The revelation that a paedophile had been working on a children's ward in Launceston for 18 years without detection stunned Tasmania. But as more details emerged about the offending of James Geoffrey Griffin, it became clear there had been repeated warnings to multiple agencies dating back two decades. As the state's commission of inquiry into child sexual abuse prepares to sit again, we revisit some of the shocking failures of the system that allowed a paedophile to offend.