Without the Commission of Inquiry, the Duncan family is convinced the full story of Zoe would never be told and justice would never be reached.
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In the 21 years after her alleged rape by a doctor in the LGH accident and emergency, parents Anne and Craig Duncan and sister Amanda have endured repeated failures by authorities to take Zoe's story seriously and fear there were attempts to cover it up.
Knowing that others had gone through similar experiences provided no relief at all. It only compounded the grief.
"It's like a scar. It's a very deep wound," Mrs Duncan said. "Zoe's story would have been buried along with her. No one ever listened," Mr Duncan said.
Towards the end of the latest section of hearings, the Duncans received apologies from former LGH chief executive Kim Stackhouse, Police Commissioner Darren Hine, and Child and Family Services director Claire Lovell.
More on the LGH hearings in the Commission of Inquiry:
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- Concern after concern, but why did Griffin's manager not act for 11 years?
- The Griffin evidence that was ignored in 2000, before he even worked with children
- One LGH nurse's battle to make James Griffin story public
- LGH worker disclosed Griffin abuse in 2011, so what happened next?
- Department described Griffin comments to girls, 14, as 'well intended'
- Former LGH CEO suffers 'medical incident' while giving evidence; discrepancies in evidence questioned
They are now awaiting the evidence of LGH clinical services director Peter Renshaw, a key figure in their attempt to get answers.
Mr Duncan said the apologies were a start, but there was still more to be done.
"It's validating for us that they're now saying they believe Zoe's disclosure," he said. "It would have been validating for Zoe, and I think it would have given her the mental strength to keep going.
"The disappointing thing is that no one has come out voluntarily to apologise. It's taken the Commission of Inquiry to prod them to."
Doctor preys upon victim
Despite living with epilepsy, chronic asthma and juvenile arthritis, Zoe Duncan was a carefree and trusting 11-year-old who loved sport.
She was taken to the LGH A&E on May 18, 2001, to be treated for asthma. This is when the Duncans first encountered the doctor, who was assigned as her treating doctor the next day.
When told that Zoe would be taken to ward 4K, Mr and Mrs Duncan went home to collect some belongings for her overnight stay.
Mr Duncan returned to find Zoe in the foetal position on the bed. She told him of her fear of the doctor, that he was "dangerous", and that he had inappropriately touched her.
More on Tasmania's out of home care system:
Mr Duncan struggled to find another doctor or nurse to speak to. The area was completely quiet. He eventually found a nurse who reported the complaint, and a meeting was held with other staff on shift.
He was told the doctor would not be permitted to see Zoe in 4K. But in the 10 to 15 minutes that Mr Duncan went to collect belongings from the car, the doctor had visited Zoe and told her: "remember, this is our little secret".
The next day, Mr Duncan encountered a female registrar - who had been on duty that night - in a lift who warned the family that the doctor could take the matter to lawyers, which he described as "a thinly veiled threat". This registrar was later identified by Zoe as a witness to the criminal act, but was never interviewed.
Mr Duncan noticed blood on Zoe's underwear when he went to put them in a washing machine. And then, the following day, Zoe made her first key disclosure to her mother that the sexual assault by the doctor was far more serious.
Failure to believe, to outright rejection
The family say they had several meetings with Dr Renshaw over the coming days that left them feeling like the matter would not be reported any further. He interviewed Zoe on May 21, 2001.
The Duncans claim they were given a range of excuses: that the doctor's English was poor and he could have been misinterpreted, that it was not unusual for doctors to follow-up with patients after they moved wards and that he squeezed her breast while trying to locate the heart.
Mr Duncan said he told Dr Renshaw that he was cautious to avoid falsely accusing someone of a crime, but he was concerned the hospital's response had been "tenuous".
This comment was later used by the hospital, police and child services to help justify the outcome of their investigation: that the allegation was unsubstantiated.
It was only after the Duncans arranged for Zoe to see a psychologist that the allegations were reported to Child and Family Services, but not until May 29 - 10 days after the incident. CFS started investigating on June 12.
Zoe continued to progressively disclose the scale of the abuse she suffered, as is common with young victims. She made reference to it in a school end-of-term reflection task and ultimately asked her mother "will I be pregnant?", disclosing she had been raped.
The next day, she was taken for a medical examination but it was found to be "inconclusive". Five weeks had passed since the incident. The Duncans claim the doctor was not trained in forensics and had no scope to make a determination, but police relied upon this report.
