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1. Introduction to case studies

In this chapter, we present seven case studies that examine different aspects of Ashley Youth Detention Centre.

The focus of our Commission of Inquiry is the State’s response to known risks of child sexual abuse in institutions, including Ashley Youth Detention Centre. In this chapter, we also examine other forms of mistreatment of detainees (for example, physical abuse or degrading treatment) that we consider relevant to understanding the context in which child sexual abuse occurs. We also note that children’s vulnerability to child sexual abuse is heightened in contexts where other abuses and rights violations are prevalent.1

In Case study 1, we describe the nature and extent of abuse at the Centre, including the evidence we received from several current and former detainees, as well as allegations made through redress schemes and civil claims. This evidence is harrowing, describing abuses that are callous, cruel and degrading. Children and young people’s powerlessness in the face of such ingrained abuse and mistreatment is palpable and devastating. The consistency of themes across all these accounts, despite coming from multiple sources, is striking and includes:

• sexual, physical and psychological abuse of detainees by staff
• harmful sexual behaviours between detainees, sometimes with the knowledge of Centre staff
• staff using strip searches as a tool of control, and as an opportunity to sexually abuse children and young people
• staff humiliating, belittling and threatening detainees
• inappropriate use of isolation and use of force, including to punish and control detainees.

While we did not test the truth of individual accounts, we gave particular weight to the consistency across the accounts of victim-survivors whom we heard from directly and those that we read in claims under the Abuse in State Care Program and the National Redress Scheme. In the accounts of different people detained at the Centre over different periods, and the information coming from direct accounts, critical incident reports and state and Commonwealth redress schemes, we saw a striking consistency (and enough variability) to the places and ways abuses occurred, the people who were allegedly responsible and the patterns and kinds of sexually abusive behaviours.

Taken together, alongside previous reviews and the evidence we received about a longstanding corrosive culture that doubts and disbelieves reports by detainees, we find that, for decades, some children and young people detained at Ashley Youth Detention Centre experienced systematic harm and abuse.

In Case study 2, we examine the extent of harmful sexual behaviours at the Centre and responses to such behaviour. We include some accounts of former detainees who describe sexual harm by other detainees at the Centre and how this was often ignored by staff. We also heard allegations that staff sometimes actively used the harmful behaviours, including harmful sexual behaviours, of some detainees to control or frighten other detainees. We make findings in this case study about failures to respond appropriately to the risks of harmful sexual behaviours, which are listed in Section 9 and explained further in the case studies. In particular, we find that Ashley Youth Detention Centre has been aware of harmful sexual behaviours at the Centre and has not taken steps to protect children and young people from these harms.

Case studies 3 and 4 examine isolation and use of force at the Centre and make a range of findings that these practices have been misused, sometimes excessively and unlawfully, to punish and degrade detainees in breach of their human rights. In particular, we find that:

• the use of isolation as a form of behaviour management, punishment or cruelty has been a regular and persistent practice at Ashley Youth Detention Centre since at least the early 2000s and, in July 2023, we received information to suggest that some harmful isolation practices are still occurring
• the excessive use of force has been a longstanding method of abusing children and young people by some staff at Ashley Youth Detention Centre, and the Department and Tasmanian Government have not always responded appropriately.

When the isolation of young people at Ashley Youth Detention Centre is unauthorised, unregulated and unreported, or there is excessive use of force, the risk of and opportunities for the physical and sexual abuse of young people increases. Such belittling and dehumanising practices also reduce the likelihood of children and young people making disclosures of child sexual abuse because their sense of what is right and wrong, trust in adults at the Centre and self-worth have been undermined.

Case studies 5 and 6 describe how complaints about the safety and treatment of detainees have been managed—including complaints by a staff member called Alysha (a pseudonym) and a detainee called Max (a pseudonym).2 We make findings about the State, the Department and the Centre’s response to these complaints, and identify systemic problems in these responses.

Case study 7 describes how the Department has responded to alleged sexual abuse of detainees by staff at Ashley Youth Detention Centre. This traces revelations from the Abuse in State Care Program (which began in 2003) and the perceived legal barriers that the Department told us limited its ability to act against staff, despite sometimes receiving multiple allegations of serious sexual assaults by staff still working at the Centre. Over time, corporate memory of the Abuse in State Care Program (and the information it revealed about current staff) was lost within the Department. Another wave of information alleging abuses by current and former staff came with the introduction of the National Redress Scheme in 2018, which was also met with confusion and inaction due to legal advice and practices that precluded use of that information, until a belated change of practice in the second half of 2020. We make a range of findings about failures to manage risks to detainees arising from this information.

1. How to read our case studies and examples

Many of our case studies are closely related and benefit from being read together. While findings may sit within a particular case study, in some instances those findings also draw on evidence described in others. For example, our finding that, for decades, some children and young people detained at Ashley Youth Detention Centre experienced systematic harm and abuse in Case study 1, also draws on the evidence we examined in Case studies 3, 4 and 7. Case studies 3 and 4 expand on some of the common themes we heard in Case study 1 about alleged abuse and mistreatment connected to isolation practices and the use of force, including previous reports and reviews. Case study 7 discusses a range of documentation outlining allegations of abuse that were in addition to the accounts we heard from people who had been detainees at the Centre or their families.

Case studies 5 and 6 describe responses to complaints (in one instance from a detainee and, in the other, a staff member). Taken together, our seven case studies have informed our recommendations in Chapter 12.

1. Key witnesses and sources of information

Throughout the case studies in this chapter, we refer to several people who held senior departmental roles. In addition to our requests for information from the Tasmanian Government, we also requested statements and information from people who had a role in the response or may have had access to relevant information. Some of these people were no longer in the Department, which limited their access to information. Some joined the Department after the events into which we inquired and gave us information based on what was available to them, but in relation to matters with which they had no personal involvement.

Here, as a reference point, we summarise the key role-holders and witnesses who provided information in relation to our case studies:

• Michael Pervan held the role of Secretary in the then Department of Health and Human Services and Department of Communities for the period from around October 2015 until July 2022 (other than between May 2018 and September 2019 during the split of the Department of Communities from the Department of Health and Human Services).3 The functions previously held by Secretary Pervan have since moved to sit within the Department for Education, Children and Young People, overseen by Secretary Timothy Bullard.4 Prior to his formal appointment, Secretary Pervan had been Acting Secretary of the Department of Health and Human Services from March 2014 until his permanent appointment in October 2015.5
• Ginna Webster has been Secretary of the Department of Justice since September 2019, and was previously the Secretary of the Department of Communities from May 2018 to September 2019.6 Prior to May 2018, Secretary Webster held the role of Deputy Secretary, Children and Youth Services in the then Department of Health and Human Services.7
• Mandy Clarke held the role of Deputy Secretary, Children, Youth and Families, which had portfolio responsibility for Ashley Youth Detention Centre, among other things.8 Ms Clarke reported to then Secretary Pervan.9 Ms Clarke was Deputy Secretary from 11 September 2019 to 11 February 2022, with her last working day being 21 January 2022.10
• Kathy Baker held the role of Executive Director, Capability and Resources between July 2018 and September 2021. That role was subsequently reclassified Deputy Secretary, Corporate Services, and was held by Ms Baker between September 2021 and 30 June 2022, although she was seconded to the Department of Health between 10 March 2020 and 5 June 2020.11 She reported directly to then Secretary Webster between July 2018 and September 2019 and subsequently to then Secretary Pervan (except during her secondment).12 The role had responsibilities for corporate areas including People and Culture, Legislation and Legal Services, and Governance Risk and Performance (as they were then known)13 14
• Jacqueline Allen commenced the role of Acting Assistant Director, Safety, Wellbeing & Industrial Relations, which was part of the People and Culture Division, in July 2020.15 She reported to the then Director of People and Culture.16 At the time she gave evidence at our public hearings in August 2022, Ms Allen was the Acting Executive Director, People and Culture (but had left that role by December 2022). We note that, despite her short tenure at the Department, Ms Allen provided us with a large amount of documentary evidence in response to our requests for information. This included in relation to events that occurred before her commencement at the Department and with which she was not involved, and often where we had not been provided with those documents in response to other requests. We were grateful for her efforts in this regard.
• Greg Brown held the role of Director, Strategic Youth Services, within the Department between December 2017 and October 2019.17
• Pamela Honan has held the role of Director, Strategic Youth Services (also titled Director, Youth and Family Violence Services) within the Department since 28 October 2019.18 The title of this role has changed over time but we understand that Ms Honan has had responsibility for Ashley Youth Detention Centre since she commenced employment with the Department.19 Ms Honan reported to Ms Clarke.20
• Patrick Ryan was Manager, Custodial Youth Justice (‘Centre Manager’) at Ashley Youth Detention Centre from January 2017 until March 2020. Mr Ryan reported to Mr Brown and Ms Honan.21
• In March 2020, Stuart Watson was appointed Acting Centre Manager (from his role as Assistant Manager, which he had held since January 2020).22 Mr Watson was appointed as the ongoing Centre Manager in March 2021.23 Mr Watson reported to Ms Honan.24

