The man has since been charged and was expected to front court today.

Police Commissioner and state emergency coordinator Grant Stevens this morning told reporters that human error was largely to blame for enabling a 33-year-old man to walk out of his room about 10pm last Thursday, undetected, and leave the Grand Chancellor medi-hotel through a fire exit stairwell.

“We acknowledge this was a failing and we’ve taken steps to ensure it doesn’t happen again,” Stevens said.

The investigation found it took seven seconds for the man to leave his room and enter the fire exit without being seen on CCTV which is monitored 24-hours a day by two staff.

There were no guards in the hallway and there was no alarm on the fire exit.

Stevens said a police and security patrol saw the man in the basement carpark and spoke to him but let him go after he told them he’d stumbled into the carpark from a nearby pub.

“In the carpark he was approached by a patrol and that patrol queried why he was in the carpark and that person told the patrol that he’d come out of the Duke of York Hotel and was just looking for a breath of fresh air,” he said.

“The patrol then moved him out of the Grand Chancellor Hotel carpark and he returned to the Duke of York Hotel.

“From our examination, this is a security breach that should not have happened.

“It’s disappointing that it did happen and it happened as a result of two specific failings and an issue in terms of how the fire exits are being managed within the hotel precinct.”

The man, who had left the medi-hotel about 10pm on August 12, spent eight hours in the community – including at the Duke of York Hotel and a nearby McDonalds – before returning about 6am the following morning.

He is from New South Wales and had arrived in SA on a Singapore repatriation flight, which required him to do 14 days of hotel quarantine.

Police say he was fully vaccinated and at the time of the incident had returned three negative COVID tests. He has since again tested negative.

Stevens acknowledges the situation could have been far worse.

“These were relatively minor failures that could have had potentially significant consequences,” he said.

“If this person had been COVID positive then I think the SA Health contact tracing team would have had a significant effort ahead of them to get in front of this virus again and minimise the potential spread of the virus into the community.”

Stevens said a series of recommendations had already been implemented “to ensure the likelihood of this type of thing happening again is dramatically reduced”.

“The people concerned in terms of monitoring CCTV didn’t get it right on the occasion even though this person was only in view for seven seconds,” he said.

“Our system should have picked up his departure from his room.

“And the police patrol that spoke to the person in the carpark on reflection should have asked more questions in relation to the reason for him being in the carpark.

“We are confident that the matter has been resolved, in terms of the staff, the management, having been spoken to about the way they’ve gone about their job. I’m very confident that this type of breach is unlikely to happen again.”

Stevens said changes to be made as a result of the findings include:

• Retraining for security staff monitoring CCTV
• Counselling police officers to ensure they thoroughly investigate the presence of people within the hotel precinct
• Improving security around fire exits with sensors
• Fixing CCTV “time lag”

“We’ve recognised the failures at this point in time, we’ve corrected those failures, the people involved understand how they could have done a better job, they’ve been spoken to by their managers and we are going to move forward now,” Stevens said.

Security personnel won’t be placed in the hotel’s hallways as part of the changes.

“Not at this point because by placing staff into the hallways we are actually potentially increasing the risk of infection spreading,” Stevens said.

“CCTV is a more effective way to go.”

He described it as an “isolated” incident from more than 22,000 people going through the state’s hotel quarantine system.

“This isolated incident happened partly due to the close proximity of the man’s room to the fire exit and his lies to police,” he said.

“While there will be changes made to systems and processes, I am confident that overall South Australia’s medi-hotel quarantine arrangements remain appropriate.”

But Opposition health spokesperson Chris Picton said it “once again” highlighted the “need” for purpose-built quarantine facilities.

“For the past nine months we have been arguing that we need purpose-built quarantine,” he said.

“Medi-hotels are risky. They continue to have leaks of the virus right around Australia into the community.

“If this was a purpose-built quarantine facility, there’s no way somebody would be able to wander outside and wander across to the pub across the road.

“We have heard from the Police Commissioner and the Chief Public Health Officer that they would support having purpose-built quarantine facilities if the government was to embark upon building them.

“But (Premier) Steven Marshall has not gone down that path.”

A State Government spokesperson accused the Opposition of undermining health advice.

“Health experts advise there is no alternative location in SA that would lead to better outcomes,” the spokesperson said.

“The Federal Government has made it clear a purpose-built facility is only an option for states who are willing to use it to lift their cap of overseas arrivals – we already do our national per capita share and do not want to increase our cap at this stage.

“Since day one, we have backed the health advice – and that advice is that the medi-hotel system is the most appropriate system we have in the short and medium term to safely bring returning Australians home from overseas.

“The State Government 100 per cent backs our health workers and SAPOL officers in how they are protecting all South Australians.

“Vaccination is our pathway out of the pandemic and I urge every South Australian to roll-up as soon as they can.”

The Opposition also called for the medi-hotel breach investigation report to be made public but Stevens said yesterday he wouldn’t do that because it was an “internal police document”.

“As long as the findings and the outcomes are made clear and transparent then I think that serves the purpose that people are seeking and that’s to understand what’s happened and what we’ve done about it,” Stevens said yesterday.

The man at the centre of the scandal, who finished his quarantine yesterday, has been charged with breaching the Emergency Management Act.

He was remanded in custody to appear in the Adelaide Magistrates Court today.