Despite Zoe giving full and detailed descriptions of the incident to CFS, the matter was not reported to police. The Duncans took this upon themselves and Zoe was interviewed by police on October 3.
But the police report stated the assault could not have happened as Zoe was in full view of others, and her account had been "contaminated" due to being asked to retell it multiple times.
Mr Duncan said this ignored his own evidence that the A&E was practically deserted at the time, and that Zoe only told her story so many times as requested by authorities.
"There appears to be a narrative in all the reports which is consistent with the view the authorities just wanted to 'make it go away'," he said.
Poor investigations start to 'cascade'
Former health minister Judy Jackson arranged a meeting with LGH leadership in November 2001 where the Duncans further outlined their concerns, including a lack of a chaperone policy at the LGH. They were told this policy had been "implied".
Once again, Zoe was criticised for not reporting the rape allegation at the time.
The following May, Laurel House wrote to LGH leadership stating the Duncans were still dissatisfied, and in August a complaint was made to the Medical Council of Tasmania.
This complaint was also dismissed due to the other reports claiming the allegation was unsubstantiated.
"Anne and I were conscious of the cascading impact the poor initial 'investigations' had on subsequent reports and ultimately the findings from the MCT," Mr Duncan said.
The doctor was able to move interstate to practice, but a subsequent complaint was upheld earlier this year. His registration was cancelled.
As her parents desperately tried to get answers, Zoe's mental health continued to deteriorate.
She developed acute anxiety in a range of situations outside of the home, had difficulty sleeping and started to self-harm.
Her medical issues meant there was the constant threat of having to attend the LGH again. When the family sought psychological support from the LGH, they were told they would need to go through lawyers.
Any last remaining trust Zoe had in the LGH was lost when a doctor claimed she was having "pseudo seizures". This came after the extent of Zoe's psychological harm was outlined to the hospital.
The Duncans were outraged. Zoe's conditions had been diagnosed at 13 months, but now she was being told she was, essentially, doing it to herself.
In 2015, she refused to attend the LGH again.
Zoe died two years later, aged 28.
Despite a provisional consideration being Zoe's epilepsy, the final coroner's report stated she had died of bronchopneumonia.
The Duncan family disputes this, as the report states there was no scarring on her lungs. Her arms were crossed in the prone position on the ground, consistent with Sudden Unexpected Death in Epilepsy.
They maintain that this was her cause of death, but that would have broader implications for the hospital.
"Can't help but wonder whether this report has also been influenced by other factors," the family said in their statement to the Commission of Inquiry.
An opportunity for change
The Commission of Inquiry has exposed significant failings in child protection in the LGH, prompting the Health Department to start a full governance review.
The Duncan family continue to reflect deeply on their own journey, but each piece of evidence since 2001 has been further proof to them that, had Zoe's complaint been handled appropriately, future issues in the LGH could have been avoided.
Mrs Duncan said she was still concerned that parents were too often being sidelined.
"There's a need for openness, to listen and to work in partnership with parents, not in a hierarchical manner. That's a key thing: to listen," she said.
They want to see "radical reform" of the LGH, including people in key positions that are "ethical and honest".
Mr Duncan said the safety of patients - particularly children - had to come first, rather than the LGH trying to maintain its image at all costs.
"There needs to be an openness to the fact that sexual assault and all sorts of other things can occur in a hospital setting, it can occur whether you're a doctor or a dentist or a teacher, it doesn't matter who you are, no one is immune from this sort of stuff," he said.
"Back then - and I'm not sure if it's changed a lot now - there's this perception that they were wanting to maintain this image that, 'no, we're above all that, that couldn't possibly happen'."
Mr and Mrs Duncan made a promise to ensure Zoe's story was told. They are grateful to former premier Peter Gutwein for giving them the opportunity to have a full investigation, and Premier Jeremy Rockliff for furthering it.
"At a family level, this has allowed an opportunity to voice Zoe's truth, which Zoe had long wanted to share but during her lifetime the opportunity, and perhaps the preparedness of the community to listen, didn't present itself," the family said in a statement.
The Commission of Inquiry continues on August 18 with a focus on Ashley Youth Detention Centre.
Further Health Department officials, including Dr Renshaw, will appear at hearings in September.
Sexual assault support services:
- Sexual Assault Support Service (Tasmania): 1800 697 877
- Lifeline (24-hour crisis line): 131 114
- Tasmania's Victims of Crime Service: 1300 300 238
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