This review was underpinned by a comprehensive methodology, including the examination of a significant number of relevant documents, interviews, surveys, workshops and observations from site visits.
Review Teams
The terms of reference intersect. However, in order to provide a specialist focus and to build in processes of challenge and validation across the various terms of reference, the inquiry was divided into four focus areas which broadly reflect the terms of reference.

Four small teams, consisting of two or three people including independent experts, were allocated primary responsibility for examining each area. The skills of selected independent experts were used to supplement OICS staff and to provide an important further level of independence and validation to the review. Other OICS staff played a key role in obtaining input from interested parties and providing research support.

These four areas were:

  • Emergency Management: This team examined adequacy of crisis/emergency management planning and the crisis/emergency management response and including the initial transfer of detainees to Hakea Prison.  Findings are reported in the Emergency management review paper.
  • Security and Physical Infrastructure: This team examined issues of strategic direction, leadership and facility design and modifications; security and integrity of the cells; security systems and infrastructure and security practices and protocols for all staff. Findings are reported in the Physical infrastructure review paper and the Security review paper.
  • Management, Staffing and Amalgamation: This team examined staffing levels at the facility as well as the impact of the incident on staff. Findings are reported in the Management, staffing and amalgamation review paper.
  • Post-Incident Management: This team addressed the temporary housing of juvenile detainees at Hakea Prison as well as the management of the male detainees remaining at Banksia Hill. Findings are reported in the Post incident review paper.
  • In addition, a review paper was developed on the Legal and Administrative context in existence prior to, during and after the riot.


Submissions, Surveys and Interviews
Processes included a call for submissions; meetings with parents and families; surveys of staff; surveys of detainees; briefings, interviews and workshops with staff, detainees and head office personnel; and engagement with key stakeholders and service providers. Public submissions to the Inquiry have not been separately published but are available on this website.

The information solicited through these processes provides a rich resource and the positive engagement of all these people is gratefully acknowledged.


Data and Documentation Analysis
A significant number of relevant documents were sought from the Department and examined.  Documents were used to substantiate information received in submissions, surveys and interviews. Literature reviews and analysis in Australia and overseas were also undertaken.


Observation and On-Site Presence
OICS staff had a heavy on-site presence in both Banksia Hill and Hakea for the first month after the riot.  This involved several visits a week including on weekends.  Following this, at least one site visit a week was undertaken through to mid-April.  Observations on the conditions of the detainees were recorded and OICS staff engaged with staff and detainees to get a broad understanding of the issues faced as a result of the riot and use of Hakea as an alternative site to house detainees.


Electronic and digital information
Electronic and digital information of the incident was examined.  This included CCTV footage, camera recording from the police helicopter, radio traffic and recorded phone conversations from within Banksia Hill.


Inter-state Site visits and discussions
Visits were made to juvenile justice centres in South Australia, Victoria, New South Wales, Queensland and the Australian Capital Territory.  The security ratings of the centres visited are comparable with those of Banksia Hill and accommodate similar juvenile populations, both sentenced and remand.  The physical infrastructure, quality and extent of case management, and programs being offered to detainees were all examined to provide a comparison for Banksia Hill.
Other Sources
One of the advantages of establishing an Office of the Inspector of Custodial Services is that it can build its own independent records and sources. This familiarity and knowledge is invaluable in conducting an inquiry of this sort. In addition, there are a number of other independent sources, including a handful of court cases and the work of other independent agencies.  The sources used during this review include:

  • Published OICS inspection reports of adult prisons from 2001 and of juvenile detention centres from 2003;
  • Other OICS reports including a 2012 Report of an Audit of Custodial Roof Ascents and a 2009 Issues Paper: Remodelling Corrections for Juveniles and Young Men;
  • Detailed records of liaison visits by OICS staff;
  • Detailed records of visits by independent prison and detention centre visitors;
  • Relevant cases decided by the Children’s Court;
  • The 2008 report by the Auditor General: The Juvenile Justice System: Dealing with Young People under the Young Offenders Act 1994;
  • The work of the Ombudsman; and
  • The work of the Commissioner for Children and Young People including the paper published during the course of this review.

The Department’s cooperation with the Inquiry and its staff, in providing an extensive array of documents and information, as well as facilitating timely numerous meetings and interviews with senior executives and officers at all levels, is acknowledged and sincerely appreciated. In addition, the Inquiry acknowledges and is grateful for the engagement and input of all of the other stakeholders and individuals who contributed to the Inquiry

Page last updated: September 4, 2014