A police doctor who was the subject of multiple complaints of sexual assault was allowed to continue examining police recruits for nearly 15 years.
The Independent Police Conduct Authority (IPCA) has found the police failed to investigate the doctor until a formal complaint was made in 2017, a year after he finished working for police.
At least seven complaints were made ahead of the formal complaint that sparked a criminal investigation in 2017.
During the investigation more than a quarter of the former recruits spoken to by police raised concerns about the doctor's conduct during examinations.
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Almost 118 people asked to contribute information to the investigation, but the team only managed to speak with about half of those who had put their hands up.
Complaints were made by both men and women and ranged from recruits saying they had been asked to undress for flexibility tests to allegations of inappropriate and intrusive examinations from the doctor.
One police staff member reportedly stopped referring women to the doctor, but men were still referred.
There was insufficient evidence to lay charges and the doctor successfully appealed a Health Practitioners Disciplinary Tribunal finding that he had departed from professional standards during examinations.
The seven initial complaints made before the formal complaint was laid were only reviewed by police, the IPCA said, and it was unacceptable police continued to contract the doctor without a full investigation or even questioning his alleged conduct, and this had put the recruits at risk.
It said police should have investigated the first complaint in 2002 and every subsequent complaint received, and there should have been support provided to each of the complainants.
But once the formal complaint was lodged an appropriate investigation did happen and the final complainant did receive appropriate support.
Judge Kenneth Johnston stressed that the IPCA was not investigating the lawfulness of the doctor's actions, but the police response.
"Our role was limited to making an assessment on the police's response to a series of informal complaints over a number of years, and then a formal complaint in August 2017.
"And our conclusion was the police didn't do what they needed to do in terms of making inquiries over that 15 year period, although they did so when the formal complaint came in.
"And also that they didn't at any stage support the recruits in a way that in our view they should have."
Police agree they failed to respond properly
Police say their failure to respond to multiple allegations of sexual assault against the police doctor reflected the way their systems worked at the time.
Deputy Commissioner Tania Kura said she accepted the authority's findings that police failed to meet their obligations for the safety and well-being of recruits.
She acknowledged the people who had the courage to come forward to complain about the doctor.
"This is clearly a situation in which police's high standards when dealing with historic allegations of this kind have not been met.
"It is important to note that both police's own criminal investigation, and a disciplinary investigation by the Medical Council's Health Practitioners Disciplinary Tribunal, both found insufficient grounds to proceed with further action including criminal charges.
"Nevertheless, police accept that the response to these historic allegations wasn't sufficiently robust or timely given their seriousness, and that this was a reflection of systemic issues at the time."
She said steps had been taken to ensure it did not happen again and there was now a clear pathway for all employees to raise their concerns and have them dealt with properly.
"There are a range of support services available which are confidential and tailored to the specific needs of the individual and clear outcomes to address behaviours that are found to be unacceptable or unlawful," Kura said.
Sexual violence advisor and advocate Louise Nicholas said police had lifted their game in responding to sexual violence in recent years.
"I'm pleased that they did do an investigation. I'm sad that it took all this time for somebody to put their hand up and say 'we will look into this', and they have done that, but obviously not enough to proceed to a prosecution," Nicholas said.
She said it was important for survivors of sexual violence to find the right person to hear about their experiences.
"When bad stuff happens it is okay to go and speak to someone. If you're not comfortable with those that are around you, step outside the region because there will be somebody out there who will listen, who will help you walk through a process. Don't give up," Nicholas said.