Zoe Duncan went into the Launceston General Hospital in northern Tasmania a carefree and happy 11-year-old who was learning to live with her epilepsy, asthma and juvenile arthritis.
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Within just hours of her admission in May 2001, the lives of herself, her parents and her sister were changed forever.
Zoe was sexually assaulted while in accident and emergency; the doctor had capitalised on the moment when Zoe was apart from her family.
She made an almost immediate disclosure to her father, and then several later disclosures.
The sexual assaults - including an allegation of rape - left her facing years of mental anguish including agoraphobia, sleeplessness and an intense fear of the LGH. She died in 2017, two years after deciding to never attend the hospital again.
Elizabeth Stackhouse - the LGH chief executive officer at the time - admitted the way the hospital responded to her complaint "collectively let the family down".
Family felt the complaints were not taken seriously
Parents Anne and Craig Duncan admit that Zoe's disclosure was so completely shocking they struggled to comprehend how to immediately respond.
They believe their confusion was taken advantage of by the hospital.
Mr Duncan said the A&E was quiet at the time, there were only two other patients and he struggled to find a nurse to discuss Zoe's immediate disclosure with.
The next day, they say they received a "thinly veiled threat" from the nurse registrar about the allegation, and were then given a meeting the day after with the director of medical services, Peter Renshaw.
The parents say Dr Renshaw then interviewed Zoe.
Mr Duncan said they were unsatisfied with the way in which Dr Renshaw responded to their immediate follow-up questions, describing it as "dismissive" and that there was a suggestion that the accused doctor's actions may have been misinterpreted by Zoe.
The matter was not reported to Child Protection for nine days.
"I felt there was a charm offensive going on that was intended to derail any further reporting," Mrs Duncan said.
"We were made to feel, I think, to be frank, guilty about trying to pursue anything," Mr Duncan said.
And even then, the parents say the hospital only reported the matter to Child Protection because they had since informed a psychologist and a GP about the situation.
In a file note, Dr Renshaw believed the parents were reluctant to have the matter reported to Child Protection and were satisfied with the "monitoring plan" that was in place after their meeting.
IN OTHER NEWS:
Mr and Mrs Duncan dispute this claim, and said the hospital staff - as mandatory reporters - should have reported it regardless. It was not until later that Zoe made her full disclosure.
They blame this "delay" by the hospital for resulting in an incomplete investigation by police and Child and Family Services. Both reports determined the assaults were "implausible" because the A&E was "busy" at the time - an assertion completely counter to Mr Duncan's evidence.
Ms Stackhouse told the Commission of Inquiry that hospital policy had not been followed in Zoe's case, and there should have been an "immediate" notification with Child Protection.
She said the matter also should have been handled independently, rather than in-house by Dr Renshaw, but she could not recall if she reprimanded him.
Ms Stackhouse offered the family an apology.
CORRECTION An earlier version of this article stated Zoe Duncan was allegedly sexually assaulted by a nurse on two occasions in the LGH. This was incorrect. Ms Duncan was allegedly sexually assaulted by a doctor - not a nurse - while in accident and emergency in one incident, not while in ward 4K.