1. Introduction

Our Commission of Inquiry shares the hopes we heard in evidence from victim-survivors, and their families, carers and supporters, that our Inquiry will result in meaningful change that benefits Tasmania and its children and young people. The Tasmanian Government has said it will implement our recommendations, and we expect this to occur. It would be a tragedy if our report were treated as the product of ‘just another inquiry’, to file and forget. The cost to taxpayers, the trust of the community and the toll on victim-survivors and whistleblowers that comes from telling their stories require a forceful and immediate response.

This chapter discusses ways to ensure our recommendations lead to positive change. We hope to see sustainable systemic improvements that will help prevent child sexual abuse in institutions and improve institutional responses to such abuse. We want better outcomes for children and young people who have been abused.

This chapter lists our recommendations and includes suggested timeframes for implementing them. It focuses on the monitoring and reporting needed to effectively implement these recommendations. We recommend the Tasmanian Government establishes the role of the Child Sexual Abuse Reform Implementation Monitor to oversee and report on the Government’s progress in implementing our recommendations and the recommendations of previous inquiries and reviews.

1. Our recommendations

Our Commission of Inquiry had three main functions.

The first was to provide a safe place where victim-survivors and their families and carers could share their accounts of child sexual abuse in Tasmanian Government institutions. These accounts informed our understanding of measures to prevent, identify and respond to child sexual abuse in Tasmanian Government institutions.

The second was to investigate the adequacy or otherwise of past and present responses to allegations and incidents of child sexual abuse in Tasmanian Government institutions, and to identify systemic issues. Institutions investigated include schools, out of home care, health services and Ashley Youth Detention Centre.

The third was to recommend concrete and practical reforms to address any inadequacies identified, so children can be better protected against child sexual abuse in Tasmanian government institutions.

Our terms of reference directed us to make any recommendations arising from our Commission of Inquiry we consider appropriate. These include recommendations about any policy, legislative, administrative or structural reforms, and to focus our recommendations on systemic issues.

Our report represents the end of our Commission of Inquiry. We make 191 recommendations. During more than two years of operation, we examined more than 95,000 documents, held more than 120 sessions with a Commissioner, conducted hearings over nine weeks and engaged widely with the Tasmanian community. This enabled us to understand the systemic failings in the Tasmanian Government’s response to child sexual abuse in institutional settings and to identify opportunities for lasting reform. Our recommendations represent an extensive reform agenda for Tasmania—the way to achieve a future where children and young people feel safe in government institutions, as they and their families have a right to expect.

Some of our recommendations focus on creating new structures to support a government-wide system where children are kept safe from child sexual abuse and where the Tasmanian Government is held to account for its responses to abuse. Other recommendations concentrate on ensuring the right care and support are available and accessible to children and young people and their families and carers, and to adult and child victim-survivors of child sexual abuse. Others focus on improving processes and procedures regarding child sexual abuse. However, at the core of all our recommendations is the view that the Tasmanian Government and State Service must be accountable for the safety and wellbeing of children and young people in government institutions.

We have articulated a six-year reform agenda that prioritises our recommendations into three waves of reform:

• short-term—by 1 July 2024
• medium-term—by 1 July 2026
• long-term—by 1 July 2029.

We consider this approach balances the need for urgent reforms but also acknowledges that implementing other reforms should and will take careful planning and require long-term investment and support. Our recommendations are listed at the end of this chapter, along with our suggested reform timeframes and role holders or agencies responsible, as a guide for the Tasmanian Government (refer to Table 21.1).

With this report representing the end of our Commission of Inquiry, it is now time for the Tasmanian Government to do the work necessary to implement our recommendations. We acknowledge this will take considerable effort and commitment. In the next section, we recommend establishing the Child Sexual Abuse Reform Implementation Monitor to hold the Tasmanian Government to this task.

1. Monitoring and reporting

The impact of our Commission of Inquiry will depend primarily on the Tasmanian Government implementing the recommendations in our report. Monitoring and publicly reporting on implementation is vital for:

• making real progress in preventing child sexual abuse in government and government funded institutions by learning from experience
• improving institutional responses to child sexual abuse
• improving outcomes for children and young people who have been abused.

This section discusses how implementing our recommendations, and those of other inquiries and reviews, should be monitored and reported against so the public can hold the Tasmanian Government and its institutions to account.

