A review into a suspected suicide at a Victorian quarantine hotel found there was a 24-hour delay between the last time the man spoke to authorities and the discovery of his body.
The Safer Care Victoria review into the death at the Pan Pacific on April 11 found five calls from authorities went unanswered before the man's body was discovered about 5:30pm.
"My review team found during their interviews that there were other incidents, other events going on at the time that may have been distracting or consuming the time of the authorised officers and police," Safer Care Victoria chief executive Euan Wallace told the state's hotel quarantine inquiry on Thursday.
The review found it was common for guests not to answer calls, "almost always for innocuous reasons".
"Unanswered calls alone did not typically trigger immediate escalation, beyond attempting follow-up calls," the report states.
The man received one welfare check, in the form of a phone call, on his fifth day in hotel quarantine.
Returned travellers were supposed to receive a daily phone call from a nurse to check for COVID-19 symptoms and a call on days three and nine to check on their wellbeing.
"The welfare check team were unable to undertake welfare check calls to the planned schedule as they did not have enough staff to match the required workload," the review states.
It was not unusual for guests to receive their first welfare check five to seven days into their stay, while subsequent checks were often infrequent.
Professor Wallace said some of the calls were made by the Department of Health and Human Services officials, while others were made by staff from travel agency Helloworld.
Some Helloworld calls, however, were unsuccessful because they had to be transferred via the hotel's switchboard, which was often overwhelmed.
The man's death is being investigated by the state coroner.
The Safer Care Victoria review also identified wider issues in the program.
It found staff were unable to access all the information they needed to provide adequate care due to "lack of comprehensive, central, accessible repository for such information".
The review described the day-to-day operations of the program as "marked by a lack of communication and coordination", while there was no formal escalation policy for when things went wrong.
Limited access to personal protective equipment was also an issue, leading to "conflict" between nursing and security staff.
Professor Wallace said the speed with which the hotel quarantine program was established could be to blame for some of the issues.
"We would never ask a health service to set up a program like this in two days, a program of this complexity in two days," he told the inquiry.
Professor Wallace said a copy of the Safer Care Victoria review has been given to DHHS Secretary Kym Peake, but he is unsure if one has been given to Health Minister Jenny Mikakos.
DHHS Deputy Secretary Melissa Skilbeck also appeared before the inquiry to defend the decision to not to put Chief Health Officer Professor Brett Sutton in charge of the state's emergency response.
The chief health officer is supposed to assume the role of 'state controller' in a pandemic, but the role was allocated to others.
Ms Skilbeck said Professor Sutton didn't have time to assume the role, which was largely logistical.
"To your mind, was the Chief Health Officer in agreement (about the decision)?" counsel assisting the inquiry Ben Ihle asked.
"No, he was not," Ms Skilbeck replied.
She noted the decisions of Professor Sutton "cannot be overridden by the state controller".
Ms Skilbeck was also not aware an offer was made prior to June 23 to use Australian Defence Force personnel "in lieu of private security".
Dozens of guards contracted COVID-19 while working at two hotels and spread it into the community, leading to the state's second wave of the virus.
The inquiry continues on Friday.
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