Case study 1: The nature and extent of abuse in Ashley Youth Detention Centre

1. Introduction

In this case study, we find that children and young people at Ashley Youth Detention Centre have experienced systematic harm and abuse for decades.

This finding is based on several sources—described in this case study—as well as the evidence outlined across the subsequent case studies.

This case study contains a series of concerning allegations against Ashley Youth Detention Centre staff. We acknowledge that there have been, and are, staff at Ashley Youth Detention Centre who have tried to do their jobs lawfully and appropriately. References to problematic practices by ‘staff’ in this case study are not intended as a reference to all staff at Ashley Youth Detention Centre, unless explicitly stated in a specific context.

While we focus primarily on allegations of abuse by staff, we also heard of allegations of abuse by other children and young people, which were sometimes said to have occurred with the knowledge or endorsement of staff.25 We discuss this type of abuse (harmful sexual behaviours) in more detail in Case study 2. Understanding the extent and nature of abuse at Ashley Youth Detention Centre was essential to informing our recommendations. It is also important that any agency responding to allegations of abuse at the Centre does so with knowledge of this history of abuse.

On the evidence that was available to us, it was apparent that sexual abuse at Ashley Youth Detention Centre occurred alongside physical and verbal abuse. The sexual abuse perpetrated by some staff appears to have been motivated by a desire for sexual gratification. For other staff, the sexual abuse appears to have been one of many ways they asserted their dominance over, and otherwise degraded, detainees at the Centre, and may not have been sexually motivated.

In this case study, we outline sources of information about sexual and other abuse at Ashley Youth Detention Centre. Data from these sources tells us that numerous allegations of abuse, including of sexual abuse, at the Centre and its predecessor, Ashley Home for Boys, have been made through formal channels since 2003, when the Abuse in State Care Program was established.

We then summarise several of the many accounts of abuse that we received from victim-survivors of Ashley Youth Detention Centre, or their family members, during our Commission of Inquiry. In total, 11 victim-survivors and family members gave us permission to report their experiences, albeit anonymously.

It was not possible for our Commission of Inquiry to test the veracity of all the allegations outlined in victim-survivors’ accounts. However, we were struck by the common accounts of sexual, physical and other abuse by staff at the Centre, or older detainees, or both. Themes included the misuse of strip searches by Centre staff, how and where the abuse was perpetrated, and the absence or failure of effective reporting mechanisms when children and young people sought help to stop the abuse. While we do not make findings in relation to any individual allegation, we note the similarities across accounts.

The accounts of victim-survivors documented in this case study allege sexual and other abuse at Ashley Youth Detention Centre from the early 2000s to as recently as the early 2020s. At least some of the staff who were alleged to have perpetrated this abuse had worked at the Centre for many years at the time complaints were first made against them. They continued to work at the Centre for many more years due to the Department’s slow and uncoordinated response to redress claims and allegations of abuse (we discuss this in Case study 7).

Later in this case study and in Case study 7, we discuss the Department’s realisation in 2020 that many staff members against whom allegations of abuse had been made were still working at Ashley Youth Detention Centre.

We have included these accounts because we consider it is necessary that the Tasmanian Government understands the experiences of young people in detention, as well as the culture of sexual and other forms of abuse, denigration and human rights violations of children and young people that has persisted at Ashley Youth Detention Centre, to respond effectively to allegations of abuse in youth detention.

1. Data about child sexual abuse at Ashley Youth Detention Centre

The Department has received allegations of child sexual abuse at Ashley Youth Detention Centre, from multiple sources, over a long period. In this section, we outline the avenues through which the Department has received these allegations. We note various inconsistencies about the extent of abuse between the data collected by different bodies and for different purposes. In Chapter 12, we emphasise the importance of collecting and comparing data about the sexual and other forms of abuse of children and young people under the care of the State and recommend an audit of allegations of abuse (refer to Recommendation 12.5).

1. Response to our notice to produce

To understand the nature and extent of child sexual abuse at Ashley Youth Detention Centre, we issued a notice to produce information, which asked the Department to:

The Department told us it collected child sexual abuse allegations made by former detainees from a range of sources including claims made through the Abuse in State Care Program, civil litigation claims and the National Redress Scheme to provide us with a number of documents.27 We continued to receive information (often in the form of spreadsheets) over the course of our Inquiry.

There were significant discrepancies across the data we received about sexual abuse incidents at Ashley Youth Detention Centre. Barriers to us understanding the scope and scale of abuses included the following:

• Incompatible documentation. We received multiple and differing documents and spreadsheets recording varying numbers of incidents, which were difficult to reconcile across different sources and agencies, particularly where dates were vague or within a broad range. Also, different aspects of an incident were described or reported to different audiences and in some instances, alleged abusers and victim-survivors were unnamed.
• Very limited details relating to some incidents. We accept that sometimes this was unavoidable due to the limited nature of information the Department received (for example, through a National Redress Scheme claim) but, at times, suggested incomplete departmental record keeping.
• Differences in how data is segmented and reported. For example, the various public reports relating to the Abuse in State Care Program segmented data differently, sometimes breaking down the number of claims by institution, allowing us to understand specifically how many related to Ashley Youth Detention Centre or Ashley Home for Boys, and other times generalising to institution type (‘government institution’), which made this impossible.

We consider some discrepancies may have arisen in the number and nature of incidents that the Department reported to us because of the following:

• Confusion around what fell within the ‘Relevant Period’. There was uncertainty about whether our request related to incidents that had occurred within that period or were reported or otherwise made known to the Department within that period (but may have occurred before 2000). In most documents, the Department has appeared to have adopted the former approach in only reporting incidents that fall within the relevant period (noting sometimes abuse may have predated but overlapped with this period—for example, 1998–2002).
• The Department not adopting a consistent definition of what constitutes child sexual abuse. For example, the Department sometimes did not include incidents relating to harmful sexual behaviours between detainees or complaints about a staff member applying cream to a detainee’s genitals. At other times, the Department did include such incidents.

We consider that the discrepancies were more likely to lead to an underreporting of incidents to us.

We invested significant effort to accurately reflect the information we received, but it has been difficult—indeed impossible—for us to entirely assure ourselves of the completeness and accuracy of some of the figures and information we received. Often, witnesses could not help us clarify discrepancies or broaden our understanding of some of these incidents.

These challenges mean there are internal inconsistencies in some of the information we present. In the interests of the reader, we have at times prioritised clarity ahead of providing detailed explanations or clarifications of inconsistencies and limitations in the documentation we received, particularly where we could find no such explanation.

