1. Introduction

This Commission of Inquiry was prompted by a groundswell of community concern in 2019–20 over child sexual abuse in Tasmanian Government institutions. It followed media reporting of incidents of abuse and inadequacies in the Government’s response to these incidents. While the Government’s initial response to these concerns characterised these matters as ‘historical’, others in the community and media questioned the extent to which failures to keep Tasmanian children safe were indeed in the past.1

On 31 July 2019, Tasmania Police searched the home of paediatric nurse James Griffin. The search revealed large quantities of child exploitation material. Later that day, Mr Griffin was stood down as an employee of the Launceston General Hospital. In October 2019, Tasmania Police arrested Mr Griffin and charged him with numerous sexual offences relating to children, before releasing him on bail. Soon afterwards, Mr Griffin took his own life.2 These events, and the rumours that circulated about them, caused great concern among the staff of the hospital and the Tasmanian community.

In 2020, the media began reporting allegations of child sexual abuse perpetrated by Tasmanian State Service employees, including teachers and health staff.3 The media also reported an impending class action against the State of Tasmania, led by people who had ‘suffered serious injuries’, including sexual abuse, as children while detained in Ashley Youth Detention Centre.4 These reports prompted others to come forward with information about current and past child sexual abuse in a range of Tasmanian Government institutions. Some accounts expressed that formal avenues to report and seek redress for child sexual abuse were unavailable or ineffective.5 One victim-survivor referred to attempts to report abuse that had ‘fallen on deaf ears or [been] swept under the carpet’.6

These reports and civil claims raised concerns that child sexual abuse had not been properly addressed in Tasmania after previous inquiries and reviews, and that it was not isolated to a single institution or a small number of people. The Honourable Peter Gutwein, the then Premier of Tasmania, noted ‘significant community concern and public angst quite rightly—over recent matters that have come to light where historically children have not been safe in our Government institutions’.7 In particular, government institutions’ responses to reports of child sexual abuse perpetrated by Mr Griffin, and others, were subject to significant media scrutiny, which included a podcast, The Nurse. As of May 2022, episodes of The Nurse had been downloaded about 1.3 million times.8

The Tasmanian Government instigated two independent reviews into child sexual abuse in the education and health systems, and an investigation into the conduct of three employees at Ashley Youth Detention Centre.9 However, as acknowledged by the then Premier, it was clear that despite establishing these reviews and other government actions more needed to be done to protect children.10

On 23 November 2020, Premier Gutwein announced that he intended to recommend to Her Excellency Professor the Honourable Kate Warner AC, the then Governor of Tasmania, that she ‘establish a Commission of Inquiry under the Commissions of Inquiry Act 1995 (‘Commissions of Inquiry Act’) to investigate the responses of Tasmanian Government Agencies in relation to the management of historical allegations of child sexual abuse’.11 In making this announcement, Premier Gutwein acknowledged that despite the Government’s efforts:

… as the number of allegations coming to light continues to grow, we must take every step necessary to ensure we identify any systemic gaps and put in place measures to fill them.

This situation is nothing short of terrible and we must take further action. I believe one of our greatest responsibilities is to learn from the past, and commit to not repeating its mistakes.12

In the announcement, the Premier stated that ‘as more claims for redress are progressed there will be more shocking examples come to light’.13 The Premier referred to five current State Service employees who had been suspended from work due to claims of child sexual abuse, one of whom was stood down pending the outcome of criminal proceedings.14 A media report in February 2021 suggested that another 14 current State Service employees had been stood down since the Premier’s announcement.15

By February 2023, the number of state servants in child-facing departments suspended by the Government since January 2000 had risen to 92.16 Some 38 of those state servants were suspended following the announcement of our Commission of Inquiry in November 2020.17

The Commission of Inquiry into the Tasmanian Government’s Responses to Child Sexual Abuse in Institutional Settings was established by Order of the Governor on 15 March 2021.18

A year after beginning our Inquiry, a personal element in the Premier’s announcement of our Commission of Inquiry became apparent. At a media conference in March 2022, Premier Gutwein stated that he is a victim-survivor of child sexual abuse perpetrated by a teacher.19 He said: ‘I’m the first Premier of this state that has taken the steps to have a Commission of Inquiry. The reason that I’ve done that is that I have great empathy, because I have walked in their shoes’.20 He further stated: ‘I know what the loss of trust feels like; I know what the shame feels like’.21

In 2003, Mr Gutwein, a Liberal Member of Parliament, had crossed the floor of Parliament to vote with the Tasmanian Greens in support of establishing a commission of inquiry into child abuse. The then Labor Government and the Liberal opposition opposed the motion. Because he crossed the floor, Mr Gutwein lost the shadow treasury, education and employment portfolios. At the time, he stated: ‘If we don’t have the courage of our own convictions, how can we expect those people out there that have been abused, that are aware of abuse, to come forward?’22

On 8 April 2022, Premier Gutwein resigned as Premier and a Member of Parliament. We commend Mr Gutwein for his bravery in supporting victim-survivors of child sexual abuse and their families, and for sharing his own story of abuse.

1. Establishment and scope

When our Commission of Inquiry was established on 15 March 2021, the Governor appointed the Honourable Marcia Neave AO, Professor Leah Bromfield and the Honourable Robert Benjamin AM SC as members of our Commission of Inquiry, with Commissioner Neave appointed as President. Commissioners Bromfield and Benjamin were born in Tasmania.

The Order of the Governor required and authorised the Commissioners ‘to inquire into the Tasmanian Government’s responses to allegations and incidents of child sexual abuse in institutional contexts’.23 The Order specified areas for inquiry that form our Inquiry’s terms of reference, which are outlined below.

The Order directed our Commission of Inquiry to make any recommendations arising from our Inquiry that we considered appropriate, including about any policy, legislative, administrative or structural reforms.24

We held an opening hearing in Hobart on 26 October 2021. We were required to report by 31 August 2022, and hearings were planned to restart in early 2022. However, after considering advice from the Tasmanian Government on the potential impact of community transmission of COVID-19 in early 2022, we decided to restart hearings in May 2022. Due to the postponement of hearings, and other factors outside our control, we sought an extension to the original reporting deadline. In February 2022, the Tasmanian Government granted an extension to 1 May 2023.25

In early 2023, our Commission of Inquiry asked for another extension because of the complexity of information provided to us, our commitment to appropriately and thoroughly address all the issues raised with us, and the need to discharge our procedural fairness obligations under the Commissions of Inquiry Act. In April 2023, the Tasmanian Government granted an extension to 31 August 2023.

We delivered our final report, comprising 8 volumes and 191 recommendations, to the Governor of Tasmania on 31 August 2023.

1. Terms of reference

The Order of the Governor asked us to inquire into what the Tasmanian Government should do to:

• better protect children against child sexual abuse in institutional contexts in the future
• achieve best practice in the reporting of, and responding to, reports or information about allegations, incidents or risks of child sexual abuse in institutional contexts
• eliminate or reduce problems that currently prevent appropriate responses to child sexual abuse in institutional contexts, including addressing failures in, and barriers to, reporting, investigation and responding to allegations and incidents of abuse
• address or alleviate the impact of past and future child sexual abuse in institutional contexts, including, in particular, in ensuring justice for victim-survivors through processes for referrals for investigation and prosecution and support services.26

As part of our Inquiry, we were also required to consider:

• the experiences of people affected by child sexual abuse in institutional contexts, and provide opportunities for them to share their experiences
• the adequacy and appropriateness of the Tasmanian Government’s responses to allegations and incidents of child sexual abuse in institutional contexts generally, and in particular, by:
  • the Department of Education to allegations of child sexual abuse in government schools
  • the Tasmanian Health Service and the Department of Health to allegations of child sexual abuse, particularly in the matter of James Griffin
  • the Department of Communities to allegations of child sexual abuse at Ashley Youth Detention Centre
• systemic issues, recognising that individual cases may need to be referred to appropriate authorities
• changes to laws, policies, practices and systems that have improved the ability of government institutions to better protect against and respond to child sexual abuse in institutional contexts.27

We did not have to inquire into matters that had been appropriately dealt with by the Royal Commission into Institutional Responses to Child Sexual Abuse (‘National Royal Commission’) or by another inquiry, investigation or court proceeding.28

1. Refinement of scope

With our terms of reference in mind, we clarified and refined the scope of inquiry to:

• accommodate key areas of concern in Tasmania
• ensure we prioritised areas that had not been addressed previously.

1. Child sexual abuse

The Order of the Governor adopted the victim-centred and legally based definition of child sexual abuse that the National Royal Commission used:

1. Any act which exposes a child to, or involves a child in, sexual processes beyond his or her understanding or contrary to accepted community standards. Sexually abusive behaviours can include the [touching] of genitals, masturbation, oral sex, vaginal or anal penetration by a penis, finger or any other object, [touching] of breasts, voyeurism, exhibitionism, and exposing the child to or involving the child in pornography. It includes child grooming, which refers to actions deliberately undertaken with the aim of befriending and establishing an emotional connection with a child, to lower the child’s inhibitions in preparation for sexual activity with the child; and
2. Any related matters.29

The National Royal Commission also considered the ‘production, consumption, dissemination and exchange of child sexual exploitation material’ to be child sexual abuse.30 While the Order of the Governor did not refer to child exploitation material in its definition, the definition captures such material.

The definition of child sexual abuse also includes sexual abuse by other children or ‘harmful sexual behaviours’. We use this term to refer to the:

… sexual behaviours displayed by children and young people that fall outside what may be considered developmentally, socially, and culturally expected, may cause harm to themselves or others, and occur either face to face and/or via technology. When these behaviours involve another child or young person, they may include a lack of consent, reciprocity, mutuality, and involve the use of coercion, force, or a misuse of power.31

While our examinations focused on child sexual abuse, we recognise that other forms of abuse can contribute to an institutionalised culture that treats violence, bullying and harassment as normal, and that sexual abuse can co-occur with other types of abuse and neglect. Such behaviour can create a risk of child sexual abuse and discourage it from being reported by the child or other people in the institution.32 Therefore, we examined other forms of abuse if there was a link between that abuse and child sexual abuse occurring in institutional contexts.

We consider the definition, nature and impact of child sexual abuse in an institutional context in detail in Chapter 3.