We are mindful the Tasmanian Government has held multiple inquiries and reviews on matters relevant to institutional child sexual abuse. It also has a history of:

• accepting and then not implementing recommendations
• not implementing recommendations in line with the intent of the inquiries or reviews
• failing to implement recommendations in a timely way.

For example, in Volumes 4, 5 and 6 of our report, we discuss how problems identified in previous reviews and inquiries into out of home care, the health system and Ashley Youth Detention Centre have not been addressed over many years. We are also conscious that key recommendations of the National Royal Commission have not been implemented, and it has been more than five years since those recommendations were made. Although the Tasmanian Government has made progress on reforms by introducing the Child and Youth Safe Organisations Bill 2022, which was passed by the Tasmanian Parliament and commenced as the Child and Youth Safe Organisations Act 2023 in July 2023, the Child and Youth Safe Standards and Reportable Conduct Scheme are still in the implementation stages.1

Ongoing monitoring is essential if our recommendations for reform are to be successfully implemented. Monitoring plays an important role in:

• maintaining momentum for reform
• embedding accountability for change
• ensuring progress is transparent
• mitigating and avoiding unintended consequences of reforms
• continuously improving and adapting reform efforts.

Jenny Gale, Secretary, Department of Premier and Cabinet and Head of the State Service, noted the need for independent oversight to ensure change occurs: ‘I do think independent oversight is a very important factor in accountability and also in raising public awareness about what is happening and what needs to be improved’.2

Ginna Webster, Secretary, Department of Justice, who is responsible for the Child Abuse Royal Commission Response Unit, acknowledged the role public monitoring and reporting can play in building trust in government action:

I think one of the barriers that I touched on at the beginning was the need to rebuild the trust and the confidence of the community, so I think that work will have to be done as well as we progress, and I think that’s through regular reporting and monitoring.3

In this section, we discuss our recommended Child Sexual Abuse Reform Implementation Monitor, which would be the key mechanism to hold the Tasmanian Government to account for implementing our recommendations. We also discuss our expectation that the Government reports on its implementation of our and other inquiries’ recommendations. Such reports should examine the implementation of particular recommendations, the broader outcomes of new policies, procedures and laws and the interaction between them.

1. An implementation monitor

In the final two days of hearings, we invited experts to advise us about the way forward, including how to ensure the Tasmanian Government effectively implements our recommendations for reform. Dr Samantha Crompvoets, Director of the Australian Human Rights Commission, told us it is important to monitor the implementation of recommendations to ensure they result in change:

I think that it’s important for people who are giving recommendations to build in a monitoring and evaluation part of it … Otherwise, what happens is in, say, two to three years after those recommendations come out and issues start to bubble up again and there’s another review, and more recommendations, and no one really understands what happened to the initial ones.4

Tim Cartwright APM and Jan Shuard PSM shared their observations and experiences as former Family Violence Reform Implementation Monitors in Victoria, a role responsible for monitoring the implementation of the Victorian Royal Commission into Family Violence recommendations. Mr Cartwright was the inaugural Family Violence Reform Implementation Monitor from August 2016 until August 2019 and Ms Shuard held the role from August 2019 until May 2023. The Family Violence Reform Implementation Monitor concluded its monitoring work on 31 May 2023.5

The Family Violence Reform Implementation Monitor was an independent statutory body. It was established in 2016 in response to the Victorian Royal Commission into Family Violence recommendation that an independent family violence agency be established to hold the Victorian Government to account.6 As Mr Cartwright outlined in his statement to our Commission of Inquiry:

Recommendation 199 concerned the establishment of an independent function to (among other things) monitor and report on implementation of the Commission’s recommendations. That function was created through the establishment of the Family Violence Reform Implementation Monitor (Implementation Monitor) under the Family Violence Reform Implementation Monitor Act 2016 (Vic).7

Mr Cartwright and Ms Shuard observed that a key aspect of the Family Violence Reform Implementation Monitor’s role is to look at how recommendations have been implemented relative to the intended outcomes of the Victorian Royal Commission into Family Violence.8 We note that a flexible approach is sometimes needed when assessing whether a recommendation has been effectively implemented. Mr Cartwright said that he sometimes needed to ‘go behind’ the intent of the Victorian Royal Commission into Family Violence recommendations to work out a better process: ‘So that critical question I always asked was what would make this better for victim-survivors … is this working to produce the outcomes that the Royal Commission in that case wanted?’9