With these limitations in mind, the next section outlines the key sources of information relating to reports of child sexual abuse at Ashley Youth Detention Centre.

1. The Abuse in State Care Program

In July 2003, the Tasmanian Government announced a review of claims of abuse, including sexual abuse, by people who had been in state care as children, including in youth detention and in out of home care. The Government ran the Claims of Abuse in State Care Program (‘Abuse in State Care Program’) over four rounds between 2003 and 2013, resulting in 2,414 claims and 1,848 ex gratia payments (voluntary payments made as a gesture of goodwill without any legal obligation). These payments totalled to $54.8 million.28 To be eligible to make a claim, a person had to be aged 18 or older on 11 July 2003 and not have been a claimant in a previous round of the Abuse in State Care Program.29 The eligibility criteria were set at the beginning of the first round and remained the same (including in relation to the age requirement) through all rounds of the program.30

The Department of Communities’ predecessor, the Department of Health and Human Services, was involved in each round of the program, with the first two rounds delivered as a joint undertaking with the Office of the Ombudsman and the Department of Health and Human Services. The third round was administered by the Department of Premier and Cabinet in partnership with the Department of Health and Human Services. The Department of Health and Human Services was solely responsible for administering the final round of the program.31

Many allegations of abuse at Ashley Youth Detention Centre (and Ashley Home for Boys) were raised in each round of the program. New rounds of the Abuse in State Care Program were initiated in response to new claimants coming forward.32

According to reports published on the various rounds of the Abuse in State Care Program (which varied in the level and type of information they provided about claims):

• During the first round, which ran from 2003 to 2004, 32 people made claims relating to abuse that occurred at Ashley Home for Boys.33 The report described, in general terms, that most of these claims related to ‘sustained physical and emotional abuse’, with allegations of sexual abuse described as ‘less common’ in boys’ homes (including Ashley Home for Boys).34
• In the second round, which ran from 2005 to 2006, 117 people came forward claiming abuse that occurred at Ashley Home for Boys.35 We are unclear what type of abuse these claims relate to but note that across all eligible claims (423) made in this period, 189 (or 45 per cent) included sexual abuse.36
• There were 995 claims (in total) made in the third round, which ran from 2007 to 2010. We have not been able to identify the number of claims that were made relating to Ashley Home for Boys or Ashley Youth Detention Centre because a detailed report on this third round of claims was not available (we drew the overall 995 figure from the report of the fourth round of claims).37
• The fourth round of the program, which ran from 2011 to 2013, resulted in 172 claims against Ashley Home for Boys and Ashley Youth Detention Centre.38 We are unsure what proportion of these claims relate to sexual abuse but note that, of the 199 claims of sexual abuse made during that round, nearly 50 per cent were made by claimants who were placed in an institution (including Ashley Youth Detention Centre).39
• The number of claims listed in the reports on rounds 1, 2 and 4 of the Abuse in State Care Program indicate that, in these three rounds alone, 321 claims of abuse were made in relation to Ashley Youth Detention Centre or Ashley Home for Boys.

The Department provided us with a spreadsheet listing allegations or incidents of child sexual abuse since 2000. The spreadsheet showed that 18 claims of child sexual abuse were made against Ashley Youth Detention Centre staff through the Abuse in State Care Program (some of which included multiple allegations).40 It also indicated that the Department of Health and Human Services began to receive these claims in 2008 and that the period of abuse to which these claims related spanned 1995 to 2013.41 Not all claims received by the Department of Health and Human Services were eligible for redress, due to not meeting the age requirement or for other reasons.42

The discrepancy between the Department’s spreadsheet and the data in the Abuse in State Care Program reports is likely to be partially attributed to the scope of our request to the Department, which did not include a request for allegations relating to Ashley Home for Boys, which closed in 2000. The discrepancy may also be partly due to the Abuse in State Care Program reports referring to physical and sexual abuse, as well as abuse alleged to have been perpetrated by other children and young people (which were not captured in the Department’s spreadsheet). Discrepancies may also be due to different interpretations of sexual abuse.

1. Other government data

The Department provided us with several other documents indicating that many claims of child sexual abuse were made against staff at Ashley Youth Detention Centre and Ashley Home for Boys through the Abuse in State Care Program:

• A spreadsheet provided by the Child Abuse Royal Commission Response Unit in the Department of Justice to the Department of Communities on 19 September 2020 indicated there were 127 claims of child sexual abuse made against named staff members through the Abuse in State Care Program (some of whom were named on multiple occasions).43
• The Department of Justice also provided our Commission of Inquiry with a different table of data relating to the Abuse in State Care Program that was ‘extracted from a manual review of hard copy files during the Royal Commission into Institutional Responses to Child Sexual Abuse’.44 This information indicated that:
  • Claims of sexual abuse were made against Ashley Youth Detention Centre or Ashley Home for Boys staff through the Abuse in State Care Program as early as 2003, although it is unclear when the Department received these earlier claims given there were different administrators of the scheme (we consider it would have been during the period of the first phase of the scheme—2003 to 2004).45
  • Based on our review of the listed claims in the Abuse in State Care Program, at least 95 of the accepted claims involved named staff, and at least 44 involved unnamed staff, at Ashley Youth Detention Centre or Ashley Home for Boys.46 Several staff had multiple claims made against them. We note that the number of claims of child sexual abuse against staff members is likely higher because there were claims that did not specifically refer to, or name, staff members and, therefore, have not been included in our analysis because they may have related to harmful sexual behaviours.
  • The period of abuse spanned much longer, dating back to the 1940s.

As we discuss later in this case study, staffing at the Centre had been relatively stable, with many staff moving from Ashley Home for Boys to Ashley Youth Detention Centre in 2000 and continuing to work there through the 2000s.

We note that the Department of Communities’ and the Department of Justice’s spreadsheets described above provide summaries of the claims made under the Abuse in State Care Program.47 It is clear from these documents that there is a commonality in the types of sexual abuse claims against staff at Ashley Home for Boys and Ashley Youth Detention Centre. The claims include allegations of rape, abuse during strip searches, abuse through applying scabies cream on detainees’ genitals, detainees being watched in the shower, the use of bribes and threats to force detainees to engage in sexual acts, forcing detainees to engage in sexual acts with each other, and sexual abuse occurring in the Centre’s ‘secure unit’ and when detainees were taken off site.48 As we describe, these types of abuse were also raised through other avenues over different periods and correlate with the accounts provided to us by victim-survivors.

1. The Abuse in State Care Support Service

When the Abuse in State Care Program wound up in 2013, it was replaced by the Abuse in State Care Support Service. The Abuse in State Care Support Service was set up to provide financial support to people who experienced abuse, including sexual abuse, in state care when they were children.

As with the Abuse in State Care Program, the Abuse in State Care Support Service is available to people who had previously been detained at Ashley Youth Detention Centre, as well as those who were in other forms of state care.49 The process for accessing financial support under the service involves the applicant being interviewed by the Department and having a ‘discussion with the Applicant about counselling and other supports’.50 Up to $2,500 is available for successful claimants to pay for goods and services related (but not limited) to education, employment, counselling, personal development, family connection and medical and dental services.51

Michael Pervan, former Secretary, Department of Communities, told us in a statement dated 14 June 2022 that 185 people had made applications or requested information since the service began in 2013, of which 89 applications alleged sexual abuse.52 We understand that this relates to claims in relation to all forms of state care. Secretary Pervan could not provide us with the number of applications that had been approved, but said that of those who received financial support through the service, fewer than 20 applicants received less than $2,000.53

Information provided to us by the Department of Communities in response to our notice to produce indicated that, as of 20 July 2021, 26 claims had been made through the Abuse in State Care Support Service involving allegations of sexual abuse at Ashley Youth Detention Centre (or its predecessor, the Ashley Home for Boys).54 Most of the allegations related to conduct by Ashley Youth Detention Centre staff.55 The period of abuse spans from 1995 to 2012.56