1. Institutional contexts

The terms of reference directed us to examine child sexual abuse in ‘institutional contexts’. According to the Order of the Governor, child sexual abuse happens in an institutional context if, for example:

1. it happens on premises of a government or non-government institution, where activities of the institution take place, or in connection with the activities of the institution; or
2. it is engaged in by an official of a government or non-government institution in circumstances (including circumstances involving settings not directly controlled by the institution) where … the institution has, or its activities have, created, facilitated, increased, concealed or in any way contributed to, (whether by act or omission) the risk of child sexual abuse or the circumstances or conditions giving rise to that risk; or
3. it happens in any other circumstances where … a government or non-government institution is, or should be treated as being, responsible for adults having contact with children.33

For government institutions, we focused on what was then the Department of Education, the Tasmanian Health Service and Department of Health, and the Department of Communities, particularly in relation to Ashley Youth Detention Centre and out of home care. The Order identified public schools, health services and youth detention for particular attention because those institutions provide significant direct services to children. As noted above, there had also been significant media coverage of child sexual abuse in those institutions, and separate inquiries had been announced for each of those institutions. We decided to include a focus on out of home care because the National Royal Commission identified that children in this institutional context are at an increased risk of child sexual abuse.34 Our case studies in Volumes 3–6 examine child sexual abuse occurring in these institutions.

The Order of the Governor defined a non-government institution as one ‘that undertakes, or has undertaken, activities on behalf of the Tasmanian Government to provide services for children’.35 Based on this definition, we focused on non-government institutions that:

• undertake activities on behalf of the Tasmanian Government and provide services for children, or
• are funded by the Tasmanian Government to provide services for children.

We concluded that non-government institutions must meet the following three criteria to be in the scope of our Inquiry:

• The activities undertaken represent an outsourcing of traditional public functions and so there is a contract for services rather than a grant funding arrangement.
• The Tasmanian Government is the principal funder of the organisation or the amount of funding is substantial.
• The public could reasonably assume that the Tasmanian Government is responsible, directly or indirectly, for the services provided.

Applying these criteria, we focused mostly on non-government institutions that are contracted and funded by the Tasmanian Government to provide out of home care services.

We did not examine child sexual abuse in private or community institutions (churches, non-government schools, sporting organisations, local clubs) unless such institutions were solely funded by the Tasmanian Government to provide services for children.36 We did not follow up or inquire into areas such as the involvement that abusers might have had with such institutions. We considered that these associations were outside our terms of reference. We have not conducted a thorough inquiry into allegations of abuse by police officers, ambulance officers or in connection with councils. Given the volume of material raised about the institutions identified in our terms of reference or, in the case of out of home care prioritised by us, we did not have the capacity to fully inquire into these other government institutions. We took this decision to use the time and resources available to our Inquiry most effectively. The State did not make this suggestion, nor did we request extra time or resources from the State to expand our terms of reference for this purpose.

We heard a small number of significant concerns about child sexual abuse in these other institutional contexts, though not to the same extent as allegations of abuse in the education, health, youth justice and out of home care systems. While we did not investigate these other institutional contexts in detail, many of our recommendations apply to them. We ask the Government to consider these government institutions—and all others that provide services for children—when responding to our recommendations.

1. Current responses to allegations and incidents

We focused on responses to reports of child sexual abuse since 2000 (even if the act or acts of abuse occurred before 2000). This period reflects current responses to child sexual abuse, including community awareness and policy responses. This focus therefore informs our findings on current and ongoing issues and our recommendations for what needs to change.

As noted in the terms of reference, we did not have to inquire into matters that the National Royal Commission or another inquiry, investigation or court proceeding had dealt with.37 Our Commission of Inquiry complements rather than duplicates the work of the National Royal Commission, which had already closely examined child sexual abuse in institutions prior to 2000, as well as some more recent cases. Consequently, we decided to focus on more contemporary responses to child sexual abuse, in order to consider how effective they are and what has changed since the National Royal Commission concluded. We only examined incidents of child sexual abuse that predated 2000 where they threw light on current issues of concern about preventing, reporting and investigating abuse or official responses to such abuse.38

In focusing on the period since 2000, we directed our resources towards identifying current and continuing systemic issues. Within this scope, we have prioritised those issues and circumstances that continued to be present at the time of our Inquiry. We did so with the view that a purposeful focus on current issues was the best way to protect current and future generations of Tasmanians from the profound and lifelong pain caused by child sexual abuse.

1. Systemic reform

As directed by the Order of the Governor, we focused on systemic problems in institutional contexts and options for reform. This systemic focus has been significantly informed by the experiences of individuals. The accounts of victim-survivors, their families and advocates enabled us to understand current practices and to develop appropriate recommendations for reform. We have accepted the truth of the accounts of victim-survivors but acknowledge that, except where we have made findings, these accounts have not been examined by reference to the legal test for criminal responsibility, which requires proof beyond reasonable doubt, or civil liability, which requires proof of the allegation on the balance of probabilities.

Equally, examining specific institutions’ responses to child sexual abuse has enabled us to identify patterns of behaviour that have gone unaddressed. In particular, we are concerned that a systemic problem in the Government’s response to institutional child sexual abuse is a failure to deal with poor conduct or behaviour, including in relation to the conduct of individuals in responding to reports about the behaviour of others. We have identified poor conduct and failures by institutions and by individuals where the evidence before us supported such a conclusion, with the goal of ensuring that persistent and systemic issues are not perpetuated. Under the Commissions of Inquiry Act, we also have the power to make findings of misconduct.39 We discuss this power further in Section 2.3.4.

We have focused our Inquiry on the institutional response to allegations of child sexual abuse in an institution, rather than investigating whether the abuse occurred. The Order of the Governor recognised that we may need to refer individual cases to appropriate authorities for investigation, including the police. We discuss our referrals in Section 2.3.3.

1. Organised abuse

Michael Salter, Scientia Associate Professor of Criminology, School of Social Sciences, University of New South Wales, defines organised abuse as ‘any case of child sexual abuse in which two or more adult offenders conspire to sexually abuse one or more child’.40 We have adopted that definition.

Over the course of our Inquiry, we have heard accounts of, or concerns about, organised abuse. We did not have the capacity to undertake proper forensic investigations into these. We consider that these matters are better investigated by other bodies with dedicated funding and mandates for investigating alleged criminal activities. Accordingly, we did not request extra resources to expand our Inquiry to cover these accounts or concerns.

As set out in Section 2.3.3, we have referred all appropriate information to Tasmania Police and other relevant authorities for their consideration. With the consent of the relevant victim-survivors and families, we confidentially identified where such information might suggest organised abuse.

We have not outlined the details of those accounts or concerns in this report because proper forensic investigations have not been undertaken and any premature disclosure may adversely affect investigations. We have also done this to ensure procedural fairness is not denied to relevant people.

We are not in a position to comment on the accuracy or truth of these accounts or concerns. We trust, however, that Tasmania Police and others will appropriately consider the matters we have referred and any support they require to properly investigate those matters.

1. Powers

Commissions of inquiry are rare in Tasmania. There have only been two others since 1990.41 Unlike other forms of inquiry and review, commissions of inquiry have extraordinary powers, which are similar to royal commissions in other Australian states. These include powers to:

• compel witnesses to give evidence and produce documents42
• apply for a warrant to enter private premises to conduct a search and take documents43
• apply for a warrant to use surveillance or listening devices44
• hold public hearings and private sessions, including examining witnesses under oath.45

Witnesses do not have the right to refuse to give evidence or produce a document on the grounds that they may incriminate themselves.46

In announcing our Commission of Inquiry, the Premier stated that a key reason for recommending its establishment ‘is the power of that Inquiry to compel witnesses to provide evidence’.47

Unlike many other forms of investigation and review, reports of commissions of inquiry must be tabled in Parliament and are therefore available to the public.48

In applying our broad powers, we have conducted a far-reaching examination. We have conducted 37 days of public hearings, held more than 120 sessions with Commissioners, examined more than 160 witnesses, received more than 260 statements and reviewed more than 95,000 documents. More about the conduct of our Commission of Inquiry is set out in Section 3.

1. Legislative and regulatory amendments

To ensure our Commission of Inquiry was appropriately empowered, several amendments were made to the Commissions of Inquiry Act and associated legislation. In March 2021, Parliament passed the Justice Miscellaneous (Commissions of Inquiry) Act 2021 to amend various Acts.49 Most of the amendments were taken to have started on 1 March 2021.50

The amendments:

• clarified the Governor’s power to amend or vary the matters that a commission of inquiry is directed to examine
• provided for a commission of inquiry to conduct private sessions with individuals when appropriate (refer to Section 3.3.2 for more about the nature of these sessions)
• provided extra support for vulnerable witnesses to give evidence, including giving evidence anonymously and using special measures, such as witness intermediaries
• created additional requirements to provide procedural fairness where a witness to a commission of inquiry or another person may be subject to a finding of misconduct or other adverse finding
• clarified a commission of inquiry’s power to use listening and surveillance devices
• empowered a commission of inquiry to inspect documents when privilege is claimed
• enabled a commission of inquiry to share information with law enforcement and other authorities for the purposes of ensuring the safety and protection of children (child safe reporting)
• enabled the Ombudsman to refer matters under the Public Interest Disclosures Act 2002 to a commission of inquiry
• established exemptions to various confidentiality provisions for people who have been affected by abuse in the child protection and youth justice systems to access their records, to enable them to share that information with a commission of inquiry and to take part in private sessions, as well as the use of that information in civil and criminal proceedings.51

In addition, the Commissions of Inquiry Regulations 2021 commenced on 14 July 2021 to support the operation of our Commission of Inquiry. These regulations negated provisions in various Acts that would otherwise have regulated or restricted information collected by, on behalf of, or provided to our Commission of Inquiry, including in the case of State Service employees who wanted to engage with our Inquiry.

We considered many of these new regulations to be necessary so that we could give the public and State Service employees more information about our processes and their relevant rights. Unfortunately, the delay in these regulations commencing due to consultation and authorisation processes required by the State hampered our capacity to provide this information in a timely manner.

1. Rights and protections of witnesses who provided information

The rights and protections available under the Commissions of Inquiry Act supported those who gave us information, including confidentially and anonymously.

The Act creates several offences in relation to those rights and protections. For example, it is an offence for:

• an employer to prejudice a person’s employment or dismiss them because that person has given evidence or produced any document or thing to our Commission of Inquiry (or because of the content of that evidence, document or thing)52
• a person to intentionally prevent, or try to prevent, another person from producing any document or thing to our Commission of Inquiry53
• a person to punish another person or cause them loss, damage or disadvantage because that other person has given evidence or produced any document or thing to our Commission of Inquiry (or because of the content of that evidence, document or thing).54

The Commissions of Inquiry Act also limits the way information provided to our Inquiry can be used. The evidence that a person has provided to our Inquiry, such as a witness statement or oral evidence, is not admissible in other legal proceedings, except in very limited circumstances.55 A person who appears before our Commission of Inquiry is given the same protections and immunities as a witness who appears before the Supreme Court.56 This includes being protected against defamation and negligence actions.

