- Banksia Hill was not prepared for an emergency. The Emergency Management Plan was out-dated and had not been reviewed post amalgamation, and other policy and procedural updates were incomplete at the time of the riot. (Read more)
- Banksia Hill staffs’ initial response to the out of bounds incident was both timely and appropriate, and early decision making was based on the increasing risks of the event. (Read more)
- The Department of Corrective Services was not adequately prepared to respond to an incident of this size on a Sunday night. (Read more)
- There was no evidence that the detainees who initially absconded planned to instigate an event on the scale that occurred. There was no concerted attempt to break out of the centre and little evidence of an intention by detainees to target staff or to injure other detainees. (Read more)
- The decision to transfer detainees to Hakea Prison on the night of the riot is likely to have been the least worst option for the detainees. However, because there is no departmental documentation of the decision making, the rationale for the decision is unclear. (Read more)
- The Department of Corrective Services made a concerted effort to support staff after the riot; however factors that staff directly attributed to causing the riot have not changed and therefore recovery will be limited. (Read more)
- Detainees were locked down excessively in the period leading up to the riot. The Department had previously failed to understand that lockdowns compromised the safety and security of the centre instead stating lockdowns provided safety and security. Many detainees noted that their participation on the night was due to those lockdowns. (Read more)
- The detainee behaviour management system is struggling because the suite of options available to Banksia Hill is primarily dependent on accommodation. (Read more)
- Banksia Hill staff and centre management lack security awareness and the Department of Corrective Services is unable to manage non-compliant staff. (Read more)
- Banksia Hill has a poor training culture which is further hampered by staff shortages and competing priorities. (Read more)
- Banksia Hill record keeping practices are inadequate. (Read more)