The claims raised through the Abuse in State Care Support Service include similar allegations against staff to those raised through other avenues and in victim-survivors’ accounts. The allegations again included abuse during regular and random strip searches; abuse by applying cream, powder and lotion to detainees’ genitals; detainees being watched in the shower; using bribes and threats to force detainees to engage in sexual acts; forcing detainees to engage in sexual acts with each other and in the presence of others including Centre staff; and sexual abuse occurring in the Centre’s ‘secure unit’ and when detainees were taken off site.57

1. The National Redress Scheme

As discussed in Chapter 17, the National Redress Scheme was created in response to National Royal Commission recommendations. The purpose of the Scheme is to hold institutions accountable for child sexual abuse and to help people who have experienced institutional child sexual abuse to access counselling, a direct personal response and a redress payment. The National Redress Scheme started on 1 July 2018. It will run for 10 years and is only available to people who were born before 30 June 2010 and whose abuse occurred before 1 July 2018.58

The National Redress Scheme is administered by the Australian Government. Tasmania’s Child Abuse Royal Commission Response Unit (which sits within the Department of Justice) responds to requests for information about the Scheme, with the assistance of other agencies.59 On receiving a request for information relevant to Ashley Youth Detention Centre, the role of the Department for Education, Children and Young People is to undertake a desktop investigation and provide a summary of material relevant to the National Redress Scheme claim to the Department of Justice.60 We outline this process in more detail in Case study 7.

As of 20 July 2021, the Department had received 49 National Redress Scheme claims for allegations of child sexual abuse at Ashley Youth Detention Centre (some of which contained multiple allegations).61 In total, these claims included 53 allegations against Ashley Youth Detention Centre staff members (including youth workers, security guards and contractors), with the alleged period of abuse spanning from 1995 to 2012.62 Allegations were also raised against other detainees.63

Of the 49 National Redress Scheme claims the Department received, 10 claims were made in 2019, 14 claims were made in 2020, 24 claims were made in 2021 and it is unclear when the remaining claim was made.64

Secretary Pervan told us that, from 20 July 2021 until 27 May 2022, there were another 49 claims made under the National Redress Scheme (and five civil claims) for incidents dating between 1997 and 2016.65 Other information in relation to these additional claims suggests that there were 48 National Redress Scheme claims and six civil claims relating to conduct alleged to have occurred over the period 1997 to 2019.66

Again, the allegations the Department received indicate a commonality in the methods of abuse allegedly perpetrated by Ashley Youth Detention Centre staff, including abuse during strip searches; abuse through applying products to detainees’ bodies and genitals; detainees being watched in the shower; rape; using bribes and threats to force detainees to engage in sexual acts; forcing detainees to engage in sexual acts with each other and in the presence of others including Centre staff; and sexual abuse occurring in the Centre’s ‘secure unit’ and when detainees were taken off site.67

1. Civil claims

As discussed in Chapter 17, the Tasmanian Government has made several legislative amendments in response to recommendations of the National Royal Commission, which pave the way for more civil claims to be issued against institutions that may be vicariously liable for the conduct of their staff, or liable for failing to protect a child from abuse.

In response to a notice to produce, the Department provided information to our Inquiry about civil claims that relate to allegations of child sexual abuse at Ashley Youth Detention Centre for the period 2000 to 20 July 2021.68 Secretary Pervan provided further information for the period 20 July 2021 to 27 May 2022.69 The data indicates that:

• In 2019, one civil claim was issued in relation to Ashley Youth Detention Centre.70
• In 2020, four civil claims were issued in relation to Ashley Youth Detention Centre.71
• In 2021, one civil claim was issued in relation to Ashley Youth Detention Centre.72
• From 20 July 2021 to 27 May 2022, six civil claims were issued in relation to Ashley Youth Detention Centre.73

The dates of the incidents raised in these claims up to July 2021 span 1998 to 2010.74 The additional civil claims the Department received between 20 July 2021 and 27 May 2022 relate to conduct alleged to have occurred between 2002 and 2008.75 Most of these claims include allegations against staff members, and the allegations involve similar methods of abuse identified in our discussion of the redress schemes above.76 The allegations in these civil claims include rape, digital penetration, being forced to engage in sexual acts with other detainees and Centre staff (sometimes in the presence of other Centre staff), being photographed while performing sexual acts, using physical abuse and threats, being placed in settings where sexual abuse by other detainees took place, sexual abuse by staff while off site, and the application of products to bodies, including genitals.77

We also received evidence that suggests many more civil claims have been issued in relation to physical abuse at Ashley Youth Detention Centre. A briefing for the Minister for Children and Youth that Secretary Pervan cleared on 4 November 2021 states:

As of 18 October 2021, 42 civil claims [have been made] in relation to physical and/or sexual abuse that involve the Department (or its predecessor). Court proceedings have commenced for 12 of these matters.78

Also, on 11 August 2022, a class action was commenced in the Supreme Court of Tasmania on behalf of more than 100 former Ashley Youth Detention Centre detainees, with more claimants being added at the time of writing.79 The claim of the lead plaintiffs is that the former detainees named as part of the class action suffered serious injuries due to systemic negligence in the management of Ashley Youth Detention Centre over the period from 1961 to 2019. Allegations include that staff:

• performed degrading strip searches
• forcibly applied scabies treatments that caused burns to detainees’ bodies, including their genitals
• failed to provide appropriate medical treatment
• used isolation and beatings as punishment.80

Lawyers acting for the plaintiffs in the class action, Angela Sdrinis Legal, told us that they act for more than 150 clients who allege abuse at Ashley Youth Detention Centre and Ashley Home for Boys, some of whom are not part of the class action.81 In a submission to our Commission of Inquiry, Angela Sdrinis Legal told us that these clients’ complaints relate to:

• sexual abuse spanning more than 40 years, with many of the same abusers (detainees or employees) committing repeated abuse against numerous children throughout their time at Ashley Youth Detention Centre82
• an extensive range of abuse, including rape (54 clients), grooming (11 clients), oral rape (nine clients), object rape (10 clients), forced sexual acts between children (two clients) and contact abuse83
• many instances of physical and mental abuse that accompanied the sexual abuse, such as extended periods of isolation and regular beatings84
• staff manipulating children into performing sexual acts on each other or on guards, sometimes through threats of physical violence or denial of certain privileges such as personal visits, or to avoid isolation85
• staff encouraging children to take part in abuse through perceived rewards or treats, such as cigarettes.86

1. Direct reports to the Department

As well as civil claims, and claims raised through the redress schemes, the Department also receives complaints and allegations directly from young people who are (or were) detained at Ashley Youth Detention Centre, staff and others with knowledge of alleged misconduct at the Centre. For example, the Department told us that it had received complaints from the then Tasmanian Greens Leader Cassy O’Connor MP in December 2020 and a member of the public in August 2020, as well as referrals from Crime Stoppers reports.87 The Department may also be alerted to complaints through reports by the Ombudsman, Custodial Inspector and Commissioner for Children and Young People.

In response to our notice to produce, the Department told us the following about complaints (in addition to allegations raised through civil claims and redress schemes) of child sexual abuse by Ashley Youth Detention Centre staff during the period 1 January 2000 to 20 July 2021:

• Several complaints about incidents alleged to have occurred between 2007 and 2016 were physically stored in a filing cabinet at Ashley Youth Detention Centre. Of the approximately 200 complaints the Department reviewed:
  • 10 related to allegations or incidents of child sexual abuse88
  • of these 10 complaints, at least six of the allegations were against staff members89
  • the allegations include staff members inappropriately touching detainees (including during strip searches), making sexual comments and walking in on a detainee while they were in the shower.90
• Another complaint was made to the Department’s Client Liaison Officer in January 2021. The detainee alleged that during the period from 2015 to 2016 they were forcibly strip searched and, on a separate occasion, assaulted.91

It is not clear to us if any of these complaints relate to staff still working at the Centre.

