Stability in a custodial facility requires the right balance between physical, procedural and dynamic security. Banksia Hill had not achieved that balance. It was an unstable facility exhibiting high and obvious risks.
In the aftermath of the riot, the Department devoted a good deal of money and time to physical target hardening but this is not a balanced solution. Unless there are fundamental improvements to dynamic security and adherence to basic procedures, the risks will remain. Indeed, they are likely escalate.
The Inquiry also found that the Department of Corrective Services failed to give balanced advice about risk to successive ministers in 2012. It also failed to follow through on commitments it had made.