Importantly, Mr Cartwright and Ms Shuard highlighted to us how the Family Violence Reform Implementation Monitor role allowed them to continue advocating for change on behalf of victim-survivors, beyond the life of the Victorian Royal Commission into Family Violence. Mr Cartwright said:

The other important part of the role which surprised me a little was eventually becoming, in some ways, not an advocate for victim-survivors, but certainly the middle person between those implementing and those who were affected or advocating for change.10

Mr Cartwright’s and Ms Shuard’s evidence showed that the role of the Family Violence Reform Implementation Monitor was effective in holding the Victorian Government to account and ensuring transparency in government actions.11 We are of the view that Tasmania needs to establish a similar role to ensure the reform work our Commission of Inquiry and previous inquiries and reviews have begun continues.

We recommend below that a Child Sexual Abuse Reform Implementation Monitor be established. The Implementation Monitor should:

• be independent
• report publicly, through Parliament
• consult and work closely across the child sexual abuse sector, including with government, peak bodies and victim-survivors.

1. Independence

Mr Cartwright told us that the independence of Victoria’s Family Violence Reform Implementation Monitor was essential to the role’s success: ‘It is critical that the legislation establishing the role of Implementation Monitor gives the Implementation Monitor independence, and the ability to report free from interference’.12

When asked to expand on this at our hearings, Mr Cartwright said:

The legislation removes any doubt that the voice of a critical Monitor or a critical person will be made public regardless of whether the bureaucracy or the government of the day agrees or disagrees with it, so that was very important to me ... I still think that some protection of the Monitor’s independence and right to speak publicly is very important as a foundational aspect.13

The Family Violence Reform Implementation Monitor is a statutory role that reports directly to Parliament.14 Mr Cartwright explained in his statement that the Implementation Monitor’s independence was achieved by:

• the statutory nature of the role and the requirement to report directly to Parliament
• the establishing legislation, which gives the Implementation Monitor independence and the ability to report free from interference from the minister or others
• security of tenure of the role, with appointment by the Governor in Council and limited grounds on which the Implementation Monitor may be suspended or removed.15

Ms Shuard agreed about the importance of the Implementation Monitor’s
independence, while maintaining productive relationships.16 She said that in order for independence to be maintained it is essential the Implementation Monitor’s monitoring and reporting functions be separate from implementation functions: ‘I think, if you’re in charge of implementation, you can’t possibly monitor, or if you’re in charge of the framework for implementation and all the elements of it you can’t possibly be an independent Monitor’.17

1. Public reporting

Ms Shuard explained the public reporting requirements of the Victorian Family Violence Reform Implementation Monitor role in her statement:

For the first four years after the Royal Commission [into Family Violence], the legislation required the Implementation Monitor to deliver an annual report to Parliament. The first three reports (tabled in Parliament in May 2018, March 2019 and February 2020) specifically looked at achievements from the previous year but the fourth report, being the last planned report (tabled in May 2021), looked back across all four years. I envisaged that, after delivery of the fourth annual report, the function would cease, as that was all the government had required. However, the Victorian Government has extended the reporting obligation for a further 18 months, although the requirement to table the report in Parliament has been removed and the resources of the office of the Implementation Monitor have been slightly reduced.18

We consider this public reporting requirement is essential to the effectiveness of the recommended Child Sexual Abuse Reform Implementation Monitor’s role in holding the Tasmanian Government to account.

1. Consulting and working across government

We consider that the Child Sexual Abuse Reform Implementation Monitor should consult broadly when determining whether the Tasmanian Government has effectively implemented our recommendations and those of other inquiries and reviews. In the family violence context in Victoria, Ms Shuard said it was important for the Family Violence Reform Implementation Monitor to establish strong relationships across the family violence sector and be transparent with all parties. Ms Shuard said:

I think for me one of the absolute critical roles of the Implementation Monitor is the relationships that you can build with the government agencies, the service providers and the victim-survivors…. The Monitor is a small office relatively to the task, and you couldn’t do your work justice without the absolute cooperation, transparency of the agencies that you’re working with.19

The role of the Family Violence Reform Implementation Monitor was to listen to and reflect all voices in the family violence sector when assessing the effectiveness of the implementation of recommendations, including government agencies, service providers and victim-survivors. Ms Shuard said:

... I guess it was really important to me … to hear the voices of everybody involved. You know, I say you have the designers and the funders of the system, you have the service providers who deliver the services, and you have the victim-survivors who are most important in terms of experiencing the changes in the system but, more than that, influencing the design of the system so that it meets their needs and I think that’s absolutely critical.