We also discuss in Case studies 5 and 7 a report in 2020 made by staff member Alysha (a pseudonym) about multiple concerns about the Centre, including allegations of child sexual abuse and staff management of harmful sexual behaviours.92

1. Observations across data

It is difficult to put a specific number to the allegations of child sexual abuse at Ashley Youth Detention Centre received by the Department. Nevertheless, there have been hundreds of allegations over the years.

Based on the material discussed above, we consider it is likely the Department of Health and Human Services knew of serious allegations of abuse against current staff working at Ashley Youth Detention Centre from at least 2006 when the second phase of the Abuse in State Care Program ended, if not from 2003. By 2006, there were 149 claims involving Ashley Youth Detention Centre or Ashley Home for Boys. As discussed below, staff at the Centre had been relatively stable and many staff moved from Ashley Home for Boys to Ashley Youth Detention Centre in 2000. We discuss the Department’s knowledge of allegations of abuse through this program in Case study 7.

1. First-hand accounts of abuse at Ashley Youth Detention Centre

In this section, we summarise the accounts of nine victim-survivors of Ashley Youth Detention Centre and two family members of victim-survivors.

As noted earlier, it was not possible for our Commission of Inquiry to test the veracity of all allegations of abuse, but we identified many common themes in the accounts we heard. We have included these accounts so the Tasmanian Government and the Tasmanian community can get a better sense of the extent and nature of the abuse that has occurred at Ashley Youth Detention Centre as safeguarding reforms are considered and implemented.

The accounts below speak to the circumstances of victim-survivors’ residency at the Centre, the alleged abuse that victim-survivors suffered, their attempts and attempts by their family members to report the abuse, the impact the alleged abuse continues to have on them, and the changes they would like to see so other children and young people in detention do not have to experience similar trauma.

Most names used in the following case examples are pseudonyms. The case examples present the accounts of victim-survivors or those of their family members.

1. Case example: Ben

1. Before Ashley Youth Detention Centre

Ben’s (a pseudonym) early life was unsettled.93 His parents separated when he was very young and his father died before Ben was 10 years old.94 Ben moved in with his mother’s new family and he began misbehaving, skipping school, stealing and using drugs.95 He then ran away from home and was exposed to more serious drugs and crime.96

1. Admissions to Ashley Youth Detention Centre

Ben was 11 years old when he was first detained at Ashley Youth Detention Centre in the early 2000s.97 He was charged with property offences and he refused to be bailed to his mother’s address.98 With no other address for bail, Ben was sent to Ashley Youth Detention Centre on remand.99

Ben described to us his experience of being admitted to the Centre. He recalled that after a three-day period of isolation and observation:

I was made to strip naked and face a wall with my hands above my head, legs apart. One of these men [a staff member] started to roughly smother some lice cream of some kind up my bum crack all over my bum between my legs and all over my genitals and surrounding area, as another one of them done the same to my underarms and my head. I was made to stand there for 5–10 minutes it was really painful and burning me. I complained but was told I’d have it left on there longer if I didn’t shut up. Upon the completion of my intake assessment I was taken to my cell/room where I would stay for several long very traumatic weeks.100

Ben spent the rest of his childhood, until the late 2000s, in and out of the Centre.101 From his first admission to when he was aged 18, the longest period Ben spent outside detention was about five months.102 Ben recalled that he spent most of his time at the Centre on remand.103 He explained that, most of the time, he was remanded for crimes for which he was eventually acquitted.104

1. Alleged harmful sexual behaviours at Ashley Youth Detention Centre

Ben said that during his first admission he ‘witnessed the most violence [he had] ever seen in [his] life’.105 Ben told us that his first experience of sexual abuse at the Centre happened immediately after his first admission.106 Ben recalled he was placed in a unit with six much older boys, four of whom physically and sexually abused him.107 Ben said that after a few weeks, he was moved to a unit with other ‘young and vulnerable detainees’.108

Ben said that he was physically and sexually abused by older boys at the Centre several times during his admissions.109 He recalled that this abuse occurred ‘every day’ during his first admission.110 Ben said that younger detainees were vulnerable to older male detainees, some of whom were 21 years of age.111

Ben told us that he was hospitalised on several occasions during his time at the Centre, including for an injury suffered during an episode of violent sexual abuse by an older boy.112 He said that some members of staff at the Centre would, on occasion, incite and reward young people for abusing or humiliating other (usually younger or smaller) detainees.113 Ben told us that young people were encouraged by staff to ‘smack their mates’ and were offered cigarettes as rewards.114

Ben said that he soon learned that the abuse at the hands of older boys ‘would be nothing compared to what several of the officers would come to do to me’.115

1. Allegations of abuse by Ashley Youth Detention Centre staff

Ben told us that he and other young people were physically and sexually abused by staff on numerous occasions. He said these incidents often occurred during activities that took place away from Ashley Youth Detention Centre.116 He told us that these activities were made available to young people as a reward for good behaviour.117 Ben believed that design changes to the Centre in the early 2000s meant that sexual abuse was more likely to take place away from the Centre’s premises.118 He soon realised that participating in excursions made him more vulnerable to abuse.119

Ben recalled one occasion when a staff member violently sexually abused him and two other young people from the Centre during an off-premises activity.120 The three boys were not yet teenagers.121 Ben remembered crying in the backseat of the car on the way back to the Centre. He said that the staff member threatened to hurt the boys again if they did not stop crying or if they told anyone what had happened.122

After this incident, Ben said he was too scared to be taken off the Centre’s premises and would try to avoid these activities. Ben said it was ‘hit and miss [whether] we would be abused or not’.123 Ben explained that missing an outing often meant being left locked inside all day because there were not enough staff left to supervise the young people who stayed on site.124

Ben also recalled a multiday camping excursion during which he was sexually, physically and emotionally abused at least once a day.125 Ben said he was raped three times on this excursion by an Ashley Youth Detention Centre staff member, Stan (a pseudonym). Ben told us that he knew of at least one other young person who was abused on that trip as well.126 We discuss the Department’s response to allegations raised against Stan in Case study 7.

Ben described the effect of the alleged abuse on him:

By the end of the trip … me and [my friend] were broken. The trip had destroyed us mentally! All we had been enduring had finally caught up to us on this trip that was supposed to be fun and exciting. Once we got back to Ashley everything was harder. I began to do poorly at school and art and all of the other programs run at Ashley. Slowly I started to notice drastic changes in my beliefs, my thoughts, my actions and my behaviour overall—at [this young age] I felt nasty, I felt like violence was the answer to everything and that rage and anger were normal, that flying off the handle over everything was OK.127

Ben said that as his behaviour escalated, he was regularly in trouble at the Centre.128 He told us he was often restrained by staff and that they targeted him for further abuse.129 Ben believed that some Ashley Youth Detention Centre staff were not ‘adequately assessed or screened’ for the work, which sometimes involved dealing with the young people’s aggressive and violent behaviours.130 He said that maintenance staff were sometimes called in to resolve incidents and restrain young people.131 Ben also recalled regular violent abuse by three staff members in particular, which twice resulted in broken bones and other serious injuries to Ben and other young people.132

Ben said that the ‘sheer scale and volume of sexual and physical acts committed upon [him at Ashley Youth Detention Centre] is astonishing and devastating’, so much so it is a ‘blur’.133 He said that the abuse pushed him into a ‘dark place’.134 He recounted an incident where he and two other young people attempted to die by suicide by breaking into a medication cabinet at Ashley Youth Detention Centre and taking the medication they found.135 Ben said that the incident resulted in a two-hour stand-off with staff, after which the boys were stripped naked, beaten and put into isolation:136

