A Show Cause Notice was issued prior to the inspection
Nearly two years after a Show Cause Notice was first issued for Hakea Prison, conditions across the custodial estate remained in crisis. The male prisons, Hakea and Casuarina, and Melaleuca Women’s Prison faced particular challenges, and all three facilities were the subject of a Show Cause Notice prepared shortly before the on-site inspection of Melaleuca.
The inclusion of Melaleuca in a subsequent, system-wide Show Cause Notice reflected the seriousness of ongoing risks at the facility, particularly in the context of chronic staff shortages, unsafe staffing levels, frequent lockdowns, and limited access to a normal daily routine. Low morale among both prisoners and staff combined with concerns about safety exposed a custodial environment that is increasingly unstable and unsustainable, underscoring the need for urgent, system-wide reform.
Human resources were inadequate across the prison
Custodial staffing at the facility was consistently and significantly below required levels, with an average shortfall of 24% across 71 days, and peaks of up to 50%. These shortages were driven by a combination of unfilled positions, leave (planned and unplanned), and workers’ compensation absences. As a result, there were insufficient officers to meet core custodial requirements, placing pressure on daily operations. The facility relied heavily on adaptive routines to maintain basic functions, redeploying staff from non-critical roles to essential posts. This approach enabled continuity of operations but led to reduced or cancelled programs and services, with the greatest impact experienced by women in custody.
The operational model was further strained by workforce capability issues, with 74% of custodial officers having less than two years’ experience. Frequent redeployment of Vocational Support Officers, who play a key role in facilitating prisoner employment and structured activity, further undermined purposeful routines. At the leadership level, insufficient staffing within the Senior Leadership Team required extended working hours to meet operational demands, raising concerns about fatigue, burnout, and the sustainability of effective oversight.
Reception and court processes were effective, but women remained disconnected
Reception at Melaleuca is a high-risk operational area that depends on adequate staffing, experienced officers, and suitable infrastructure. Despite ongoing short staffing and infrastructure challenges, reception processes were well managed and efficient. Positively, video-link and legal visit arrangements were prioritised, and a proactive Bail Coordinator ensured the timely release of eligible remandees. Other than these, we found few targeted supports for remand prisoners.
Social visits had declined from four daily sessions to a single one-hour timeslot, limiting access for families. Cancellations due to staff shortages have further restricted access. While core reception and legal processes have been sustained, constrained staffing has reduced important supports and contact opportunities.
An unsuitable environment for a vulnerable population
Perceptions of safety at Melaleuca have deteriorated significantly since the 2023 inspection, with both staff and prisoners reporting they do not feel safe. In 2026, only 49% of women reported feeling safe, a substantial decline from 66% previously and below the state average. Despite most custodial staff reporting they had received adequate training in trauma-informed management, there was little evidence of structured training or consistent application in practice. Weak complaint and request processes, reliant on paper-based systems with limited transparency or follow-through, further reduced trust and confidence in staff among women.
Persistent hygiene and maintenance issues were evident across accommodation units, including mouldy and leaking showers, deteriorating grout and blocked drains. Laundry operations presented additional concerns, with untrained prisoners managing washing processes without appropriate Personal Protective Equipment (PPE). Equipment was not fit for purpose, with domestic washing machines unable to meet the volume or hygiene standards required.
Health and wellbeing services were stretched
Instability in the health workforce increased the risk to service continuity and clinical oversight at Melaleuca. While staffing levels were generally adequate and most shifts were filled, reliance on an acting Clinical Nurse Manager and casual nursing staff created workforce risks, particularly in covering some night shifts.
Although a broad range of primary and allied health services was available, women reported significant barriers to access. Survey results were poor, with only 14% rating general health services as good. Dental care was a particular concern. Access to dental services relied on limited weekly transfers to Wandoo and was further affected by staffing shortfalls, which reduced utilisation. In 2025, only 14 of 51 available dental visits were attended. The mental health team was committed but under-resourced and unable to meet the needs of a complex population.
Melaleuca was not fit for purpose, with no dedicated spaces for pregnant women, a number of whom reported feeling unsafe and vulnerable in shared, often chaotic accommodation. Conditions in the Crisis Care Unit (CCU) had further deteriorated since 2023, with crowding and unsuitable infrastructure undermining its intended therapeutic function. Overcrowding saw up to 11 women in a unit designed for four. Support services were present but under-resourced: the peer support team and Prison Support Officer allocation were insufficient for the size and vulnerability of the population. While the Aboriginal Visitor Scheme provided valuable cultural support, reliance on a single resource limited its capacity to meet the needs of First Nations women.
Limited opportunities to engage in a purposeful regime
Recreation, programs and education at Melaleuca were constrained despite committed staff and good intentions. While a structured recreation schedule existed and VSOs were proactive, chronic staff shortages and frequent redeployment led to regular cancellations, reflected in worsening prisoner perceptions of organised sport. Program delivery faced similar barriers, with limited infrastructure, including only one available program room, and insufficient custodial staffing preventing external facilitators from accessing the prison. Lengthy security clearance processes further delayed the introduction of new providers. Notwithstanding these challenges, the programs that were delivered were relevant to the needs of the population and education was appropriately focused on practical skills and employability.
Employment opportunities were limited. Melaleuca lacked the infrastructure and resourcing to support an adequate employment program, with more than half the population not working and a further proportion confined to unit-based roles such as cleaning and laundry. Frequent redeployment of VSOs further reduced available work opportunities.
Overcrowding and understaffing impacted security operations
Frequent lockdowns were the most significant concern for women and were inconsistent with a trauma-informed model of care. Extended periods confined in units or cells limited women’s ability to maintain relationships with family. Time out of cell declined substantially during the 12 months before the inspection, falling from an average of 8.45 hours per day in January 2025 to 6.54 hours in January 2026 and 5.36 hours in February 2026. As a result, women were spending close to 19 hours each day locked in their cells or behind wing grilles.
The decline in conditions coincided with chronic staff shortages, frequent redeployments, an inexperienced custodial workforce and reduced opportunities for positive staff-prisoner interaction. As operational priorities shifted towards maintaining basic safety and security, staff had less time to build relationships with prisoners and understand their individual needs and circumstances. This contributed to a growing disconnect between prisoners and officers. During this period, use of force incidents increased significantly, averaging 38 incidents per month and peaking at 80 in late 2025. Although incidents declined afterwards, they remained elevated into early 2026, and Melaleuca continued to record some of the highest use of force rates across the adult prison system.
Staff shortages also affected key security functions, with redeployments reducing capacity to complete security processes, maintain timely use of force reviews, and manage prisoner disciplinary matters. These challenges were compounded by the absence of a dedicated management unit, leaving Melaleuca as the only maximum-security remand prison without a purpose-built facility for managing prisoners on restricted regimes.
The inspection also identified concerns about searching practices. Although Melaleuca had a full-body x-ray scanner intended to reduce or eliminate the need for strip searching, strip searches remained common practice.