For the past two years, shocking stories of abuse against children at the hands of Launceston General Hospital nurse James Geoffrey Griffin have been in the public domain.
The events of the past week revealed in devastating detail the series of missed opportunities for authorities to act.
Griffin started working in the children's ward on September 11, 2001. The commission uncovered his conduct in 2004 was the first written warning that he hugged an adolescent patient.
The complaints piled up in the years following. Griffin was counselled and warned, but ultimately maintained his access to vulnerable young patients.
Senior managers and human resources representatives from the Health Department were asked to explain their failure to intervene after Tasmania's commission of inquiry into child sexual abuse.
The commission was told that there was no training for hospital staff to identify sexual abuse or grooming behaviours.
Key human resources meetings could not be recalled.
One manager was unaware of the existence of the Tasmanian Advice and Referral Line - the single contact point for child abuse notifications - and obtained much of her information about Griffin from a podcast.
Another admitted that there had been catastrophic failures at the hospital over its handling of Griffin.
A former chief executive said he took only a marginal interest in the revelation that a paedophile had worked in the hospital's children's ward while he was there.
It was this context in which Premier Jeremy Rockliff and Health Secretary Kathrine Morgan-Wicks announced on Sunday afternoon that there would be a governance review of the Launceston General Hospital and the department's human resources area, with a focus on handling serious misconduct.
Following a week of devastating testimony and another set to begin today, it signals a dramatic shake-up.
Those in management's upper echelons have been put on notice.
Ms Morgan-Wicks said I was devastated by the response that some victim-survivors had received from my department.
That means that it is not about tweaking around the edges, it means actually going down and resetting the organisational structure for the LGH. Ms Morgan-Wicks was due to give evidence last Friday, but the hearing was put on hold due to LGH former chief executive Stephen Ayre suffering a medical incident.
The evidence given to the commission showed that devastating mistakes had been made, resulting in harrowing experiences for victim-survivors, for whom the Premier had a message, according to Rockliff.
He said that he is so sorry for your hurt and the pain you've endured due to the failures of governments present and past.
Within a few weeks a central complaints management unit will be established in the office of the secretary.
The changes come many years too late for those affected by the predatory behavior of Griffin and others.
They are a signal that the many lived experiences shared with the commission of inquiry have not fallen on deaf ears.