We [were] locked down on 23-hour-a-day lockdowns for weeks on end. Every couple of days we would be belted for the standoff in [the] office and [to] scare us into mercy and [to] never do it again. … I would be on and off the [behaviour management program] all the time … when they would lock us down for 23 hours a day in our cells with one book, one pen and pad, a mattress and bedding.137

Ben also recalled a violent beating after an escape attempt, during which he was stripped naked, handcuffed behind his back and had his feet cuffed together.138 He told us that he was left handcuffed and unable to move off the floor for about five hours, before being placed in lockdown for another three weeks.139

Ben was transferred to an adult remand centre in his late teens, where he said he was placed with violent offenders and sex offenders.140 Ben told us that he continued to suffer physical and sexual abuse there.141

1. Reporting allegations of abuse at Ashley Youth Detention Centre

During his first admission to Ashley Youth Detention Centre, Ben reported the physical and sexual abuse he said he experienced from other young people in detention to staff.142 Ben said that, in response, he was restrained, taken to an observation cell and stripped naked by senior staff.143 He recalled that staff members told him that ‘if [he] had to suck dick to survive then [he] shouldn’t steal tax payers’ cars’.144 Ben said he learned very quickly to keep his mouth shut.145

Ben recalled that after he was hospitalised following an episode of violent sexual abuse, it appeared some steps were taken at Ashley Youth Detention Centre to separate the younger, more vulnerable boys from the older boys.146 He said this involved placing the younger detainees in makeshift container accommodation, where they had to use buckets as toilets.147 Ben told us that, eventually, young people charged with sexual offences were placed with these younger detainees and the abuse resumed.148

Ben described how he and another young person at Ashley Youth Detention Centre made complaints against two staff members.149 Police investigations began, but Ben and his friend withdrew their complaints because they feared reprisals.150 Consequently, these staff members returned to work at Ashley Youth Detention Centre.151 Ben said that soon after this incident, he suffered a medical event, and doctors ordered that he not be moved due to the significant pain he was in.152 He said that an hour after that medical advice was given, staff at the Centre and police forced Ben into a car so he could attend a meeting at the local police station.153

Ben also recalled instances where privileges were taken away from him when he complained about staff members and that favours were granted when he withdrew his complaints.154 He told us that people external to the Centre visited every four to six weeks to check on the young people.155 Ben said he was never asked by these visitors if he was being mistreated and that, even if he had been asked, he knew better than to say anything when he was being observed by Ashley Youth Detention Centre staff.156

In addition to his fear of repercussions, Ben also believed that the culture at Ashley Youth Detention Centre among young people discouraged reporting abuse.157 He said:

I … wanted to be a criminal, and making complaints is not what criminals do. In a way we wanted to be like the people that were abusing us. We wanted to be big and tough. We believed that we only had one way out and that way was violence. There was also no CCTV cameras, so nothing that happened was recorded.158

Ben said that staff saw the young people detained at Ashley Youth Detention Centre as ‘the scum of society’ and that they normalised violence and abuse against young people.159 He described watching as new staff were absorbed into this system:

… there was the perception that any staff who didn’t follow these rules would not have a job. On countless occasions I witnessed staff new to Ashley be ridiculed by long term staff because they did not join in on restraints. These new staff would quit or get kicked out for not toeing the line. In my opinion they were the sort of people that should have been employed at Ashley. They could have made a difference if they weren’t continually pushed out.160

In Ben’s view, operational leaders of the units wielded the most power over the young people at the Centre.161 He felt that young people had little access or recourse to Ashley Youth Detention Centre management.162

1. After Ashley Youth Detention Centre

As an adult, Ben said he was approached by representatives of the Abuse in State Care Program.163 He was told that making a claim would be trauma-informed and that his best interests would be prioritised throughout the process.164 Ben recounted some of the abuse he suffered while at the Centre to these representatives.165 A few days later, Ben told us that he was informed that there had been a mistake and that he was ineligible for the program.166 He was ‘shattered’. He added:167

While I don’t think they did it on purpose, they should have followed up after this monumental mistake. I felt so worthless, confused, and suicidal after this meeting. To me it was like … there was nothing anyone could do about the horrific sexual and physical abuse I had suffered. This was devastating and has consumed my mind, my thoughts, and my feelings until now. I’d come so far and this [brought] me back so much. It wrecked me.168

Ben further recounted that, a few years later, he was visited by lawyers in relation to the National Redress Scheme.169 He said he was wary about talking to these lawyers because of his experience with the Abuse in State Care Program and that he asked them how they knew he and others had been at Ashley Youth Detention Centre.170

Ben is now bringing a civil claim against the State for the abuse he suffered at Ashley Youth Detention Centre.171 He is frustrated by how long the process is taking:

The length of time that the process has taken makes me feel betrayed and worthless, and I am starting to question the legitimacy of the process and whether it is worth it for me. … [The Government] are dragging their feet as much as they can. I personally feel like they are weighing up my longevity. They hope that I die of an overdose, die of murder, die in prison – because I chose to go the civil route. I know they won’t want to give me a cent. They see it that I’ve already cost the state money. It doesn’t matter what happened to me as a child, it only matters what I have done since then … The process of trying to seek compensation has eaten me up from the inside.172

1. Improving youth detention

Ben wants the Government to acknowledge that it allowed the wrong people to work at Ashley Youth Detention Centre.173 He wants the Government to ensure people like those who abused him are never employed in institutions like the Centre again.174 Ben considers that greater scrutiny of youth detention staff is required.175 In his view, a National Police Check or registration to work with vulnerable people is not enough.176 He also believes that greater care should be taken when placing young people together in detention to ensure they do not pose a risk of harm to each other.177

Ben thinks that more community supports would have prevented him from falling into a life of crime, and that these supports are critical for other youth in crisis and to prevent youth detention.178 Ben also thinks there is a need for more residential facilities for struggling young people.179 In his experience, existing residential facilities are wary of taking on young people with a history of violence, mental illness or drug use, which has led to the most vulnerable children ending up back in the community without support, destined to return to Ashley Youth Detention Centre.180

1. Case example: Eve

1. Before Ashley Youth Detention Centre

Eve’s son Norman (both pseudonyms) had struggled with significant mental health issues from the age of 13, for which he was prescribed medication.181 Before Norman experienced mental health issues, Eve recalled that Norman was a ‘nice, happy, great kid, everyone loved him, got along well with everybody in the community’.182 After his mental health issues presented, Norman began ‘hanging out with a really bad group of people and he made a bad decision’ that resulted in criminal charges and a sentence to be served at Ashley Youth Detention Centre.183

Norman was admitted to Ashley Youth Detention Centre in the early 2010s when he was 17 years old.184

1. Admission to Ashley Youth Detention Centre

When Norman was first remanded at the Launceston Remand Centre (now Launceston Reception Prison), staff refused to accept Norman’s medication from Eve.185 Eve was told that any medications that Norman required would be provided at Ashley Youth Detention Centre.186 Norman was transferred to Ashley Youth Detention Centre the next day. When Eve called to ask if Norman had received his medication, staff told her they did not have any medication at the Centre and that Norman would have to wait until after the weekend to see the doctor.187 On Monday, Eve drove from Hobart to Ashley Youth Detention Centre to supply Norman’s medication herself.188

Although staff eventually gave Norman his medication, Eve said they questioned Norman’s mental health diagnosis and the dosage of his medication. She said they gave him a lower dose than his doctor had prescribed.189 Staff told Eve that an Ashley Youth Detention Centre psychiatrist would have to review the dosage.190 Eve also recalled being told that the psychiatrist visited the Centre from the mainland every six weeks.191 She said that it was impossible for Norman to get an appointment with a psychologist at the Centre, and the Centre refused her attempts to get him access to a local psychologist on the basis that he was under state care.192 She could not recall how long Norman went without receiving his prescribed dosage of medication.193

Eve told us that she advocated for her son through every channel at her disposal. She had her doctor write to the Centre regarding her concerns about Norman’s mental illness and wellbeing.194 She also had the Shadow Minister for Children write to the Minister for Children about Norman’s history and her concerns.195 Further, she contacted the Minister directly but did not receive a response.196 Eve said she also engaged with Ashley Youth Detention Centre staff but did not find them helpful. She said they would block her attempts to get information about Norman’s situation or to help Norman.197 Where she raised concerns about Norman’s welfare, the response was to put Norman on suicide watch in a small cell with observations every three minutes.198

Eve said she worried that her advocacy for Norman only made things worse for him:

If [Norman] rang and told me things, I continued to call Ashley and let them know I had fears for his safety. The outcome of this would be that they would put [Norman] back on three-minute observations. It became a deterrent for him to tell me things. Every time I rang there would be repercussions for him.

