The human resources staff member who drafted the finding had no training in grooming behaviour.

Registered nurse Will Gordon - who worked alongside Griffin in the Launceston General Hospitals' ward 4K - made the complaint on the incident management system, SLRS.

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It followed an incident where Mr Gordon was supervising a group of girls who were being treated for eating disorders. They had commented that Griffin had given them advice for boys, and described a colleague as "titsy" who he wanted to "shag".

Mr Gordon raised this with nurse unit manager Sonja Leonard and was asked to make a complaint on SLRS, requesting anonymity in his initial email.

The way in which this complaint was handled proved to be a key precursor to the Commission of Inquiry. Mr Gordon, unsatisfied with the lack of response, took it to the very top of Tasmania's health system.

Health Department human resources consultant Mathew Harvey was immediately notified by Ms Leonard of the SLRS complaint.

They sought a response from Griffin, who admitted to giving the girls advice to "look natural" on Snapchat, but said the "titsy" comment occurred outside of the workplace in a different context.

His evidence was accepted.

Only several other nurses on shift were interviewed, but none had witnessed the incident.

Griffin's response was not run past Mr Gordon, nor were the four girls interviewed. One of the girl's mothers - who could have given evidence on Griffin's account - was also not interviewed.

Mr Harvey said a decision was made not to interview the girls due to concerns it could interfere with their therapeutic treatment, but admitted he had no qualifications to make this determination.

"We thought we had sufficient evidence to make the finding on these allegations," he said.

"Could we have gone to the four girls? Yes we could have."

It was deemed a "low level investigation" based on a risk matrix. The comments were not seen as sexualised in nature.

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The allegations "cannot be substantiated", the finding reads. It was provided to Mr Griffin, but not to Mr Gordon.

The letter to Mr Griffin described his actions as "reasonable, well intended and appropriate".

Counsel assisting Elizabeth Bennett SC asked Mr Harvey why this "positive finding" was made.

"I don't recall why those words were used," he said.

Mr Harvey had access to a range of past conduct complaints against Griffin.

These included three incidents in 2009 and findings that he had breached professional boundaries with children, including cuddling a patient and contravening a child's care plan.

Griffin had already been told that a failure to change his behaviour would result in an escalation of the matters.

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Mr Harvey said he was aware of these past professional boundaries breaches.

"I didn't have the full details of the other investigations," he said.

This was based on an interpretation of an Industrial Commission decision. The government had previously used Solicitor-General advice to argue it could use previous "unsubstantiated" complaints as part of future investigations into staff, but this was rejected.

That matter, however, did not involve allegations involving the safety of children.

"I mean, it's the same thing," Mr Harvey said.

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"If we were to find him guilty and then he ... appealed it through the Industrial Commission ... then you've relied on unsubstantiated claims to make a finding and you can't do that."

Ms Bennett questioned whether unsubstantiated complaints were effectively "put in a memory hole", even if they were only six months apart.

Mr Harvey said this was "a risk".

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