A dysfunctional staff culture in the children's ward of a Tasmanian hospital created the "perfect storm" for a male nurse to take advantage and abuse kids.
An inquiry into state government responses to child sexual abuse allegations in the public service is this week examining James Geoffrey Griffin.
Griffin worked in ward 4K at the Launceston General Hospital for almost two decades until being charged with child sexual abuse offences in 2019.
He took his own life not long after being charged, while on bail.
His unit manager for 11 years, Sonja Leonard, told the inquiry of multiple professional boundary breaches recorded against Griffin.
In separate 2009 incidents he stayed with a child against her care plan, cuddled a child, gave his mobile number to a patient and was reported as a "sleaze" by the mother of a patient.
Griffin was warned about the breaches and several others, but the matters weren't escalated.
Ms Leonard agreed from the time she became manager in 2008 Griffin had an "everyday manner" of hugging child patients and using terms like "baby".
Counsel assisting the inquiry Elizabeth Bennett SC asked: "In all the boundary violations we have talked about, did you perceive a risk to children?"
"Not at the time I didn't," Ms Leonard replied.
"Looking back now?" Ms Bennett asked.
"Most definitely," Ms Leonard replied.
Ms Leonard said she didn't receive training about identifying grooming until 2020 and has a "lot to learn".
"The complexities ... the culture and the conflict and the undermining that was going on in the ward at the time unfortunately were a perfect storm for Griffin to take advantage of," she said.
"I feel deeply that we were deceived, we were manipulated. We were sold a version of Griffin he wanted us to believe."
Several people have told the inquiry they were abused by Griffin at the hospital and elsewhere.
One woman, a then-colleague of Griffin, said she told the hospital in 2011 he had abused her as a child.
She said the response of human resources personnel was that nothing could be done without a conviction.