to apply for an indemnity or legal assistance on the condition they provide the government with all documentation and information relevant to the commission. But here's the kicker. According to the Act evidence given by a person before a commission is not admissible in subsequent legal proceedings. So the state supported lawyers representing many mostly senior public servants could not only gather all relevant evidence but also had advance warning about whether adverse findings may be in the pipeline and most importantly had the capacity to render this relevant evidence inadmissible in any subsequent legal proceedings whether civil or criminal simply by giving it to the commission. What's more, the Act states that an employer must not dismiss or prejudice an employee on account of them having given evidence before a commission or any evidence given by them. So many hands tied. Any disciplinary, civil or criminal action relying on discoveries made during the commission would need to be reinvestigated entirely and even then OSG lawyers have been arguing in recent months if evidence came to light because of the commission's inquiries it remains inadmissible. This also applies to a current class action, Tasmania's first ever class action in which more than 150 former residents of Ashley are suing the government for serious injuries suffered due to systemic negligence. As stated in the commission's final report, as far as we're aware, none of the staff who we examine in our case examples have been charged with any child sexual abuse offences. Last September a 14 year old boy was released from Ashley. He'd been remanded there on petty crime charges without seeing a lawyer. Inside he'd been assaulted by several guards. He'd tried to commit suicide twice. Instead of being allowed to see a nurse he was put in solitary confinement. Management didn't even tell his parents. At the time of writing, Dr Peter Renshaw is still a registered medical practitioner and APRA reported no conditions, no undertakings and no reprimands on his record. The Department of Premier and Cabinet, when asked directly, is unable to cite a single instance since October 2020 in which an employee has been dismissed from the public service as a result of child sexual abuse or related cover-ups. More than 70 state servants have been suspended on full pay pending departmental investigation for almost a year on average and in some cases several years as a result of allegations of child sexual abuse. Five months after the end of the commission of inquiry late last December, the police minister Felix Ellis reported to a parliamentary committee that of the 43 criminal referrals by the commission to Tasmania Police, just one remained under investigation. Only a single alleged perpetrator had been brought to court and this case had already been under investigation prior to the commission's referral. Every other case had already been dismissed. There is a bizarre final twist to the commission of inquiry tale. It isn't so much a case of the commission having the last laugh, more a mirthless chuckle. Its governing legislation, parts of which were amended after the commission had been appointed, had prevented the commissioners from making the findings they wished to make. So the commissioners instead quietly seeded into their reports footnotes references to those who had replied to their notification of a possible adverse finding or one of misconduct with a procedural fairness response. The list of individuals who provided such a response includes the Solicitor General, Ombudsman, Chief Executive of the Integrity Commission, Commissioner for Children and Young People, Current and Former Managers of Ashley Youth Detention Centre and Current and Former Executives of the Departments of Communities, Education and Health. The list of entities that received notice of a possible adverse finding includes Tasmania Police, the Departments of Health and Education, Children and Young People, the Teachers Registration Board, the Office of the Solicitor General, the Office of the Director of Public Prosecutions and the State of Tasmania. It is hard to conceive of a more devastating indictment of a government or a more catastrophic complete failure. There was complicity and negligence at every level, across departments and authorities. The victims are in the thousands and their number is growing. The responsibility for fixing these problems resides with the Tasmanian Government and if it is unwilling or incapable of it, these are problems of national significance. They demand national attention.