The announcement in 2009 that Banksia Hill and Rangeview Remand Centre would be amalgamated and that Banksia Hill would be redeveloped to accommodate all detained juveniles, including remandees and girls, led to a number of linked projects. One such project was the development of a new operating philosophy for Banksia Hill.  Although a new operating philosophy was endorsed by management in April 2011, the philosophy was neither communicated to Banksia Hill staff nor implemented in any coherent way. As a consequence, ad hoc provisional operating philosophies and operating models for Banksia Hill emerged. The opportunity to apply a single coherent philosophy to Western Australia’s youth justice system was lost.

Although the endorsed operating philosophy stated that a security framework for Banksia Hill would be introduced as part of the amalgamation, it was never developed or implemented. At time of the amalgamation in September 2012 Banksia Hill had no key security policies and procedures in place. That was still the position at the time of the riot.

An escape from Banksia Hill in August 2010 highlighted serious security failings. A number of internal security reviews which followed in 2010 resulted in 57 wide-ranging recommendations to address physical and procedural security risks at the centre. Despite management endorsement in January 2012 of a report accepting that the 2010 recommendations had been addressed, some of those risks remained.

A further escape from Banksia Hill in August 2012 provided confirmation that some of the security risks identified in 2010 remained. These included risks such as unsecured building rubble, which was used in the 2012 escape to gain access to a contractor’s vehicle and attack the occupant.

Banksia Hill was allowed to become operational post-amalgamation without key security policies and procedures in place. There is considerable literature on the consequences of failures to integrate good security processes into custodial management.

The fact that a major security incident was foreseeable at Banksia Hill is highlighted by an email of 26 October 2012 from the Director of Security Services to the Deputy Commissioner which, in addition to warning that the centre had reached a crisis point, noted that:

From a risk perspective every major prison disturbance in Australia in the past 60 years has been the result of a drop in the living conditions of inmates to a critical level. The warning signs regarding a drop in hygiene, rolling lockdowns, lack of access to canteen, education and recreation and poor staff discipline and morale are all present at Banksia and all point towards the very real possibility of a major disturbance … in the near future.

At the request of the Commissioner, the Security Services Directorate again assessed the security risks at Banksia Hill in November 2012. The security assessment identified a number of ‘significant risks that required immediate remedial action’ including detainee movement control, vehicle control, the management of the security function, poor communication, apathy in following procedures, visibility of senior managers, and staff shortages. The security assessment confirmed that at that time there was no security strategy, no drug strategy and no searching strategy in place.

Observations made at Banksia Hill during the Inquiry revealed a significant number of weaknesses in physical infrastructure (for example, unnecessary fences, fences which provided ready footholds and handholds, steel cans and rubble lying around the site and the use of building materials which would not be used in a more secure site), process security deficiencies (for example, staff unaware of processes for reporting matters, medical kits in poor condition, mobile phones being brought into the centre and inadequate responses to security issues) and problems with dynamic security (for example, ineffective supervision, staff non-adherence to procedures, lockdowns and the overuse of regression.

The Department’s response to the riot has relied heavily on greater physical infrastructure, in particular more bars and grilles. The development of effective dynamic and process elements, involving good inter-personal relationships and consistent adherence to procedures, is essential to achieving a safe and secure environment at Banksia Hill.

It is obviously important to have a coordinated approach to security at the detention centre. The risks were identified by OICS and the Department as far back as mid-2008. The December 2010 Making a Positive Difference philosophy document emphasised that while YCS had responsibility for ensuring security at the new centre, the Security Services Directorate in head office also had a key role. The aim was to ensure that a statewide security framework would encompass all custodial functions of the Department, while ensuring Banksia Hill retained its identity as a detention centre not a prison. It said that the YCS executive was ‘fully supportive’ of this and that there would be ‘significant developments over the coming year prior to the final amalgamation’.

Despite the commitment to support YCS security functions more coherently from head office, a departmental representative advised the Inquiry in March 2013 that:

The Security Framework has never been implemented at Banksia Hill; in fact it’s only just at the pilot stage, occurring at Bandyup. The plan has always been to roll out the Framework (once endorsed) to Adult Custodial first and then to Community and Youth Justice. I believe the reference within the ‘Making a Positive Difference’ report is an extract from the Security Framework CET submission.

Central security support was obviously important to Banksia Hill’s stability and the Director Security Services was a member of the Project Control Group (PCG) for the Youth Custodial Transition Project. The Director Security Services position is located in the Adult Custodial division not in Youth Custodial.  Meetings were generally held in head office for convenience but the Director had been directed at some point by his superior, the Deputy Commissioner Adult Custodial, to attend PCG meetings only when required. He rarely did so even though the risks at  Banksia Hill were high and the PCG frequently considered security matters.

Outcomes are, of course, far more important than meetings. Unfortunately, the outcomes speak for themselves. A departmental security assessment dated November 2012, some weeks after amalgamation, found Banksia Hill still had no security strategy, no drugs strategy, no searching strategy and no strategy to manage the facility over the coming hot summer months. Such obvious failings should not have been allowed to occur and, if they did, they should have been identified and rectified much earlier.