I think a view that our job was ... to add value to the outcomes for the family violence systems, so therefore to provide an independent view by listening to all of the voices that were involved in the system, and sometimes there’s a difference, I guess, of view about how it’s going, what’s working, whether it’s being effective in its implementation, and to be able to represent all of those voices so that the designers of the system and the users of the system and those delivering the services get a shared understanding of our independent view.20

Ms Shuard explained how she worked with the Victorian Government in practice:

… when you form your independent view and you do a report, the process of providing that report to the government agencies that are affected, allowing those government agencies to have input into that report insofar as, not just factual errors, but if they think you’ve been unduly harsh perhaps or haven’t captured a point correctly, then it should be—it’s open for them to provide that advice back to the Implementation Monitor.21

Mr Cartwright and Ms Shuard emphasised the importance of a formal mechanism to ensure victim-survivors’ views on the impacts of reform were heard and acted upon during implementation.22 In Victoria, this was achieved through the Statewide Family Violence Advisory Committee, which was set up after the Victorian Royal Commission into Family Violence to advise the Government on family violence policy and service provision.23

In Chapter 19, we recommend the Tasmanian Government ensures children and young people and adult victim-survivors of child sexual abuse can contribute to policy and reform work through the Premier’s Youth Advisory Group and through the establishment of an adult victim-survivors of child sexual abuse advisory group (refer to Recommendation 19.5). We also recommend a peak body for the sexual assault service system in Chapter 21 (refer to recommendation 21.3).
The Child Sexual Abuse Reform Implementation Monitor should consult regularly with these entities about the effectiveness of the implementation of our recommendations and the recommendations of other reviews and inquiries.

1. Future reporting

The National Royal Commission recommended that each state and territory government reports on its implementation of the National Royal Commission’s recommendations through five consecutive annual reports tabled in their respective parliaments.

Adhering to this recommendation, the Tasmanian Government issued its fifth and final annual report and action plan in December 2022.24 The report indicated that, while the Government was committed to ongoing annual reporting on implementing reforms for the safety and wellbeing of children, it was considering changing the form of this reporting.25 The report stated that, given the ‘several inquiries and commissions’ that have examined child sexual abuse in the Tasmanian institutional context in recent years, it proposed annual reporting shifts from a focus on completing the recommendations to outcomes-based reporting.26

While we support a focus on intended outcomes rather than superficial acquittal of recommendations, we are concerned this may result in reducing accountability for implementing individual recommendations, particularly considering evidence we heard from Mr Cartwright and Ms Shuard about the importance of accountability, transparency and reporting at all levels. Any focus on outcomes needs to identify how the intent behind the implementation of individual recommendations has been met.

We consider that implementing recommendations from our Commission of Inquiry and those of other reviews and inquiries across the child sexual abuse sector would benefit from being monitored and reported against by an implementation monitor model similar to the Family Violence Reform Implementation Monitor that was established in Victoria.

Recommendation 22.1

1. The Tasmanian Government should introduce legislation to establish and fund an independent Child Sexual Abuse Reform Implementation Monitor to:
   1. monitor and report to Parliament annually on the implementation of
      1. the recommendations of this Commission of Inquiry
      2. any recommendations of the Royal Commission into Institutional Responses to Child Sexual Abuse that were accepted by the Tasmanian Government and have not been implemented
      3. the recommendations of the Independent Inquiry into the Tasmanian Department of Education’s Responses to Child Sexual Abuse
   2. undertake independent evaluations of the effectiveness of the measures and actions taken in response to the recommendations identified above, especially the impact on the safety and wellbeing of children in government and government funded institutions and victim-survivors of child sexual abuse in institutional contexts.
2. Independent evaluations should enable assessment of change over time and involve:
   1. identifying an evaluation framework and baseline data requirements within the first year of the appointment of the Implementation Monitor
   2. commencing collection of data identified in the evaluation framework as soon as possible after the evaluation framework has been developed
   3. assessing the change against the evaluation framework at five- and ten-year intervals following the tabling of this report
   4. making independent evaluations publicly available.
3. The Tasmanian Government should protect the independence of the Implementation Monitor by:
   1. appointing the Implementation Monitor for a fixed term that cannot be prematurely terminated except in extraordinary circumstances
   2. maintaining the role of the Implementation Monitor until implementation of the recommendations identified above is substantively complete
   3. separately and directly funding the Implementation Monitor, rather than through a line agency.
4. The Tasmanian Government, through the Secretaries Board, should be required to report to:
   1. the Implementation Monitor as requested and in the form required by the Implementation Monitor
   2. the public on its implementation and reform activity through the Department of Premier and Cabinet’s annual report.
5. The Implementation Monitor should consult as required with:
   1. the Premier’s Youth Advisory Council
   2. the adult victim-survivors of child sexual abuse advisory group (Recommendation 19.5)
   3. the peak body for the sexual assault service system (Recommendation 21.3)
   4. the institution-specific advisory groups established within Tasmanian government agencies (Recommendations 9.6, 12.8 and 15.7).