Importantly, however, our Commission of Inquiry is inquiring into certain facts and matters. This does not prevent the State from also inquiring into those facts and matters. If information is available to our Inquiry and the State, both can investigate and, in the case of the State, take action in response to those facts or matters. For example, if it is alleged that a State Service employee has breached the State Service Code of Conduct, the State can still investigate that allegation and take any action it considers appropriate, provided it does not rely solely on evidence before our Inquiry. In this example, the State must already have this information or have obtained it through its own investigations. Also, our Commission of Inquiry can share information with, and refer matters to, the State and appropriate authorities for investigation.

1. Power to make referrals to appropriate authorities

Commissions of inquiry are not courts. They do not have the power to determine whether someone has committed a crime or is legally liable for their actions. Instead, if a commission of inquiry has any information that may be relevant to a criminal prosecution or disciplinary matter, that information can be referred to the appropriate authorities.57 In addition, our Inquiry is legally bound to report certain matters. For example, if we reasonably believe matters constitute an ‘abuse offence’ against a child, we must disclose that information to a police officer as soon as practicable.58

During our Commission of Inquiry, we referred more than 100 people to appropriate authorities. Referrals were made to a range of organisations and people, including the:

• Registrar of the Registration to Work with Vulnerable People Scheme
• Australian Health Practitioner Regulation Agency (‘Ahpra’)
• Assistant Commissioner, Tasmania Police
• Secretary, Department for Education, Children and Young People and, before that, the Secretary, Department of Communities and the Secretary, Department of Education
• Secretary, Department of Health
• Secretary, State Growth
• Teachers Registration Board.

In several cases, a referral was unnecessary because those involved were already subject to an investigation, proceedings, disciplinary findings or criminal conviction.

In addition, the Order of the Governor required us to report to the appropriate authorities where we identified a risk or potential risk to the welfare of a child or children generally.59 We also had an obligation to take steps to prevent abuse or neglect if we knew, or suspected on reasonable grounds, that a child was suffering, had suffered or is likely to suffer abuse or neglect.60 These steps can include reporting our concerns to the Secretary of the Department for Education, Children and Young People or a community-based intake service.61 During our Commission of Inquiry, we made more than 230 referrals to Tasmanian and other authorities regarding risks or potential risks to the welfare of children.

1. Power to make a finding of misconduct and an adverse finding

Our Commission of Inquiry has the power to make findings or draw conclusions from evidence we gather. Under section 19 of the Commissions of Inquiry Act, if we intend to make an adverse finding against a person, we must first notify the person in writing, including the details of the adverse finding, and allow the person at least 10 working days to respond to the findings before our Inquiry’s report is finalised.62 The rules of procedural fairness apply if our final report makes an adverse finding about that person.63 In Volumes 3–6 we make a number of adverse findings against individuals and the State. Each individual and the State were given written notice of these findings.

Under section 18 of the Commissions of Inquiry Act, we also have the power to make a finding of misconduct against a person.64 Misconduct is defined in the Commissions of Inquiry Act as:

… conduct by a person that could reasonably be considered likely to result in a criminal charge, civil liability, disciplinary proceedings, or other legal proceedings, being brought against that person in respect of the conduct.65

Before making a finding of misconduct, if we are satisfied that an allegation of misconduct should be made against a person before calling that person to give evidence, we must give the person notice of the allegation of misconduct and provide them with an opportunity to respond to the notice (a ‘section 18 notice’).66 The notice must give the person a reasonable period before they have to give evidence in response to the allegation.67 It must outline the allegation and the evidence that supports it.68 In response, the person may make oral or written submissions, give evidence to contradict or explain the allegation, cross-examine the person making the allegation, and call witnesses.69 The person has a right to be represented by legal counsel.70 We issued 30 section 18 notices to 22 people. In Volume 6, we make one finding of misconduct.

During our Inquiry, various interpretations of sections 18 and 19 of the Commissions of Inquiry Act, and the relationship between them, were presented by the State and lawyers acting for individuals. In relation to state servants, some have argued that the interpretations of these provisions have the effect that if our Commission of Inquiry wishes to make an adverse comment about the conduct of a state servant, this may effectively be a finding of misconduct against that person and require the specific process under section 18 to be followed. This argument is based on the fact that the definition of misconduct includes conduct that ‘could reasonably be considered likely to result in … disciplinary proceedings’ and conduct by state servants that might attract adverse comment could require consideration of whether there has been a breach of the State Service Principles or Code of Conduct, and hence give rise to a disciplinary proceeding (even if the outcome of such proceeding is uncertain). A similar argument could be made about any person who, by virtue of their profession or employment, might be subject to any form of disciplinary proceeding.

We consider that there should be scope for a commission of inquiry to make adverse comments about state servants without this automatically or necessarily also constituting findings of misconduct. We consider the Commissions of Inquiry Act reflects that there can be both types of findings and that a range of conduct might be criticised without it constituting misconduct.

Our view is that section 18 only applies to the extent that we consider any allegations, or make any findings, of misconduct. We consider that, under section 19 of the Act, we can make adverse findings that are not findings of misconduct. In those circumstances, we consider that it is not necessary to issue a notice under section 18, provided we comply with sections 19(2A) and 19(2B) of the Act.

We have maintained that distinction in the language of our report, where we have only designated one of our findings to be a finding of misconduct. We understand that lawyers would adopt the most beneficial interpretation for their clients and seek to minimise any adverse findings or findings of misconduct, but note that the State also advocated for the interpretation that had the effect of combining adverse comment and misconduct in relation to a person’s conduct. We quote at length:

… the findings against individuals in this Inquiry must still be characterised as misconduct findings. The State does not accept any argument that section 18 of the Act must be ‘read down’ to provide a ‘functional interpretation’. This Inquiry is ‘out of the ordinary’ in that it focuses on workers who are in a highly regulated profession. Unlike many Inquiries which could be constituted under the Act, these are findings made against State Servants. As the Commission is aware, State Servants are subject to the statutory Code of Conduct found within the State Service Act 2000. Any adverse findings will bring the full effect of the Code of Conduct into play against any named individual and accordingly, adverse finding is likely to result in the consideration of disciplinary proceedings against that worker.

… Any finding which may have the result of leading to disciplinary proceedings are findings of misconduct and as such, those workers have all the protections afforded them pursuant to section 18 of the Act.71

To avoid drawn-out legal argument and dispute, we adapted our procedural fairness processes to align with this interpretation and to avoid making adverse findings against individuals where they may have been considered to be findings of misconduct.

The Commissions of Inquiry Act shares some similarities with legislation in other Australian jurisdictions in relation to royal commissions and commissions of inquiry. Like most of these other jurisdictions, Tasmanian legislation provides that an inquiry is not bound by the rules of evidence (section 20(1)) and must observe the rules of procedural fairness (section 3(b)(i)).72 We are not aware, however, of any other Australian jurisdiction imposing the requirements for a finding of misconduct that exist in Tasmania under section 18.73

In our view, the procedural requirements under section 18 for making a finding of misconduct are onerous. In particular, the requirement to provide reasonable notice with a level of specificity about the allegation, and the evidence supporting the allegation, while concurrently running an inquisitorial process within a limited timeframe, presents practical difficulties. Also, providing a person who receives a notice of an allegation of misconduct the option to choose how to respond, which might include requiring further hearings, also significantly limits the capacity of a commission of inquiry to conduct that inquiry in the manner it considers appropriate, including to appropriately address any trauma-informed considerations in relation to vulnerable people.

While procedural fairness—including a person’s right to know any potential adverse findings against them and to be able to respond to those findings—is a cornerstone of our legal system, it is not clear to us why this right could not be adequately met through the procedural fairness requirements set out in section 19, as relevantly supported by the common law.

These complexities and challenges were discussed even before the Commissions of Inquiry Act was introduced in 1995. A 1993 report from the Law Reform Commission noted that:

[a] balance must be maintained between the rights of individuals and the need for the commission conducting the public inquiry to properly and fully investigate and report upon the issues referred to it.74

The Commission of Inquiry into the Death of Joseph Gilewicz in 2000 identified specific difficulties in achieving this balance. Some, but not all, of these concerns were addressed in the Commissions of Inquiry Amendment Act 2000.75 Despite the amendments, the section of the Act relating to misconduct was still thought by some to be ‘overly complicated’ and inflexible, hampering the ability of commissions to achieve their goals.76 A 2003 Tasmania Law Reform Institute report therefore recommended further amendments to the Act.77 Once again, some but not all of these concerns were addressed in the Justice Miscellaneous (Commissions of Inquiry) Act, which was said to implement the work of the Tasmania Law Reform Institute and the Australian Law Reform Commission.78 Relevantly, this amending Act created separate misconduct (section 18) and adverse (section 19) findings processes, which we find overly complicated and ultimately unnecessary. Indeed, the Australian Law Reform Commission focused on adverse findings (that might include findings of misconduct) and suggested that procedural fairness process matters might be better addressed outside legislation (for example, through policy guidance) to offer greater flexibility.79 This amending Act also sought to amend the definition of ‘misconduct’ to address concerns it was too broad. But it ultimately inserted a new definition that, as explained above, is also broad and problematic in practice.

As a matter of principle, we consider it would be better for an inquiry to make any findings it wishes, including adverse findings, subject to complying with procedural fairness. It should be a matter for the inquiry to choose whether a finding is of such seriousness, given the subject matter of the inquiry, that it might be appropriate to describe it as a finding of misconduct. In our view, it is unnecessary for an inquiry to follow any other procedural requirements in relation to such a finding, noting that the seriousness of the matter should also be taken into account in any balance of probabilities deliberations.

Also, forcing an inquiry to adopt extra ‘misconduct’ processes in relation to a broad category of conduct, not all of which may be of equal seriousness, risks unnecessarily increasing the impact on those who receive a notice of such alleged findings. Once again, it would be better for the inquiry to have the flexibility to treat any finding, including an adverse finding, in the way that is most appropriate and fair in the circumstances, rather than being artificially required to treat all adverse comments as ‘misconduct’.

In considering other Australian jurisdictions, it is not clear to us why the Tasmanian legislation requires separate misconduct processes. This position is inconsistent with contemporary inquiry practices. Ultimately, we are concerned the Tasmanian legislation invites arguments and disputes that prevent local inquiries from being as effective and efficient as they might be, and so limits the impact they can have for the benefit of the community.

We have outlined our concerns about section 18 and other provisions under the Tasmanian legislation in Chapter 23.