Over time the phone calls between [Norman] and I became less frequent and [Norman] stopped telling me things. In the end he said, ‘please mum, stop’. My advocating for [Norman] meant there were repercussions for him. He wouldn’t even tell me how he was feeling anymore.199

Eve initially visited Norman at the Centre every two weeks.200 However, Norman asked her to stop visiting because, as she learned later, he would have to endure ‘cruel’ strip searches after each visit:201

So, when I would go and visit, it’s a little bit upsetting for a parent to know that, just for a child to come visit its mother in a room, that the guards are going to fossick through their anus and their genitals on their way back out. It wouldn’t be something that most people would want to have to happen, and it was—it did feel awful knowing that that did happen every time I visited him, but it wasn’t until later on that I found out that there was a lot of bastardisation going on during these searches, I won’t go into details, but it was enough to make him not want me to visit anymore.202

During Norman’s time at Ashley Youth Detention Centre, a detainee died in custody. Eve said Norman heard the detainee being sick in a nearby cell and begging for help, but staff did not assist.203 Norman told Eve that the other kids heard the detainee whimpering in bed during the night and then the noise stopped.204 After not showing up for breakfast, the detainee was found dead. Eve said Norman felt really unsafe and was afraid that this sort of thing could happen to him as well.205 Eve reflected that:

It really affected him. I remember him distressed on the phone. When you’re 17, and you hear a friend die, it’s going to affect you for the rest of your life. Despite this, none of the kids got proper counselling.206

1. After Ashley Youth Detention Centre

Eve described her son before he went to Ashley Youth Detention Centre as ‘saveable’.207 She said: ‘He was a child that still could have been turned around and had a future, but they changed that and his future’s been pretty awful’.208

Eve believes that nothing was done at Ashley Youth Detention Centre to help Norman to address his behaviour and that he ‘came out ten times worse than he went in’.209 She said that:

When he came out, he was a different kid. He wasn’t coping. He wasn’t acting like himself. He was very angry. He wouldn’t speak. There was no happiness in him. He wouldn’t tell me what was wrong, but it was clear he was really traumatised.210

Eve said that Norman had a lot of bad experiences at Ashley Youth Detention Centre that he does not want to tell her about because he knows how much it will affect her and he doesn’t want her to worry about it forever.211

Recently, Eve went through the right to information process to try and learn more about Norman’s time at the Centre. She believes the records she received show the unwillingness of staff at the time to give her information or constructively address Norman’s behaviours. She said the records focus on punishing Norman and satisfying the public perception that young people in youth detention should be treated as ‘criminals’.212

Eve told us that Norman has recently started engaging with the Sexual Assault Support Service and was talking to them about what happened to him at Ashley Youth Detention Centre more than a decade ago.213

1. Improving youth detention

Eve believes that the detention of young people should be therapeutic rather than focusing on punishment.214 She stated that Norman’s behaviour worsened due to a lack of alternative support for young people with mental health issues and the fact that non-violent young people were detained together with violent young people.215 She said: ‘There needs to be a better way of dealing with children than just destroying them in detention’.216

Eve also feels the location of Ashley Youth Detention Centre, a three-hour drive from Hobart, is an issue and that there should be facilities in the north and south of Tasmania so children in detention can stay connected to their families.217 She told us:

As a mother that wanted to stay involved and advocate for [Norman], they cut me off. It’s detrimental to children to separate them from their families when they are trying to rehabilitate. Family support when they are released from detention is critical.218

1. Case example: Max

1. Alleged harmful sexual behaviours at Ashley Youth Detention Centre

Max (a pseudonym) was detained at Ashley Youth Detention Centre from the late 2010s to 2021. He was 12 years old when first detained and, at the time, he was the youngest person in his unit.219 Max told us that, barely an hour after arriving at his unit, he became the target of bullying by other young people in detention.220 Max said he asked staff if he could be moved elsewhere because he felt unsafe, but they responded: ‘If you don’t like coming here, then don’t do the crime’.221 To keep himself safe, Max ‘locked [himself] down’ in his cell until he was released on bail a few days later.222

Max returned to the Centre for breaching his bail conditions.223 Soon after arriving, Max was placed in a unit with three boys who were much older than him, including Floyd (a pseudonym), who Max knew from the community.224 As soon as Max found out that Floyd was in the unit, he told staff that he was not safe there and would likely be ‘bashed’.225 Max told us that staff refused to move him, saying he ‘had no choice’.226

Max said that on the same day, Floyd verbally threatened Max.227 Max recalled that a staff member, Alan (a pseudonym), was present when Max was threatened, but Alan left the room and sat in the office, watching the boys through a window.228 Max recalled feeling as though Alan ‘had purposely walked away from us’.229 As soon as Alan left the room, Max was assaulted by Floyd and another boy, Ned (a pseudonym), when Max refused to perform oral sex on Floyd.230 Alan yelled at the boys to stop fighting but did not physically intervene until other staff arrived to assist.231

Max was angry and upset that staff had not listened to his concerns about being placed in a unit with Floyd. He said:

I was bleeding from the nose. I started saying to the youth workers, ‘I told you this would happen’. They just ignored me and didn’t say anything. The thing that really pissed me off was that I told all of the youth workers that it was going to happen but they didn’t listen to me. [Alan] heard [Floyd] threaten me. They should have been more aware.232

Max refused to press charges against Floyd or Ned for the assault because he thought it was a ‘dog thing to do’.233 He also felt it would just make life harder for him at the Centre and put his family at risk because the boys knew where his mother lived.234 Max said he was aware that the Centre’s management took steps to charge other young people for assaults committed at the Centre, and he does not know why this didn’t happen in his case.235 Instead, Max recalled that as punishment, Ned was dropped a ‘colour rating’ in the Centre’s behaviour management program.236

Max was moved to another unit, again with boys who were bigger and stronger than him.237 He said he was picked on because he had got the boys from the previous unit in trouble.238 Max told us that on one occasion, a boy, Arlo (a pseudonym), tried to insert a table tennis bat into Max’s anus.239 Max said that the staff at the Centre were aware of the incident and dropped Arlo’s colour rating in the behaviour management program, but they did not take any other steps to keep Max safe.240 Eventually, Max was moved to another unit when he refused to go to bed at the same time as the other boys in the unit.241

On a later admission to the Centre, when Max was still aged under 15, he was again placed in a unit with Floyd.242 Fearful, Max asked the staff why he was being placed with Floyd after what had happened; he was told he was ‘exaggerating’ and that there were no other units available.243 Max told us that staff threatened to put him into isolation if he did not calm down.244 Max said that Floyd apologised for what had happened previously, but Max was still afraid.245 He recalled:

… I was still scared and thought it was only a matter of time before something else serious happened to me. I don’t understand how they could put me back in a unit with someone who nearly raped me. The youth workers knew about it but they weren’t even concerned about it.246

Desperate to be moved, Max said he intentionally damaged the roof of his cell and was transferred to another unit the next day.247