1. Hope for the future

Despite reforms having been made in response to the National Royal Commission, there is much more work to do. These reforms will not be easy. As noted in Chapter 19, the Tasmanian Government has committed to an extensive reform agenda regarding institutional child sexual abuse. The multiple systems involved in responding to institutional child sexual abuse are complex and so, too, are the causes of institutional child sexual abuse. Strong and committed leadership is required across government and institutions for change to occur. We saw this commitment during our Commission of Inquiry—the Premier, along with all major parties, made a public apology in Parliament. The Premier said:

We have failed you; we are all accountable, and we are sorry.

Our institutions have a responsibility to ensure the safety and wellbeing of children, and our institutions have clearly failed in that responsibility ... 27

In the same apology, the Premier committed to implementing our reforms:

Over the past eight months—throughout this Inquiry—we have heard about a very dark chapter in Tasmania’s history.

It’s a chapter no-one should ever, ever forget. And today we give a solemn undertaking to all Tasmanians, to never, ever allow a repeat of this abuse, secrecy and suppression.

To never, ever allow a repeat of the failures that allowed such abuse to occur.

Our Government is acutely aware of the enormous responsibility to act swiftly and decisively to implement the Commission’s recommendations …

This Parliament will be defined by the actions we take now to ensure that the injustices perpetrated by Tasmanian Government institutions can never ever happen again ...

We know there is still much more work to do, and we are committed to making the changes required to ensure Tasmania is a safer place for all children and young people.28

We are pleased the Premier has committed to implementing our recommendations and emphasise that the work is in ensuring that appropriate structures are set up to enable our recommendations and those of other inquiries and reviews to be not only accepted but effectively implemented.

Secretary Gale also committed to achieving change:

It was difficult to listen to but very important and I sincerely thank all of the brave people who have spoken out as part of the Commission’s proceedings, including our state servants, as hearing their stories, their sadness, their frustration, their anger and their feelings of powerlessness has highlighted that there are significant improvements that must be made across the service.

The traumas that systemic failures has caused children, young people and their families has been palpable, and I commit to doing whatever I can to effect change.29

Although our Commission of Inquiry has focused on child sexual abuse in institutions, we also see the potential for our recommendations to have benefits beyond the scope of our Inquiry. These benefits include:

• enhancing responses to all victim-survivors of institutional child sexual abuse
• improving the safety of institutions in relation to all forms of harm that may be experienced by vulnerable people and the responses of institutions when this harm occurs
• providing increased transparency and accountability to change the culture of silence and fear that was so dominant in people who spoke to us.

Throughout our report we have raised the challenges facing a small island state in preventing and responding to institutional child sexual abuse. But these challenges can also be strengths. Having strong, local connections can enable change to be achieved quickly. As Sam Leishman, a victim-survivor, told us (and as we have quoted before):

… we talk about Tasmania as being a small jurisdiction and a small island, and it’s isolating and … we don’t have the resources and how difficult all of that is …. I sometimes think, well, why do we look at it like that, why can’t we look at Tasmania as being a small, isolated state and that’s actually our advantage? We are small, we can set the standards and we can be the one that says, this is the benchmark that everyone else has to meet, and we can do that because we’re small and because we’re isolated. There’s no reason why we can’t do things better here than the rest of the country.30

We agree. There is much cause for hope that effective and lasting reform can and will be achieved.