The findings we make in this report are based on a civil standard of proof. That is, we were satisfied that a matter had been proved on the balance of probabilities, rather than proved to the criminal standard of beyond reasonable doubt. We based our assessment on the following principles, as set out by Justice Dixon in Briginshaw v Briginshaw:

… it is enough that the affirmative of an allegation is made out to the reasonable satisfaction of the tribunal. But reasonable satisfaction is not a state of mind that is attained or established independently of the nature and consequence of the fact or facts to be proved. The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding are considerations which must affect the answer to the question whether the issue has been proved to the reasonable satisfaction of the tribunal ... the nature of the issue necessarily affects the process by which reasonable satisfaction is attained.80

The findings in this report seek to discharge our terms of reference, which ultimately aim to inform systemic reforms. These findings are not, and cannot be, substitutes for criminal prosecutions or civil or disciplinary proceedings. As indicated above, the State can investigate, prosecute or bring other proceedings in relation to the facts and matters that are relevant to this report, including where our Commission of Inquiry has referred matters to the State or appropriate authorities. Under section 21 of the Commissions of Inquiry Act, the State cannot generally use evidence given before our Inquiry directly. However, the rights and protections under the Commissions of Inquiry Act do not prevent the State conducting its own investigations. Indeed, it would defeat the purpose of a commission of inquiry if the State could not take appropriate action in relation to the underlying facts and matters.

1. Conduct

Our Commission of Inquiry’s job was to understand the complexity of institutional responses to child sexual abuse in government funded institutions, and to identify ways to create tangible and lasting change in these institutions. In this section, we outline how we approached our task.

We intend that the work of our Inquiry will protect Tasmanian children and young people from sexual abuse in and in connection with these institutions. We hope it will increase community understanding and improve responses to child sexual abuse and its impacts.

1. Who we heard from

To help accomplish our task, we engaged with more than 500 people including:

• Tasmanian children
• victim-survivors—children, young people and adults
• the families, communities and supporters of victim-survivors
• government and institutional representatives
• key service providers and stakeholders
• community members with relevant information
• experts in the field.

We acknowledge the strength and commitment to change demonstrated by many of those who came forward to talk to us about their own experiences or about their attempts to protect children and ensure effective responses to allegations and incidents of child sexual abuse.

1. Information handling

Much of the evidence we considered was given by victim-survivors and their loved ones and communities. We were particularly careful to treat this evidence respectfully. Accordingly, we put in place a procedure for handling information provided by victim-survivors. This procedure was possible because of recent changes to laws relevant to sexual assault.

The #LetHerSpeak campaign—also known as #LetUsSpeak—was founded in 2018 to ‘abolish sexual assault victim gag-laws in Tasmania, the Northern Territory and, more recently, Victoria’.81 Advocates described these laws as ‘gag-laws’ because they had the consequence of:

• silencing victim-survivors who wanted to speak out
• removing victim-survivors’ control over their experiences and denying personal agency
• maintaining the social stigma around sexual violence
• enabling and protecting offenders
• disempowering victim-survivors
• restricting public education around sexual assault.

After significant public pressure, some laws were changed to allow victim-survivors of sexual abuse to self-disclose or permit third parties to disclose their identity, and for courts to make orders to permit disclosure.82

As a result of the #LetHerSpeak campaign and legal amendments, people who shared information with our Commission of Inquiry could tell us how they wanted their information handled. Before we began receiving information from prospective participants, we explained that we could treat their information as:

• public—information could be viewed, referenced, quoted or published as required by Commissioners and Commission of Inquiry staff, and attributed to the participant
• anonymous—information could be used, but identifying details about the participant were removed and not published or made public
• confidential—information could only be viewed by Commissioners and Commission of Inquiry staff, and not used or published in the report.

We told participants that they could choose their preferred information-handling option and could later change their mind about how their information was handled. We also emailed a diagrammatic fact sheet titled ‘How will my information be handled?’ to victim-survivors who registered their interest in contributing to our Inquiry. This gave them time to digest and consider this information before taking part.

1. Support for people sharing information

We were aware that providing information about institutional responses to child sexual abuse is a complex process. It could be experienced as challenging, distressing, validating, triggering or healing, and could invoke other reactions. We therefore wanted to ensure our interactions with people sharing information were trauma-informed. This refers to understanding the impact of trauma on a victim-survivor and interacting in ways that support recovery and reduce the possibility of retraumatisation.83 Chapters 19 and 21 detail why it is important for all services interacting with victim-survivors to provide trauma-informed care.

The core principles of trauma-informed care are safety, trustworthiness, choice, collaboration and empowerment.84 We sought to implement these principles from our first contact with victim-survivors. We tried to be open and transparent about the Commission of Inquiry’s processes so that our role and limitations were clear. In particular, and to reduce the likelihood of retraumatisation, our sessions with a Commissioner were adjusted according to victim-survivors’ choices.85 Victim-survivors could bring a support person, meet in whatever setting felt most comfortable (including online) and control what information to share and how it was used.

People who took part in our Inquiry could also access counselling if needed. During and after their engagement with us, they could speak with an independent counsellor or an appropriately trained member of our team. In this way, we provided psychological first aid, risk assessments, safety planning, referrals to services and other means of support.

Aboriginal engagement officers were also available to provide culturally sensitive support to Aboriginal people who wanted their contribution to our Inquiry facilitated by an Aboriginal person.

1. Our staff

Many dedicated and hardworking staff made conducting a comprehensive inquiry possible.

We were well supported in our work by staff across four teams:

• Our Community Engagement Team comprised professionals with experience assisting vulnerable people (such as victim-survivors of child sexual abuse). This team worked closely with two Aboriginal engagement officers. The team supported our Inquiry’s consultation processes, including sessions with a Commissioner, stakeholder consultations, engagement with Aboriginal communities, site visits and roundtable discussions and briefings. This team also included a media and stakeholder engagement officer, who assisted with community and stakeholder consultations, and liaised with the media to convey information about our activities and communicate with the public.
• Our Policy and Research Team comprised policy officers and an investigator seconded from the Australian Federal Police (the Australian Federal Police paid for this secondment). This team handled research strategies and programs that informed the strategic direction of our Commission of Inquiry. The team developed investigation strategies and programs, informed the hearings and stakeholder consultations and briefings, led the drafting of our final report and ensured we were well informed to make strong recommendations that could be feasibly implemented.
• Our Operations Team established our Commission of Inquiry’s offices and coordinated staff across four states. This team provided logistical support, secured venues for public hearings and other Commission of Inquiry events, made travel arrangements, and ensured that public hearings ran smoothly and efficiently. They also took care of finance, human resources, infrastructure, decommissioning and archiving.
• Our Legal Team included Counsel Assisting, General Counsel and Solicitors Assisting. This team of lawyers provided our Inquiry with legal advice, administered inquiry procedures, sought an extensive amount of material, and conducted proper and effective hearings. The team identified and called appropriate witnesses and questioned them in a way that elicited useful evidence for our consideration. Our Legal Team also helped develop our final report.

Staff of our Commission of Inquiry and the Legal Team are named in Appendix C.

We express our gratitude to the Commission of Inquiry staff and the Legal Team who so ably assisted us to undertake our inquiries, prepare our final report and make recommendations.

1. Our forms of inquiry

The information and evidence that have informed the discussions and recommendations in this report have been obtained through multiple forms of inquiry including:

• written submissions
• sessions with a Commissioner
• sessions with our Community Engagement Team
• public and targeted stakeholder consultations
• consultations with Aboriginal communities
• site visits to youth detention and youth justice facilities
• research undertaken by our Legal Team and commissioned researchers
• public hearings
• roundtable discussions and briefings with government and agency representatives.

Because our Commission of Inquiry coincided with the COVID-19 pandemic, some of these forms of inquiry could not go ahead in person as planned. In line with COVID-19–safe protocols and relevant directions under the Public Health Act 1997 (‘Public Health Act’), we conducted our Inquiry online using remote-access technology, when necessary and appropriate.86 There were some benefits to technology-facilitated access, such as extending access to victim-survivors and experts based interstate and overseas.

Each form of inquiry is described in the following sections. Rather than standing alone, evidence obtained through each method informed our approach to, and discussions held in, other forums.

1. Written submissions

On 13 May 2021, we published an information paper calling for written submissions that addressed our terms of reference. The paper explained the scope of our Inquiry and that submissions would help inform our ‘understanding of the gaps, challenges and problems with the Tasmanian Government’s responses to allegations and incidents of child sexual abuse in institutional settings’.87 The paper also included a list of guiding questions and details about the submission process.

We welcomed written submissions in any length or format, to be submitted online, by mail or by email. People wanting to submit a hard copy of their written submission could do so with the support of our Operations Team. Those who needed help to write a submission could get support from Tasmania Legal Aid and our Community Engagement Team.

We invited victim-survivors and their supporters to tell us about their experiences and the ways in which the Tasmanian Government’s responses to allegations and incidents of child sexual abuse might be improved.88

Within a month, we had received 60 written submissions. To enable as many people as possible to contribute, we then simplified the submission process and extended the closing date for submissions from 2 July 2021 to 3 September 2021. Our Commission of Inquiry continued to receive and consider submissions after this time.

By 14 February 2022, we had received 143 submissions from a wide range of people and organisations. Our Legal Team assessed each submission to determine whether the subject matter was within our terms of reference, as well as whether the submission should be treated as public, anonymous or confidential. Some 139 of the 143 submissions were within our terms of reference. Of these, 45 submissions were public, 49 were confidential and 45 were anonymous. Tasmania Legal Aid assisted four people to make submissions.

Our Policy and Research Team reviewed and further analysed the submissions, categorising those making allegations about instances of child sexual abuse and those identifying systemic issues in relation to child sexual abuse.

From 143 submissions, we noted 160 individual allegations of instances of child sexual abuse (excluding one submission that contained hundreds of allegations). We further analysed this material against criteria including whether the allegation concerned an adult abuser or harmful sexual behaviours, and to which relevant case study or thematic area the allegation related. Because submitters were not asked to provide this information, we note that the following quantitative information is an approximation and based on volunteered information available in the submissions.

Of the 160 allegations, 132 related to adult abusers, 14 to harmful sexual behaviours and 14 were unclear.

Among these specific allegations:

• 63 allegations related to child sexual abuse in schools, with many raising concerns about abuse occurring before 2000
• 25 allegations related to Ashley Youth Detention Centre
• 25 allegations related to health services, particularly the offending of Mr Griffin
• 6 allegations related to out of home care.

