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Legislative Assembly for the ACT: 1999 Week 12 Hansard (24 November) . . Page.. 3607 ..

MR KAINE (continuing):

Chief Minister at that time, it is a matter for their conscience. But I suspect it may well be a matter of electoral consequences for those individuals as well some time in the future.

This onus of propping up the Chief Minister must be sorely testing the continuing loyalty of those individuals. Five months on here we are again in similar circumstances. What has changed? For some here present today, this debate seems to be entirely about the tragic hospital implosion and the consequences, if any, for the Government. For some, it is all so very simple. The coroner has said that the Chief Minister had no responsibility directly or indirectly for the tragic death of Katie Bender, end of story. I wish it were so, but the coroner said a great deal more than that. For those people, there are therefore no other considerations. Consequently, for them there can be no consequence for the Government or anybody else. I do not agree with them. It is not that simple.

The Government has attempted to simplify what the coroner said and to assert that he exonerated Mrs Carnell. The coroner has made a number of significant criticisms of the system which led to the tragedy and criticisms of many of the people involved in it. I will quote just a few. "There were systemic failures", the coroner said. "The contract process was a sham", the coroner said. The coroner further said:

There was an intermeddling by certain officers of the Chief Minister's Department that was not warranted ... There was intermeddling of people who had no knowledge of the subject matter ... Senior officials of the CMD and the Chief Minister's media adviser, with no knowledge of the demolition process, played a prominent, intrusive role that was wholly unwarranted ... Nobody knew who was in control -

and even the Chief Minister was "mistaken" about this -

The responsible organisations lacked expertise ... The handling of the tender process was nothing less than appalling ... The whole process of assessment and review of the tender bids contained flaws and deficiencies ... The process amounted, in effect, to a rubber-stamping of what had already been agreed.

So far as turning the event into a public spectacle was concerned, it:

was a total abrogation of responsibility to the safety and wellbeing of the public ... There is no doubt that the events of Sunday the 13th July 1997 failed such a primary requirement of public safety ... what occurred when Katie Bender was killed was inexcusable.

This is not a total exoneration of Mrs Carnell. It is a litany of criticisms of the organisation and the processes which the Chief Minister set up in the interest of effecting government. These coruscating criticisms sear our conscience as guardians of the public welfare, or they should. These criticisms, while relating solely to the

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