Table 22.1: List of recommendations with suggested reform timeframes and implementation leads31

Recommendation No.	Suggested reform timeframe (short, medium or long-term)	By when	Suggested implementation lead
Recommendation 6.1	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 6.2	Short term	By 1 July 2024	Office of Safeguarding
Recommendation 6.3	Short term	By 1 July 2024	Department for Education, Children and Young People
Recommendation 6.4	Short term	By 1 July 2024	Department for Education, Children and Young People
Recommendation 6.5	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 6.6	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 6.7	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 6.8	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 6.9	Medium term	By 1 July 2026	Department for Education, Children and Young People (Harmful Sexual Behaviours Support Unit)
Recommendation 6.10	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 6.11	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 6.12	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 6.13	Short term	By 1 July 2024	Tasmanian Government
Recommendation 6.14	Short term	By 1 July 2024	Tasmanian Government
Recommendation 6.15	Medium term	By 1 July 2026	Tasmanian Government; Teachers Registration Board
Recommendation 6.16	Short-medium term	By 1 July 2026	Tasmanian Government
Recommendation 9.1	Short term	By 1 July 2024	Tasmanian Government
Recommendation 9.2	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 9.3	Medium term	By 1 July 2026	Department for Education, Children and Young People; Tasmanian Government
Recommendation 9.4	Short term	By 1 July 2024	Tasmanian Government
Recommendation 9.5	Short-medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 9.6	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 9.7	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 9.8	Medium-long term	By 1 July 2029	Department for Education, Children and Young People
Recommendation 9.9	Short-medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 9.10	Medium-long term	By 1 July 2029	Department for Education, Children and Young People
Recommendation 9.11	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 9.12	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 9.13	Long term	By 1 July 2029	Department for Education, Children and Young People
Recommendation 9.14	Long term	By 1 July 2029	Tasmanian Government
Recommendation 9.15	Long term	By 1 July 2029	Tasmanian Government; Department for Education, Children and Young People
Recommendation 9.16	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 9.17	Medium-long term	By 1 July 2029	Department for Education, Children and Young People; Office of the Chief Practitioner
Recommendation 9.18	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 9.19	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 9.20	Medium-long term	By 1 July 2029	Department for Education, Children and Young People
Recommendation 9.21	Medium-long term	By 1 July 2029	Department for Education, Children and Young People
Recommendation 9.22	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 9.23	Long term	By 1 July 2029	Tasmanian Government; Department for Education, Children and Young People
Recommendation 9.24	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 9.25	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 9.26	Short-medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 9.27	Short-medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 9.28	Medium-long term	By 1 July 2029	Department for Education, Children and Young People; Tasmanian Government
Recommendation 9.29	Medium-long term	By 1 July 2029	Department for Education, Children and Young People; Tasmania Police; Office of the Chief Practitioner
Recommendation 9.30	Short term	By 1 July 2024	Tasmania Police
Recommendation 9.31	Short-medium term	By 1 July 2026	Department for Education, Children and Young People; Office of the Chief Practitioner
Recommendation 9.32	Medium term	By 1 July 2026	Department for Education, Children and Young People; Child-Related Incident Management Directorate; Office of the Chief Practitioner
Recommendation 9.33	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 9.34	Long term	By 1 July 2029	Tasmanian Government
Recommendation 9.35	Long term	By 1 July 2029	Tasmanian Government
Recommendation 9.36	Long term	By 1 July 2029	Tasmanian Government
Recommendation 9.37	Short-medium term	By 1 July 2026	Department for Education, Children and Young People; Tasmanian Government
Recommendation 9.38	Long term	By 1 July 2029	Tasmanian Government
Recommendation 12.1	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 12.2	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 12.3	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 12.4	Short term	By 1 July 2024	Department for Education, Children and Young People; Office of the State Archivist
Recommendation 12.5	Short-medium term	By 1 July 2026	Tasmanian Government