As indicated above, all submissions were coded for systemic issues relevant to child sexual abuse, including the following themes (noting that some submissions addressed more than one theme):

• 20 submissions addressed topics relevant to raising awareness of and preventing child sexual abuse, including calling for prevention and early intervention measures, addressing Tasmanian attitudes to child sexual abuse, and the need for a community-wide response
• 32 submissions addressed topics relevant to making government institutions safer, such as addressing the physical design of buildings, calling for child safe standards, improving screening practices (such as professional registration and registration to work with vulnerable people), training for staff to recognise abuse, and developing codes of professional conduct for staff and a reportable conduct scheme
• 13 submissions addressed topics relevant to improving supports for children, including supporting children with specific backgrounds or experiences (such as being Aboriginal or having disability), how to support adults to understand when children are making disclosures to them, and providing supports, including therapeutic responses, for children displaying or experiencing harmful sexual behaviours
• 36 submissions addressed topics relevant to system-wide improvements, including improving coordination across agencies, strengthening mandatory reporting, improving record keeping, strengthening oversight bodies (such as the Commissioner for Children and Young People, the Ombudsman and the Integrity Commission), and increasing funding
• 27 submissions addressed topics relevant to improving institutions’ identification of and response to disclosures, including barriers to making complaints, concerns about Tasmania’s culture and size, having clear complaints processes, and difficulties with disciplinary processes and internal investigation processes
• 8 submissions addressed topics relevant to improving the criminal justice system, including police responses, criminal offences and procedures, bail and sentencing, and training legal practitioners in matters relevant to child sexual abuse
• 19 submissions addressed topics relevant to civil justice matters, redress and support for victim-survivors, including the National Redress Scheme, the conduct of civil litigation matters and therapeutic supports for victim-survivors, as well as preserving records and providing official apologies
• 28 submissions addressed topics relevant to our four focus institutions—education, youth detention, out of home care and health.

These themes are summarised in Figure 1.1.

Figure 1.1: Systemic themes from submissions to our Commission of Inquiry

From these submissions, we gained a sense of the problems in the Tasmanian Government’s response to child sexual abuse, including:

• a lack of a systemic response to child sexual abuse
• fears of reprisals for speaking out about child sexual abuse
• concerns about misconduct and cover-ups
• a lack of human empathy in responses to child sexual abuse
• a lack of priority given to the safety of children
• problems with disciplinary processes.

The firsthand insight and experiences conveyed in the submissions we received, as well as observations made by organisations, deepened our understanding of the nature and breadth of child sexual abuse in government institutions. We appreciate the time people spent considering and writing their submissions. We are particularly grateful to people who provided accounts of their personal experiences, sometimes for the first time.

1. Sessions with a Commissioner

By 17 July 2023 (from 13 August 2021), 132 people affected by child sexual abuse had shared their experience with a Commissioner in person, online, by video-conference or on the telephone. Sessions with a Commissioner were due to be completed by the end of February 2023 to allow information shared to be included in our final report. In practice, some sessions were held after this date, and Commission staff continued to receive information from people who wished to share it.

Because it can be distressing and exhausting for victim-survivors and their supporters to recount traumatising experiences, each session with a Commissioner was designed to be welcoming and trauma-informed. Many people who attended a session later reported feeling supported during their engagement with our Commission of Inquiry, which we hope reflects the sense of privilege and respect we felt when people trusted us with their experiences. For example, one participant said after their session with a Commissioner: ‘Thank you for listening to my story. I think that, in a way, I can have some closure now’.89 Another said, ‘I’m relieved that I’m being taken seriously, I’m relieved that someone out there aside from me cares this happened and happens … It’s validation. I have validation and that means so much’.90 We discovered while undertaking our Inquiry that the very existence of our Inquiry had a positive impact on many victim-survivors. For example, one participant told us:

Thank you for all your work. Thank you for addressing the concerns of survivors, and for looking at a difficult problem with a fresh set of eyes … Your work has had a major positive impact on my life experience (and others I’m sure) and has been integral to my own healing.91

Sessions with a Commissioner had a profound impact on the Commissioners and inquiry staff. We consider it a privilege to have spent time with the victim-survivors, their loved ones and supporters, who have shared their stories and experiences of sexual abuse and their attempts to obtain justice, healing and the protection of others. The strength and resilience of the people who spoke to us in these sessions often restored our faith in humanity in the face of confronting conduct by others. These sessions have helped us understand the varied and complex ways in which trauma can profoundly alter the everyday lives of many people in our community. Our task would have been made far more difficult without victim-survivors and their supporters placing their trust in us. We do not take that trust for granted.

Registering for a session

Tasmanians became aware of sessions with a Commissioner in several ways. Many learned about sessions because of their previous engagement with us—by writing a submission, contacting us by telephone or email, or attending a stakeholder consultation. Other paths for engagement included referrals from our Aboriginal engagement officers and the ‘Sessions with a Commissioner’ page on our website. People interested in attending a session with a Commissioner generally registered their interest by emailing us or calling our 1800 number. People in prison could contact us via our 1800 number, which was placed on prison telephone systems.

When a person called to register for a session, they were connected to a member of our Community Engagement Team, who then became their point of contact for the length of their engagement with us. The Community Engagement Team assessed the eligibility of each person to attend a session based on the nature of the information they wanted to share and the relevance of this information to our Inquiry.

Next, the team talked to people about what to expect during a session and supported them to make an informed choice about how the information they may contribute should be managed. We also outlined our mandatory reporting obligations to participants.

The wellbeing of people attending a session was of paramount importance to us. During the registration process, the Community Engagement Team determined each person’s support needs and let them know that we would provide them with access to counselling supports before, during and after their session with a Commissioner. The Aboriginal engagement officers offered culturally sensitive support to Aboriginal participants.

Conducting a session

Commissioners spoke with victim-survivors, their loved ones and supporters, as well as people with information about Tasmanian Government institutions. We heard from a diverse group of people who were located variously in regional and metropolitan areas across Tasmania. We spoke with people in prison and other secure or residential environments, and with people from different age groups, including teenagers. We also spoke to people with an experience of child sexual abuse in a Tasmanian Government institution who now live interstate or overseas.

Many parents and caregivers took part in a session on behalf of their children. Although it was open to children to have their own session with a Commissioner, children most commonly contributed to our Inquiry through the child-centred research project discussed in Section 3.3.8.

Sessions usually ran for one hour. They were conducted in a range of formats and settings depending on the needs of the participant. In-person meetings were held in private meeting rooms. Virtual sessions were conducted (primarily using Microsoft Teams) with participants who spoke from locations in which they felt safe and assured of privacy. Sessions were attended by the participant, a Commissioner and a member of our Community Engagement Team. Participants decided how to use the time available and what they wanted to talk about. Participants could also choose to bring a support person or lawyer. People providing support did so on the understanding that information disclosed and discussed during a session would be used only for the purpose of our Commission of Inquiry and in line with the participant’s expressed wishes about confidentiality.

When the session concluded, we arranged counselling support and transport home for participants if requested. Table 1.1 displays the data collected about Commissioner sessions and Table 1.2 shows the primary institution type in which session participants described child sexual abuse occurring.

Table 1.1: Sessions with a Commissioner data

Session, submission and participant-specific data	Total
Number of sessions held	132
Sessions held face to face	78
Sessions held by telephone	3
Sessions held by videoconference	51
Sessions held with people living interstate	15
Sessions held with people living overseas	5
Participant location—northern Tasmania	45
Participant location—North West Tasmania	7
Participant location—southern Tasmania	59
Participant location—eastern Tasmania	1
Age of youngest and oldest participant	17 and 72
Gender diverse participants	3
Female participants	82
Male participants	47
Participants who identified as Aboriginal	16
Participants who wanted their information to be public	45
Participants who wanted their information to be anonymous	71
Participants who wanted their information to be confidential	16
Pathway for participant engagement—written submission	44
Pathway for participant engagement—telephone or email	65
Pathway for participant engagement—referral	16
Pathway for participant engagement—stakeholder consultation	7

Table 1.2: Participant information

Primary institution type	Victim-survivor	Supporter of victim-survivor	Third party with information	Total
Health (excluding in relation to Mr Griffin)	7	3	9	19
Health (in relation to Mr Griffin)	11	5	8	24
Education	22	11	13	46
Out of home care	11	2	5	18
Ashley Youth Detention Centre	6	1	6	13
Other*	4	2	6	12
Total	61	24	47	132

• ‘Other’ refers to institutions other than those that could be categorised as health, education, out of home care or Ashley Youth Detention Centre.

Key themes

Participants brought a range of issues to our attention during their sessions with a Commissioner. Many spoke of their lived experience in government funded institutions such as schools, hospitals, out of home care facilities and Ashley Youth Detention Centre.

Below are the themes that struck us from personally attending these sessions:

• Child sexual abuse victim-survivors showed extraordinary courage and generosity in their motivation to make systems better and to protect other children.
• Child sexual abuse has significant and lifelong impacts on emotional, physical and spiritual wellbeing, as well as developmental capacity and milestones.
• Victim-survivors showed tremendous strength and resilience; they make positive contributions to their families, their communities and/or through their work while living with the pain and lasting impacts of child sexual abuse.
• Children have often been poorly treated in institutional settings, particularly children with special needs, children already exposed to abuse and trauma and children without family to stand up for them.
• Institutional responses to allegations, complaints and disclosures of child sexual abuse have sometimes been inadequate. Some responses have minimised the abuse, children have not been believed or not offered support, investigations have been non-existent, hurried and/or inefficient, and abusers have been protected and relocated to other workplaces.
• The responses to child sexual abuse in school, health, out of home care and detention settings, and in the justice system, have often not been informed by an understanding of victim-survivor trauma.
• Clear reporting and complaint mechanisms have often been lacking. At times, staff have feared reprisal, bullying or loss of their job and career prospects if they raised concerns about child sexual abuse.
• At times, toxic workplace cultures have meant that identifying risks and problematic behaviours has been discouraged among staff, and shifting responsibility and blame has been common.
• Too often, staff across institutions have not had the knowledge to recognise grooming or understand child safety reporting requirements.
• At times, redress and compensation processes have been difficult, not adapted to the impacts on victim-survivors and not focused enough on therapeutic supports for victim-survivors.
• Victim-survivors and their parents or supporters have frequently struggled to access affordable, timely therapeutic and practical supports to meet their needs.

1. Sessions with our Community Engagement Team

If a person was interested in sharing their experiences but did not want to write a submission or talk directly with a Commissioner, or their experience fell outside our terms of reference, we gave them the option of speaking one-on-one over the telephone with a member of our Community Engagement Team.

When we received information this way, the Community Engagement Team member first ensured that the caller felt safe, was in an appropriate location, and had privacy. The same protocols that applied to a session with a Commissioner about the use of information were applied in each session with a member of our Community Engagement Team, and were explained to the caller.

During the conversation, the team member took notes and asked clarifying questions when needed. The conversation was not otherwise recorded.

Eighty-three people chose to share information in this way. Although only 49 of these conversations were in the scope of our Inquiry, we believe it was important to extend an opportunity for all interested people to share information and understand our work.

