Calls are growing for Daniel Andrews to resign after an inquiry heard the state's hotel quarantine disaster caused 768 deaths and more than 18,000 coronavirus infections.
Victorian Opposition leader Michael O'Brien said the quarantine operation was 'the worst failure of public administration in Victorian history'.
He added: 'If accountability for the deaths and damage is to mean anything, all those responsible must go - starting with Andrews.'
Calls are growing for Daniel Andrews (pictured) to resign after an inquiry heard the state's hotel quarantine disaster caused 768 deaths
Victorian Opposition leader Michael O'Brien said the quarantine operation (pictured are travellers arriving) was 'the worst failure of public administration in Victorian history'
On Monday afternoon the final day of Victoria's hotel quarantine inquiry heard the program's failure was responsible for the deaths of all 768 residents who have died in the state's second wave.
Counsel assisting Ben Ihle said: 'The failure by the hotel quarantine program to contain this virus is at today's date responsible for the deaths of 768 people and the infection of some 18,490 others.
'One only needs to pause and to reflect on those figures to appreciate the full scope of devastation and despair'.
'This was a program which failed to meet its primary objective.'
Mr Ihle said protective gear was not used properly, staff were poorly trained and there was a lack of social distancing at the quarantine hotels.
He said the system was set up quickly and the government failed to monitor it.
'What was established was necessarily untested and prudence dictated that the program should have been accompanied by intensive ongoing monitoring and auditing,' he said.
'The Victorian government failed to adequately ensure that this was done.'
Former Health Minister Jenny Mikakos resigned on Saturday after Mr Andrews said she was 'accountable' for the quarantine program.
On Sunday Mr Andrews said he would not resign, telling reporters: 'I don't run from problems and challenges'.
The final day of Victoria's hotel quarantine inquiry heard the program's failure was responsible for the deaths of all 768 residents who died in the state's second wave. Pictured: Security guards at a quarantine hotel
Melbourne's second wave of coronavirus was sparked in late May when the disease escaped from a quarantine hotel and rapidly spread around the city.
'The scientific evidence now strongly suggests, and we submit that the board can comfortably find, that 90 per cent of positive cases in Victoria since [26 May] are attributable to that initial outbreak at the Rydges in late May,' Mr Ihle said.
The Victorian government has been criticised for using private security guards to man the hotels instead of the police and ADF troops like in New South Wales and Queensland.
The inquiry heard the fateful decision to use guards was likely made at a meeting at the state control centre on the afternoon March 27.
But the decision wasn't made by one person or government department.
Rather, counsel assisting the inquiry Rachel Ellyard said it was a 'creeping assumption that became a reality'.
'While no one person made a decision, by the end of that state control centre meeting, it was understood by all present that that was what was going to happen,' Ms Ellyard said in her closing submission on Monday.
Opposition leader Michael O'Brien
In that meeting, Victoria Police Assistant Commissioner Mick Grainger said it was the force's 'preference' that private security be used.
Emergency Management Commissioner Andrew Crisp stepped out of the meeting to take a call from Victoria Police Chief Commissioner Graham Ashton.
Mr Crisp then texted Mr Grainger: 'I stepped out to speak to Graham and I let him know you're in this meeting... He made it clear... that private security is the first security option at hotels and not police'.
Ms Ellyard said Victoria Police's preference was a 'substantial contributing factor to that creeping consensus'.
'The expression of a preference can readily be understood to have given the clear impression that police weren't going to do it and there needed to be an alternative,' she said.
Ms Ellyard said once the decision had been made, no one in the meeting gave 'any specific consideration' to the suitability of private security for the role.
Contracts written up by the Department of Jobs, Precincts and Regions left infection control and training in personal protective equipment use to the security companies.
Hotels, meanwhile, were responsible for cleaning, unless a returned traveller tested positive to Covid-19.