Recommendation 12.6	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 12.7	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 12.8	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 12.9	Medium-long term	By 1 July 2029	Department for Education, Children and Young People
Recommendation 12.10	Short term	By 1 July 2024	Department for Education, Children and Young People
Recommendation 12.11	Medium-long term	By 1 July 2029	Tasmanian Government
Recommendation 12.12	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 12.13	Medium-long term	By 1 July 2029	Tasmanian Government
Recommendation 12.14	Long term	By 1 July 2029	Tasmanian Government
Recommendation 12.15	Medium-long term	By 1 July 2029	Tasmanian Government
Recommendation 12.16	Long term	By 1 July 2029	Tasmanian Government
Recommendation 12.17	Medium term	By 1 July 2026	Tasmanian Government; Commission for Children and Young People
Recommendation 12.18	Medium term	By 1 July 2026	Tasmanian Government; Custodial Inspector
Recommendation 12.19	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 12.20	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 12.21	Short term	By 1 July 2024	Tasmanian Government
Recommendation 12.22	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 12.23	Short term	By 1 July 2024	Department for Education, Children and Young People
Recommendation 12.24	Long term	By 1 July 2029	Tasmanian Government
Recommendation 12.25	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 12.26	Short term	By 1 July 2024	Tasmanian Auditor-General
Recommendation 12.27	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 12.28	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 12.29	Medium term	By 1 July 2026	Tasmanian Government; Department for Education, Children and Young People
Recommendation 12.30	Medium term	By 1 July 2026	Department for Education, Children and Young People (Harmful Sexual Behaviours Support Unit); Tasmanian Government
Recommendation 12.31	Medium term	By 1 July 2026	Tasmanian Government; Department for Education, Children and Young People
Recommendation 12.32	Medium term	By 1 July 2026	Tasmanian Government; Department for Education, Children and Young People
Recommendation 12.33	Medium term	By 1 July 2026	Tasmanian Government; Department for Education, Children and Young People
Recommendation 12.34	Medium term	By 1 July 2026	Department for Education, Children and Young People; Tasmania Police
Recommendation 12.35	Medium term	By 1 July 2026	Department for Education, Children and Young People
Recommendation 12.36	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 12.37	Short term	By 1 July 2024	Ombudsman Tasmania
Recommendation 12.38	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 12.39	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 15.1	Short term	By 1 July 2024	Department of Health
Recommendation 15.2	Medium term	By 1 July 2026	Tasmanian Government; Department of Health
Recommendation 15.3	Short term	By 1 July 2024	Department of Health
Recommendation 15.4	Medium term	By 1 July 2026	Department of Health
Recommendation 15.5	Short term	By 1 July 2024	Department of Health
Recommendation 15.6	Medium term	By 1 July 2026	Department of Health
Recommendation 15.7	Short term	By 1 July 2024	Department of Health
Recommendation 15.8	Short term	By 1 July 2024	Department of Health
Recommendation 15.9	Long term	By 1 July 2029	Department of Health
Recommendation 15.10	Medium term	By 1 July 2026	Department of Health
Recommendation 15.11	Short term	By 1 July 2024	Department of Health
Recommendation 15.12	Short term	By 1 July 2024	Department of Health
Recommendation 15.13	Short term	By 1 July 2024	Department of Health
Recommendation 15.14	Short term	By 1 July 2024	Department of Health
Recommendation 15.15	Medium term	By 1 July 2026	Department of Health
Recommendation 15.16	Short term	By 1 July 2024	Department of Health
Recommendation 15.17	Medium term	By 1 July 2026	Department of Health
Recommendation 15.18	Short term	By 1 July 2024	Department of Health
Recommendation 15.19	Medium term	By 1 July 2026	Department of Health
Recommendation 15.20	Short term	By 1 July 2024	Department of Health; Launceston General Hospital; Tasmania Police
Recommendation 15.21	Long term	By 1 July 2029	Tasmanian Government
Recommendation 16.1	Medium term	By 1 July 2026	Tasmanian Government; Tasmania Police
Recommendation 16.2	Medium term	By 1 July 2026	Tasmania Police; Department of Justice; Department for Education, Children and Young People
Recommendation 16.3	Medium term	By 1 July 2026	Tasmania Police
Recommendation 16.4	Medium term	By 1 July 2026	Tasmania Police
Recommendation 16.5	Medium term	By 1 July 2026	Tasmania Police
Recommendation 16.6	Medium term	By 1 July 2026	Department of Health
Recommendation 16.7	Medium term	By 1 July 2026	Tasmania Police
Recommendation 16.8	Medium term	By 1 July 2026	Office of the Director of Public Prosecutions
Recommendation 16.9	Short term	By 1 July 2024	Tasmanian Government
Recommendation 16.10	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 16.11	Short term	By 1 July 2024	Tasmanian Government