1. Stakeholder consultations

Between 13 August and 13 December 2021, we held 21 targeted and public stakeholder consultations. We also held several informal discussions with individuals and groups. We spoke to people with experience of government institutions and relevant sectors, including teachers, social workers, police, healthcare professionals, specialist child sexual abuse professionals, people working with children and young people, academic experts, staff from local councils, community leaders, and representatives of Aboriginal communities and culturally and linguistically diverse communities.92

Stakeholder consultations were conducted in metropolitan and regional locations, as well as online. Each consultation ran for about 90 minutes. Consultations with many attendees were guided by an external facilitator, and Commission of Inquiry staff members took notes on the day.

More than 150 people attended these consultations. They provided a wealth of information relevant to our terms of reference and informed other aspects of our Inquiry, such as priority topics for our later public hearings. We thank everyone who attended a consultation for taking the time to share their expertise and insight with us.

Public stakeholder consultations

Of the 21 stakeholder sessions we held, seven were public consultations in Hobart, Launceston, Devonport (two sessions), Burnie, Queenstown and Scamander. Those who wanted to take part registered in advance. Attendance at each session ranged from one person to 41 people (refer to Table 1.3). In total, we heard from more than 100 people during our public consultations.

At each consultation, participants worked in small groups to discuss topics related to current government responses to child sexual abuse. In relation to each topic, participants were asked:

• What works well?
• What is not working well?
• How could the current system be improved?

At the end of each consultation, a Commissioner provided an overview of what we heard.

Table 1.3: Public stakeholder consultations

Date	Location	Number of participants
13 August 2021	Hobart	41
19 August 2021	Launceston	29
23 August 2021	Devonport	13
23 August 2021	Devonport	1
24 August 2021	Burnie	11
27 August 2021	Queenstown	10
31 August 2021	Scamander	4

Information received during public stakeholder consultations was wide-ranging and reflected the lived experiences of participants in dealing with child protection and child safety issues in various institutional settings. Consultations gave us a detailed insight into the struggles that victim-survivors, communities and frontline workers faced, and continue to face, as they try to negotiate systemic gaps and failures.

Importantly, participants in consultations highlighted statewide and regionally-specific issues, giving us a clear and immediate picture of the issues relevant to child sexual abuse in Tasmanian Government institutional settings as a whole.

Key themes

Key themes that emerged from public stakeholder consultations included:

• Many Tasmanians showed persistence and courage in raising issues to protect children.
• There was an absence or failure of mechanisms to respond to known risks and, if there were mechanisms, transparency and/or knowledge about them was lacking.
• There was a fear of reprisal and a sense that those who spoke out (victim-survivor or whistleblower) would be punished.
• There was a lack of care and compassion in responding to victim-survivors.
• Tasmanian institutional responses to prevent and respond to child sexual abuse were absent or out of date and did not incorporate contemporary knowledge.
• There was a failure to understand or consider that child sexual abuse, including grooming, was continuing to take place in Tasmanian Government institutions.

Participants also provided feedback on issues and ideas for improvement—for example, in prevention, reporting and responding, as well as on organisational, systemic and regional issues.

Across all stakeholder consultations, participants were asked about, but most struggled to identify, what was working well.

Targeted stakeholder consultations

We conducted 14 targeted stakeholder consultations in Hobart, Launceston and online (refer to Table 1.4). Attendance ranged from one person to 15 people per consultation. In total, we heard from more than 50 invited participants who regularly dealt with child sexual abuse matters, such as police and judicial officers, service providers, academics and advocates.

These targeted consultations allowed us to focus on a particular theme or issue, often identified through the submissions or the public consultations. Our questions and discussions at these consultations varied according to the stakeholder or stakeholder group we were meeting and the theme we were exploring. Information was provided in a private and closed setting, and although we draw on information provided in these consultations in our report, we have not identified individual participants or identified themes in detail here.

Table 1.4: Targeted stakeholder consultations

Date	Location	Number of participants
19 August 2021	Launceston	4
20 August 2021	Hobart/online	8
25 August 2021	Hobart/online	6
26 August 2021	Hobart	7
1 September 2021	Hobart/online	2
2 September 2021	Hobart	1
2 September 2021	Hobart	4
9 September 2021	Hobart	1
16 September 2021	Hobart	3
15 October 2021	Hobart	1
25 October 2021	Hobart/online	15
29 October 2021	Hobart/online	8
23 November 2021	Hobart/online	2
13 December 2021	Hobart	1

1. Engagement with Aboriginal communities

One of the continuing impacts of colonisation is that Aboriginal children are over-represented in certain government institutions, including the out of home care system and youth detention (refer to Volumes 4 and 5 for more on these institutions). We worked with two Aboriginal engagement officers to ensure our consultation processes with Aboriginal communities were culturally safe and inclusive, and that Aboriginal perspectives were heard and reflected in our findings.

Tasmanian Aboriginal context

In Australia, the definition of ‘Aboriginal’ has been subject to different classification systems at different times.93 In the current Tasmanian context, the issue of who should be able to identify as Aboriginal is contentious and central to longstanding community divisions, notably between the Tasmanian Aboriginal Centre and other Aboriginal-led organisations.94

The Tasmanian Aboriginal Centre was founded in the early 1970s. It is the earliest government funded and highest profile Aboriginal organisation in Tasmania.95 However, Aboriginal communities in Tasmania are diverse and represented by numerous organisations.96

The Tasmanian Aboriginal Centre previously endorsed state-based eligibility criteria as a prerequisite to accessing services funded for Aboriginal people, namely documented evidence of Aboriginal ancestry. Concerns have since been raised about this criteria because people who could not prove their ancestry through public records were excluded from accessing services.97

In 2016, the Tasmanian Government decided to redefine eligibility criteria for accessing Aboriginal-specific services. The Government adopted a definition of Aboriginal that removed the need for documentary evidence of Aboriginal descent. Currently, eligibility for access to Aboriginal services is based on:

• completing an Eligibility Form for Tasmanian Government Aboriginal and Torres Strait Islander Specific Programs and Services98
• providing a statement from an Aboriginal organisation, as well as a statutory declaration of self-identification.99

The Tasmanian Aboriginal Centre opposed this change because it was concerned that non-Aboriginal people would identify as Aboriginal to access funding earmarked for Aboriginal communities, and therefore ‘put a strain on resources’.100

We are conscious of the over-representation of Aboriginal children in some government institutions (such as out of home care and youth detention) as a direct and continuing impact of colonisation. We considered it our responsibility to listen and learn from the experiences and expertise of as many Aboriginal people as possible. We therefore sought to engage Aboriginal organisations across Tasmania, including the Tasmanian Aboriginal Centre, to inform our Inquiry. We did not consider it the role or appropriate function of our Commission of Inquiry to determine who is Aboriginal. We therefore accepted the self-identified cultural identity of all people who engaged with us.

Engagement through community consultation

In mid to late 2021, our Community Engagement Team contacted 22 Aboriginal organisations via letter, telephone and/or email to initiate conversations about how communities might wish to engage with our Inquiry.101 Ten of these organisations agreed to pass on information about our Commission of Inquiry to their members.

The Community Engagement Team also met with several prominent Aboriginal community members and organisations for further advice on developing an effective engagement strategy. This process led to engaging two Aboriginal engagement officers, who worked with our Inquiry to organise and facilitate statewide community consultations with Aboriginal people. Various community organisations or regions hosted 10 consultations (refer to Table 1.5). We then prepared a summary of reforms we were considering that were most relevant to Aboriginal communities. This was provided to community members and organisations that had attended consultations, and they were invited to provide feedback. This process was undertaken in response to advice from Aboriginal community members about how our Commission of Inquiry could engage in meaningful consultation.

Before holding consultations, we organised for all Commission of Inquiry staff to attend cultural awareness training. The Community Engagement Team received more in-depth training so they were better equipped to take part in consultations with Aboriginal communities.

Table 1.5: Consultations with Aboriginal communities

Date	Area of Tasmania	Number of participants
8 April 2022	North West	8
24 May 2022	North West	12
31 May 2022	Northern	6
3 June 2022	Southern	6
18 July 2022	Northern	8
19 July 2022	Northern	8
28 September 2022	North West	12
24 October 2022	Southern	16
21 February 2023	Southern	4
22 February 2023	Southern	5

Other forms of engagement

Aboriginal people also took part in our Inquiry in other ways. Some Aboriginal people contacted us independently or after attending a consultation. Others came to us via our Aboriginal engagement officers.

Sixteen Aboriginal people took part in sessions with a Commissioner. Another five people who identified as Aboriginal gave us information over the telephone or in writing. However, we did not routinely collect demographic data from people we spoke with on the telephone, and it was not always appropriate to ask our standard demographic questions of people participating in sessions with a Commissioner. It is therefore likely that these numbers are conservative.

We received a written statement from the chief executive officer of the Tasmanian Aboriginal Centre, who also gave evidence during a public hearing (refer to Section 3.3.9).102 We also received a written submission from the Tasmanian Aboriginal Legal Service.103

Of the 59 children and young people who took part in our primary research project (refer to Section 3.3.8), 11 identified as Aboriginal and/or Torres Strait Islander.104

We convey our deepest thanks to the Aboriginal people who contributed their insight to our Inquiry. They have informed our views and the recommendations we make in this report.

Key themes

The information we received from Aboriginal members of the community was wide-ranging. For Aboriginal people, child sexual abuse is inextricably linked to colonisation and its traumatic intergenerational impacts. As with the approach taken by the National Royal Commission, we decided to include information from Aboriginal people that did not fit within our terms of reference but better reflected the whole story that has led to the over-representation of Aboriginal children in child sexual abuse statistics.105 It was of vital importance that we listened to all that Aboriginal people had to say and reflected their perspectives in our findings and recommendations.

Key themes that emerged from our consultations with Aboriginal people included:

• Prevention and healing
  • There has been a lack of education and prevention programs for Aboriginal communities, specific to child sexual abuse.
  • Significant numbers of Aboriginal children have been abused by members of their own community because of the trauma of colonisation and dispossession. There has been a culture of silence around this and, as a result, these children have been more vulnerable to abuse in institutions, as well as being affected by another layer of trauma.
  • Conversely, there are false assumptions about Aboriginal culture and parenting that inaccurately identify the risk of child sexual abuse.
  • Culture and cultural programs are essential to healing Aboriginal children who have experienced sexual abuse, as well as to strengthening communities and thereby preventing abuse.
• Child Safety Services and Tasmania Police
  • Many Aboriginal families fear that Child Safety Services will remove their children, which has been a barrier to reporting child sexual abuse.
  • There is a lack of trust in police in Aboriginal communities due to experiences of mistreatment, which has also been a barrier to reporting child sexual abuse.
  • Aboriginal children and families have experienced culturally inappropriate and negative treatment from Child Safety Services.
  • Sexual abuse of Aboriginal children in out of home care has been prevalent.
  • There is a need for culturally appropriate alternatives to out of home care and child safety interventions, governed by Aboriginal people.
• Ashley Youth Detention Centre
  • Many Aboriginal children have been negatively affected by Ashley Youth Detention Centre—abuse has been prevalent, and there has been minimal cultural care and follow-up support.
  • There is a need for culturally appropriate youth justice alternatives governed by Aboriginal people.
  • There has been insufficient funding and a lack of culturally appropriate support for victim-survivors of child sexual abuse. There is a need for Aboriginal-led programs and safe cultural spaces.
• Other challenges
  • Designing and implementing initiatives tailored to Aboriginal children in government institutions and their families is complex. There has been a lack of support for Aboriginal people working in these institutions.
  • Distributing resources and implementing new programs across Tasmanian Aboriginal communities has been challenging due to divisions between communities.