Recommendation 16.12	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 16.13	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 16.14	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 16.15	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 16.16	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 16.17	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 16.18	Short term	By 1 July 2024	Tasmanian Government; Director of Public Prosecutions
Recommendation 16.19	Short term	By 1 July 2024
Recommendation 16.20	Medium term	By 1 July 2026	Department of Justice; Sentencing Advisory Council
Recommendation 17.1	Long term	By 1 July 2029	Tasmanian Government
Recommendation 17.2	Short-medium term	By 1 July 2026	Tasmanian Government; Tasmanian Solicitor-General (or the State Litigation Office)
Recommendation 17.3	Short term	By 1 July 2024	Tasmanian Attorney-General; Tasmanian Government
Recommendation 17.4	Short term	By 1 July 2024	Tasmanian Government
Recommendation 17.5	Short term	By 1 July 2024	Tasmanian Government
Recommendation 17.6	Medium term	By 1 July 2026	Department of Justice
Recommendation 17.7	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 17.8	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 18.1	Long term	By 1 July 2029	Tasmanian Government
Recommendation 18.2	Short term	By 1 July 2024
Recommendation 18.3	Short term	By 1 July 2024	Tasmanian Government
Recommendation 18.4	Short term	By 1 July 2024	Tasmanian Government
Recommendation 18.5	Long term	By 1 July 2029	Tasmanian Government
Recommendation 18.6	Short term	By 1 July 2024	Tasmanian Government; Commission for Children and Young People
Recommendation 18.7	Short term	By 1 July 2024	Tasmanian Government
Recommendation 18.8	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 18.9	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 18.10	Short term	By 1 July 2024	Integrity Commission; Ombudsman Tasmania
Recommendation 18.11	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 18.12	Short term	By 1 July 2024	Tasmanian Government
Recommendation 18.13	Short term	By 1 July 2024	Tasmanian Government
Recommendation 18.14	Short term	By 1 July 2024	Commission for Children and Young People; Registrar of the Registration to Work with Vulnerable People Scheme; Integrity Commission; Ombudsman Tasmania
Recommendation 18.15	Medium term	By 1 July 2026	Commission for Children and Young People; Integrity Commission; Ombudsman Tasmania; Registrar of the Registration to Work with Vulnerable People Scheme
Recommendation 19.1	Short term	By 1 July 2024	Tasmanian Government
Recommendation 19.2	Short term	By 1 July 2024	Tasmanian Government
Recommendation 19.3	Short term	By 1 July 2024	Department of Premier and Cabinet
Recommendation 19.4	Short term	By 1 July 2024	Premier of Tasmania; Department of Premier and Cabinet; Heads of Agencies
Recommendation 19.5	Medium term	By 1 July 2026	Tasmanian Government; Department of Premier and Cabinet
Recommendation 19.6	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 19.7	Medium-long term	By 1 July 2029	Tasmanian Government
Recommendation 19.8	Medium term	By 1 July 2026	Department of Premier and Cabinet; Tasmanian Government
Recommendation 20.1	Long term	By 1 July 2029	Tasmanian Government
Recommendation 20.2	Short term	By 1 July 2024	Heads of Agencies; Tasmanian Government
Recommendation 20.3	Short term	By 1 July 2024	Tasmanian Government
Recommendation 20.4	Short term	By 1 July 2024	Tasmanian Government
Recommendation 20.5	Medium term	By 1 July 2026	Department of Premier and Cabinet; Child-Related Incident Management Directorate
Recommendation 20.6	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 20.7	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 20.8	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 20.9	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 20.10	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 20.11	Medium term	By 1 July 2026	Head of the State Service; Heads of Agencies
Recommendation 20.12	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 20.13	Medium term	By 1 July 2026	Head of the State Service
Recommendation 20.14	Short term	By 1 July 2024	Tasmanian Government
Recommendation 20.15	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 21.1	Medium-long term	By 1 July 2029	Department of Premier and Cabinet; Tasmanian Government
Recommendation 21.2	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 21.3	Short-medium term	By 1 July 2026	Tasmanian Government
Recommendation 21.4	Short-medium term	By 1 July 2026	Tasmanian Government; Department of Premier and Cabinet
Recommendation 21.5	Short-medium term	By 1 July 2026	Tasmanian Government
Recommendation 21.6	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 21.7	Medium-long term	By 1 July 2029	Tasmanian Government
Recommendation 21.8	Medium-long term	By 1 July 2029	Tasmanian Government
Recommendation 21.9	Medium term	By 1 July 2026	Tasmanian Government
Recommendation 21.10	Short term	By 1 July 2024	Tasmania Police; Department for Education, Children and Young People
Recommendation 22.1	Short term	By 1 July 2024	Tasmanian Government; Child Sexual Abuse Reform Implementation Monitor