1. Site visits to youth detention and youth justice facilities

In 2021 and 2022, we visited four institutions that detain children and young people. Our first site visit was to the only youth detention centre in Tasmania: Ashley Youth Detention Centre at Deloraine. This detention centre was a major focus of our Inquiry. The other site visits were to youth detention and youth justice facilities in other states and territories. We visited these facilities to understand and compare different models of detention.

During site visits (summarised in the following sections), we saw the facilities and workings of each complex, spoke directly with staff and young people, and learned about their model of care and approach to behaviour management. We also observed the institution’s relationship with the community at large.

We discuss Ashley Youth Detention Centre and alternative detention models in detail in Volume 5.

Ashley Youth Detention Centre

On 18 August 2021, President Neave, Commissioner Bromfield and Commissioner Benjamin visited Ashley Youth Detention Centre. They were accompanied by three Commission of Inquiry staff members, as well as representatives of the Solicitor for the State and the Department of Communities, being the Deputy Secretary and Executive Director for Ashley Youth Detention Centre. These two departmental officials were there to support centre staff. The assistant manager and other centre representatives hosted the visit.

The visit occurred at the insistence of our Commission of Inquiry. Upon arrival, Commissioners were met with consternation about our visit and assurances that there were no issues of concern at Ashley Youth Detention Centre. This was in direct contrast to other youth detention centres in other states, where, despite having no powers, Commissioners were welcomed, visits were low key and staff spoke openly about their strengths and the challenges of operating youth detention facilities. Our experience at Ashley Youth Detention Centre was consistent with the accounts of others who have suggested that the Centre is a closed institution with a culture of cover-up and denial, as further evidenced in Volume 5.

Ashley Youth Detention Centre is Tasmania’s sole custodial facility for children between the ages of 10 and 18. At the time of our visit, most children at the Centre were on remand.

On 9 September 2021, the Government announced that Ashley Youth Detention Centre would close within three years.106

Adelaide Youth Training Centre—Kurlana Tapa

On 14 October 2021, Commissioner Bromfield and a Commission of Inquiry staff member visited Kurlana Tapa, the Adelaide Youth Training Centre at Cavan in South Australia. The general manager of Youth Justice, South Australian Department of Human Services, hosted this visit. COVID-19 restrictions prevented us from entering the units at the centre, but we could visit other buildings as well as the grounds, including the Aboriginal cultural garden. Commissioner Benjamin also visited the centre on 2 June 2022, which was again hosted by the general manager of Youth Justice. With COVID-19 restrictions now eased, Commissioner Benjamin visited the educational facilities, health facilities, sporting and activity centres, and residential buildings.

Adelaide Youth Training Centre is a custodial facility for young people between the ages of 10 and 20. We were told that the numbers of children detained in South Australia had declined over time, but that most of the smaller number of children placed in the centre require intensive and complex supports and case management.

Cobham Youth Justice Centre

On 18 May 2022, Commissioner Benjamin visited the Cobham Youth Justice Centre at Claremont Meadows in New South Wales. The visit was organised with the executive director of Youth Justice New South Wales and was hosted by the acting centre manager at Cobham and the acting director of Custodial Operations, Youth Justice New South Wales.

Cobham Youth Justice Centre detains boys and young men between the ages of 15 and 20, who often present with drug and mental health issues. A significant proportion are from Aboriginal and Pacific Islander communities.

Bimberi Youth Justice Centre

On two occasions in 2022, Commissioners visited the Bimberi Youth Justice Centre in Gungahlin in the Australian Capital Territory. On 20 May, Bimberi’s centre manager hosted Commissioner Benjamin. On 10 October, Bimberi’s acting executive branch manager hosted President Neave.

Bimberi Youth Justice Centre uses a ‘school campus model’ and is the first youth justice facility in Australia to comply with human rights legislation.107 It accommodates up to 40 children and young people between the ages of 12 and 21. Young people receive a health assessment when they arrive. Some have significant and complex mental health issues. Most are at the centre on remand.

1. Visit to Launceston General Hospital

On 14 March 2023, Commissioner Benjamin and a Commission of Inquiry staff member visited the Launceston General Hospital’s child and adolescent and paediatrics wards. Our Commission of Inquiry instigated the visit, which the Department of Health facilitated. Hospital staff welcomed us and provided a comprehensive tour and explanation of the recently completed renovations.

1. Research

For further context with regard to what victim-survivors and other stakeholders were telling us and to inform priority topics for our public hearings (refer to Section 3.3.9), we undertook considerable research relevant to our terms of reference. This research included commissioned literature reviews and reviews of policy and related documents provided by the State. We also commissioned independent research to learn directly from the experiences of Tasmanian children and young people.

Literature and policy review

Our Legal Team collated more than 95,000 documents produced by agencies and government departments. We obtained this information in numerous ways, including by exercising our power to issue notice to produce documents. The Legal and Policy and Research teams reviewed this material. Table 1.6 lists documents that informed our hearings.

The National Royal Commission undertook extensive research on child sexual abuse in institutional settings and added significantly to the body of academic work on this issue. We reviewed the work of the National Royal Commission to inform our Inquiry.

In addition, after a targeted tender process, we funded the Australian Centre for Child Protection at the University of South Australia to source peer-reviewed articles on the topic of child sexual abuse, published since 2016.108 The results of this search provided recent academic insight into five key areas:

• supporting children
• disclosure and response
• systems oversight
• making government institutions safe
• justice and support for victim-survivors.109

Table 1.6: Summary of documents that informed the hearings

Topic	Education	Out of home care	Health	Ashley Youth Detention Centre	Access to justice	The future	Other	Total
Requests for statement or information issued	13	7	51	67	12	0	3	140*
Notices to produce material issued	3	0	13	4	2	0	8	31
Questions on notice	2	3	7	5	1	3	6	27
Orders made	7	6	2	4	1	1	0	21
Material produced	N/A	N/A	N/A	N/A	N/A	N/A	N/A	95,000+ documents

• Because requests for statement or information were issued to people under more than one category, the total value is less than the sum. The total also excludes those requests that did not progress for various reasons.

Commissioned research

In 2021, after a targeted tender process, we commissioned research from Associate Professor Tim Moore and Emeritus Professor Morag McArthur, initially via the Australian Centre for Child Protection, University of South Australia. The research project later moved to the Institute of Child Protection Studies at the Australian Catholic University in line with academic convention when Associate Professor Moore changed institutions. The purpose of this research was to hear directly from Tasmanian children and young people about their experiences and perspectives relevant to their safety in institutions.

The research involved speaking with 59 Tasmanian children and young people between the ages of 10 and 20 who had a variety of experiences with Tasmanian institutions in our areas of interest. In line with our key focus areas, participants were invited to reflect on their experiences in government schools, out of home care, hospitals or in Ashley Youth Detention Centre.

The researchers engaged children and young people in discussions about their experiences and feelings of safety in government institutions, their ability to raise safety concerns, and their awareness of high-risk and harmful adult and peer behaviours.

The report of this research, titled Take notice, believe us and act! Exploring the safety of children and young people in government run organisations, was provided to us in October 2022. The key findings of this report included:

• Most children and young people felt safe most of the time in institutions, but those who had experienced youth detention or been in out of home care were more likely to share experiences of violence, abuse and victimisation in institutions.110
• Access to trusted adults was important to make children and young people feel safe, recognising the role they can play in protecting them and advocating for them.111
• Children and young people reported feeling safer when they felt respected, valued and cared for, and they appreciated when adults involved them in decision making and listened to their concerns and ideas.112

The research report concluded that for institutions to be (and to feel) safer for children and young people, they needed to:

• embed child safety as a shared responsibility and ensure children and young people feel empowered and supported to share their safety concerns and engage meaningfully with the adults caring for them113
• have clear strategies to improve safety that are understood and visible for children and young people, including information about what to do if they are hurt or harmed114
• recognise that the past maltreatment of children and young people will heighten their risk of further abuse, requiring institutions to recognise and understand the impacts of trauma and to work with other agencies to minimise risks to children, and ensure they receive any therapeutic support they may need.115

Our Commission of Inquiry, along with two young people with experiences in Tasmanian Government institutions, launched the research report and an animation of a report summary designed for children and young people in February 2023.

More specific findings from this research (particularly how it relates to our focus institutions) are described throughout this report.

1. Public hearings

The primary purpose of holding public hearings was to explore ways in which the Department of Education, the Department of Health (particularly Launceston General Hospital), Ashley Youth Detention Centre and the out of home care system have dealt with the risk and occurrences of child sexual abuse in their institutions. We also dedicated a few hearing days to considering system-wide issues such as oversight of institutions, the statewide response to child sexual abuse, state disciplinary processes and the justice response to child sexual abuse.

In hearings that focused on specific institutions, we examined and evaluated the effectiveness of past and current Tasmanian systems, laws, policies and practices relevant to preventing and responding to child sexual abuse in that institutional context. Where appropriate, these hearings were informed by the accounts of victim-survivors or specific case studies that illustrated the themes we had observed. At these hearings, we also discussed how children might be better protected from sexual abuse in that institutional context, and how the Tasmanian Government might better address and alleviate the impact of past and future child sexual abuse.116

We held public hearings over 37 days between October 2021 and September 2022. Hearings took place in three venues: in Hobart at the Mövenpick Hotel and the Tasmanian Civil and Administrative Tribunal, and in Launceston at the Country Club Tasmania. The tribunal kindly provided its facilities free of charge.

Members of the public and the media were generally welcome to attend hearings in person or to watch our livestream. We usually provided public access to records of our proceedings. Daily hearing lists, transcripts, some witness statements and orders were published on our website and were also available in a range of accessible formats on request.

We were committed to being open and transparent, respecting the preferences of victim-survivors, and considering the effect that evidence from these hearings may have on other investigations, legal proceedings and the wider community. At times, our Commission of Inquiry made restricted publication orders to limit the publication of information that may identify victim-survivors, abusers or other people who may have been referred to during the hearings. Our Inquiry made those orders when we were satisfied that the public interest in the reporting on the identities of certain people was outweighed by legal and privacy considerations. We redacted (or did not publish) information in transcripts and witness statements in line with the restricted publication orders. These orders were published on our website and made available outside the hearing room and to media.

We recognised that, in some circumstances, it was important to protect the identity of a witness by allowing them to give their evidence using a pseudonym. In these circumstances, Counsel Assisting read from the witness’s statement or their evidence was not livestreamed. Members of the public could be present to hear that evidence in the hearing room. In addition, we have used pseudonyms to refer to abusers, as required by law, throughout our Inquiry and in this report.117

We also received evidence in a closed hearing where we considered it necessary, including to avoid prejudicing current investigations or proceedings. In that circumstance, only certain people could be present in the hearing room. Transcripts of closed hearings were not published on our website.

We conducted hearings in line with our COVID-19 Vaccination Policy and the Public Health Act. We engaged specialist consultants to provide counselling support to witnesses and attendees.

The hearings process

We identified witnesses for public hearings from our stakeholder consultations, sessions with a Commissioner, public submissions and through other research activities. Individuals and organisations were generally issued with a notice to appear or to prepare a witness statement. Interested parties who wanted to give evidence could apply for leave from their workplace to appear at a public hearing. Witnesses were offered help to prepare for a hearing and counselling support.

Counsel Assisting our Commission of Inquiry, supported by our Legal and Policy and Research teams, led the hearings. Counsel Assisting, in consultation with the Legal and Policy and Research teams, determined the topics of hearings and questioned witnesses, subject to President Neave’s direction.

Counsel Assisting’s general approach to examining witnesses was informed by the victim-survivors and their families and supporters who had been in contact with our Commission of Inquiry. Counsel Assisting aimed to ensure these voices were heard and that the need for systemic change was considered in light of their experiences.118

Witnesses gave evidence orally or by written statement or both, and did so under oath or affirmation.

People granted leave to appear could also ask for leave, through their legal representative, to examine or cross-examine a witness, at the discretion of the President. Leave to cross-examine a witness was requested and granted once during our hearings.119

The role of Commissioners at public hearings was to listen and learn, and to assess the evidence. This evidence, along with all other evidence that we have received during our Inquiry, has informed our recommendations to the Tasmanian Government.

Hearings schedule

Our first public hearing was held in Hobart on 26 October 2021. Due to the ongoing impact of the COVID-19 pandemic, President Neave attended this hearing remotely. At this hearing, President Neave gave an overview of our Inquiry’s progress and next steps. Counsel Assisting summarised the themes and lines of inquiry that had emerged from our work to date.

The next public hearing was held on 2 May 2022. Hearings then continued over the next four months. Each set of hearings had a particular focus, as outlined in Table 1.7.

Table 1.7: Public hearings

Date	Area of focus	Location
26 October 2021	Overview	Hobart
2–6 May 2022	Week 1: Common themes	Hobart
9–13 May 2022	Week 2: Education	Hobart
14–17 June 2022	Week 3: Out of home care	Hobart
27 June–1 July 2022	Week 4: Health	Launceston
4–8 July 2022	Week 5: Health / Criminal justice	Launceston
18–19 August 2022	Week 6: Ashley Youth Detention Centre	Hobart
22–26 August 2022	Week 7: Ashley Youth Detention Centre	Hobart
7 September 2022	Week 8: Ashley Youth Detention Centre	Hobart
8–9 September 2022	Week 8: Health	Hobart
12–13 September 2022	Week 9: Moving forward	Hobart

Who we heard from

We heard from 165 witnesses at public hearings. Most hearings began with evidence from people who had been directly or indirectly affected by child sexual abuse in the institutional settings under review. We heard from victim-survivors and their families and supporters, and from people who have advocated for reform.

We also heard from witnesses who held government and agency roles, including the:

• Secretary of the Department of Premier and Cabinet
• Secretary of the Department of Justice
• Secretary of the Department of Education
• Secretary of the Department of Communities
• Secretary of the Department of Health
• Commissioner of Police
• Director of Public Prosecutions
• Solicitor-General
• Registrar of the Registration to Work with Vulnerable People Scheme
• Registrar of the Teachers Registration Board
• Child Advocate
• Commissioner for Children and Young People
• Ombudsman (who is also the Health Complaints Commissioner and Custodial Inspector)
• Chief Executive Officer of the Integrity Commission.

We also heard from several Deputy Secretaries and managers of government departments, as well as academics, professionals and other experts working in the field of child safety in Tasmania and from other jurisdictions.

Throughout this report, we refer to current Secretaries and staff of relevant government departments by name. These Secretaries are responsible—and therefore accountable—for the Tasmanian Government’s current responses to child sexual abuse in institutions. We have chosen not to name most past Secretaries and departmental staff because our recommendations are based on current systems, policies and practice.

Table 1.8 provides a summary of our public hearings across our areas of focus.

Table 1.8: Summary of hearings

Topic	Education	Out of home care	Health	Ashley Youth Detention Centre	Access to justice	The future	Other	Total
Number of hearing days	5	4	9	8	3	2	6	37 (including opening hearing)
Pages of transcripts	552	503	970	1,054	316	173	137	3,705
Witnesses called	21	27	36	36	13	10	31	165 (some called multiple times)
Witnesses not called but who gave sworn statements	2	5	17	29	0	0	1	51 (some also appeared in other weeks)*
Documents to support Counsel Assisting and parties appearing during hearings	504	529	1,772	1,497	171	72	254	4,779

• Some witnesses gave sworn statements for a hearing topic and then gave oral evidence on a different hearing topic.

What we learned

The public hearings brought much new information to light. They helped us to better understand the systemic and cultural issues relevant to our terms of reference that were unique to Tasmania and had not been addressed by the National Royal Commission. They also allowed us to closely examine the conduct of individuals and institutions in relation to specific reports of child sexual abuse, particularly in education, out of home care, health services and youth detention.

We heard that past and present Tasmanian governments have collectively failed to adequately prioritise the safety of children or the wellbeing of victim-survivors. Prominent among the themes to emerge from the evidence was the need for achievable reform that could be implemented in simple steps.120

Public hearings also offered another opportunity for victim-survivors to speak about their experiences, and for the community, including our Commission of Inquiry, to bear witness. We thank victim-survivors for coming forward and sharing their hopes that tangible, meaningful change will result from our work.

We are aware that thousands of people across Tasmania and Australia followed the progress of our hearings, and we thank the community for its interest. We believe there is a greater community awareness of the prevalence and impact of child sexual abuse in government institutions because of our hearings.

1. Roundtable discussions and briefings

Targeted discussions with senior staff from government agencies and statutory authorities were another source of evidence that informed our Inquiry. These discussions enabled us to better understand aspects of the system and proposals for reform.

On 25 October 2022, we held a roundtable discussion in Hobart with representatives of the Department of Justice, the Director of Public Prosecutions, Tasmania Legal Aid, the Law Society and the University of Tasmania. The topic of this discussion was the Justice Miscellaneous (Royal Commission Amendments) Bill 2022. The Bill introduces legislative amendments in response to the recommendations of the National Royal Commission.121 The purpose of this discussion was to understand the Tasmanian Government’s reform intentions and progress relevant to child sexual abuse.

On 16 November and 5 December 2022, we received briefings from representatives of the Department of Justice on the Bill that became the Child and Youth Safe Organisations Act 2023. The Act establishes the Child and Youth Safe Organisations Framework in response to recommendations of the National Royal Commission. The Act also sets out new child safe standards and a reportable conduct scheme.122

On 9 December 2022, President Neave and Commissioner Benjamin held a roundtable discussion in Melbourne with representatives of Victoria Police. The topic of this discussion was child sexual abuse specialisation in police services. The purpose of the discussion was to understand how a police service in another jurisdiction responds to child sexual abuse in government institutions, with a view to comparing this model with the current response of Tasmania Police.

On Thursday 29 June 2023, we met with the co-chairs of the Child Safe Governance Review, Adjunct Professors Karen Crawshaw PSM and Debora Picone AO, to receive an update on the implementation of their recommendations by the Department of Health and Launceston General Hospital. The Child Safe Governance Review was established by the Department of Health in July 2022 in response to evidence that emerged from our public hearings in relation to responses to child sexual abuse at Launceston General Hospital.123

On Tuesday 4 July 2023, we met with Timothy Bullard, Secretary of the Department for Education, Children and Young People. The purpose of this meeting was to discuss ways to improve responses to allegations of child sexual abuse and harmful sexual behaviours within the Department and across the State Service.

On Wednesday 5 July 2023, we held a roundtable discussion with Jenny Gale, Secretary of the Department of Premier and Cabinet and Head of the State Service, along with representatives from the State Service Management Office. The topic of this discussion was ways to reform the State’s disciplinary processes, including the State Service Act 2000, the State Service Code of Conduct, and Employment Directions.

1. The structure of this report

This report reflects the evidence we received through all our methods of inquiry. We make findings about the conduct of individuals and the systemic problems we identified. We also outline our recommendations for the future, to help prevent child sexual abuse in Tasmanian Government institutions, and to improve responses when it does occur.

Our report has eight volumes:

• Volume 1 provides a summary of our report and our recommendations.
• Volume 2 (this volume) outlines the establishment, scope and conduct of our Inquiry, the international, national and Tasmanian context of our Inquiry, and our understanding of child sexual abuse in an institutional context.
• Volumes 3–6 outline our findings and recommendations for the specific institutional contexts we were directed, or chose, to inquire into, namely schools (Volume 3), out of home care (Volume 4), youth detention (Volume 5) and health services (Volume 6). These volumes differ in their structure, style and approach, which reflects the nature and extent of the evidence we received and the nature of the response of the relevant organisations (and departments) to that evidence.
• Volume 7 provides our findings and recommendations for the criminal and civil justice systems.
• Our final volume, Volume 8, outlines our recommendations for system-wide reforms, including to support the Government to implement our recommendations and to monitor this implementation.

All material referred to in our report is current at 10 February 2023, unless otherwise specified.

1. Conclusion

Since our establishment in March 2021, we have undertaken extensive work to inform our Inquiry into systemic problems in the Tasmanian Government’s response to child sexual abuse in its institutions. We have been informed by submissions, sessions with Commissioners, consultations, engagement with Aboriginal communities, site visits, research, hearings and roundtables, as well as an enormous number of government documents.

Hearing from victim-survivors, their families and supporters has been particularly important to us, and we thank all those who shared their experiences.

All aspects of our Inquiry have informed the views and recommendations in this report. We trust we have done the task justice.