1. Alleged abuse by Ashley Youth Detention Centre staff

Max recalled that, as he got older, the abuse and assaults by other young people at the Centre stopped, but the frequency of physical and sexual abuse by staff increased.248

Max said that the lack of surveillance cameras was a big problem at the Centre and that staff knew how to exploit the ‘black spots’.249 He said that: ‘Nine times out of 10 [those black spots are] where everything happens’.250 He said staff would regularly take young people to these places to ‘belt’ them, or threatened to do so if the young people did not behave.251 On one occasion, in the early 2020s, Max recalled being assaulted by staff on a construction site on the Centre’s property—Max believes that this was a deliberate attempt to avoid the assault being caught on surveillance cameras.252

Max had been told to ‘talk before you use actions’ to help regulate his behaviour, but, in his experience, Centre staff often did not listen.253 He recalled one occasion where he had been sent to his room after assaulting a teacher.254 A staff member asked him what the problem was, to which Max replied that he did not want to talk about it and said that if the staff member did not leave the room Max would hit him.255 Max told us that the staff member did not leave and Max started towards him, at which point Max was tackled by two other staff who had been outside the room.256 Max explained that he knew assaulting a staff member was wrong, but he thought the incident could have been avoided if they had listened to him:257

… the way they always say, like, if you’ve got something, they say talk about it with case management; they say, ‘talk about stuff before you do something, like, just try and talk about it, talk before you use actions’, so I tried it and it just didn’t work, like. So, there was nothing else for me to do.258

Eventually, Max felt that the only way he could keep himself safe was to be moved out of the Centre.259 He continued to act out, including assaulting staff, until he was sent elsewhere in his late teens.260

Max said that he was forcibly strip searched by at least three or four staff members in his cell, where there were no cameras.261 He recalled that on at least two occasions a staff member inserted a finger into Max’s anus.262 On one occasion, he told us that staff handled his genitals and searched between his buttocks.263

Max remembered another incident when he was dragged to his room following a stand-off with staff. Max told us that when he refused to be strip searched, staff responded that they could ‘do whatever the fuck [they] want’.264 Max said that none of the other detainees involved in the stand-off were strip searched.265 He further recalled that, after another incident, staff members ripped his clothes off and started searching him, after which they threw him to the ground and then left him in his cell.266 Max said he ‘felt disgusting after what [the staff] did’ and that it made him ‘feel like shit knowing that [he] had no power over anything’.267

On another occasion, Max recalled that he and another young person were strip searched by Alan and other staff in the breezeway, after they had been caught with cigarettes and drugs.268 Max told us that he lashed out during the search, at which point Alan punched Max, reminding him that ‘there are no cameras up here’ in the breezeway, and that ‘no one knows what happens up there’.269

Max observed that new staff members would quickly adapt to the culture at Ashley Youth Detention Centre.270 He explained that new staff often started off well, acting nicely towards the young people and not assaulting them, but after a year or so they would ‘normally turn into the same as the other ones’.271

1. Reporting allegations of abuse at Ashley Youth Detention Centre

A couple of years after his first admission to Ashley Youth Detention Centre, Max began to engage with the Commissioner for Children and Young People.272 At first, Max did not want to speak to the Commissioner because he thought it was a ‘dog thing to do’, but he was encouraged when he saw other young people doing it.273 Max said that Ashley Youth Detention Centre staff did not like the people in detention speaking to the Commissioner and that, once he started doing this, the staff began treating him even more poorly and made it ‘obvious’ that they were punishing him.274 He said that staff thought that by speaking to the Commissioner for Children and Young People, the young people were ‘trying to get [them] in trouble’.275

Max explained that he did not report the abuse by other young people in detention and staff members at the Centre because he thought that no one would believe him. He recalled that a staff member had told him that making a report to the Commissioner was no use because ‘no one will believe you’.276 Max said that without surveillance footage, he had little hope:

Because there were no cameras, it was just my word against all of the youth workers. When there are three or four youth workers against one resident, people are always going to believe the youth workers. I’m a criminal and they’re government. Everyone is going to believe them. They will just see it as a kid crying wolf.277

Max told us he was also scared of the staff at the Centre and how they would react if he were to complain. He felt that the close relationships between staff members meant that they would share information or support one another.278 He felt that even telling people outside the Centre, including his Youth Justice worker or his lawyer, might result in information getting back to youth detention centre staff.279 He explained:

The staff at Ashley are all like family to each other. They all know each other from the outside. They aren’t just like work colleagues. They are family and friends or in relationships. That’s why you can’t tell anyone about another staff member. It always gets back to them and it just ends up worse in the end.280

Today, Max thinks that failing to complain about what other young people in detention and staff members did to him made him a target:

It was like they saw that I wasn’t going to be a dog, so they could do these things to me. I look back now and think that I should have done more about it so all of these things would have stopped. I should have told someone. At the time I felt like if I did tell someone I would have been treated even worse.281

More recently, Max has told the Commissioner for Children and Young People about his treatment at Ashley Youth Detention Centre and his view of the way staff at the Centre responded to his contact with our Commission of Inquiry. We discuss Max’s complaint in Case study 6.

1. Improving youth detention

Max felt that he ‘should have [had] the right to complain’ when he was at the Centre, rather than be made to feel as though no one would take him seriously or that he would be harmed if he did so.282 He thinks that the complaints of young people in detention ‘need to be taken seriously’ and that more needs to be done to ensure problems are addressed before something serious happens or before it is too late.283

Max thinks that if Ashley Youth Detention Centre is replaced, there must be an entirely new workforce employed.284 He commented: ‘You can open a thousand centres but if you keep the same staff there the same stuff is going to happen’.285

Max hopes that there will be cameras everywhere in any youth detention centre that replaces Ashley Youth Detention Centre.286

1. Case example: Warren

1. Before Ashley Youth Detention Centre

Warren (a pseudonym) told us that, from a young age, he was regularly physically abused by his mother, who struggled to care for him after he was diagnosed with attention-deficit/hyperactivity disorder (ADHD).287 Warren was taken from his mother’s care and made a ward of the State before he was 10 years old.288 He was placed with numerous foster families and would steal or run away from them in the hope that he would be sent home.289

1. Admissions to Ashley Youth Detention Centre

Warren was first admitted to Ashley Youth Detention Centre in the mid-2000s when he was 13 years old.290 He was charged with theft and assault while on bail for other offences and was remanded to the Centre for four months.291 Warren said he was detained at the Centre about 21 times in the 2000s, usually for a couple of months at a time.292 The longest period he was at the Centre was for about a year, from just before he turned 18 until he was almost 19.293 Warren’s detentions at the Centre were about evenly split between him being on remand and under sentence.294

1. Alleged abuse by Ashley Youth Detention Centre staff

Warren said that initially he did not think the conditions at the Centre were too bad.295 He said he got along with some of the staff really well and that they would treat him like a human being, rather than just a criminal, and try to help him out and keep him out of trouble.296 Warren said he also learned how to read and write at the school at Ashley Youth Detention Centre and had the opportunity to learn life skills such as woodworking and being a barista.297

Warren also said that some staff would ‘bring their bad mood to work’ and would be ‘physical’ with the detainees who they did not like.298 There was also some violence among the young people detained.299 Warren said he tried to ‘keep out of stuff’ by staying in his room a lot and avoiding interactions with other people.300

Warren said he was sexually abused at the Centre for the first time when he was 14 years old.301 He recalled that it happened during his second admission while he was being searched.302 He told us that strip searches, usually conducted by two staff, were ‘degrading and abusive’.303 Warren said he was forced to strip naked in front of staff and to bend over so they could check for contraband, despite this being contrary to the procedure at the time, which stated that a person in detention only had to expose the top or the bottom half of their body at a time.304

Warren said that, starting from his third admission when he was 15 years old, he was abused in his room.305 He said that three staff members, while giving him medication, forced him to masturbate in front of them.306 Warren said that the staff would also force him to touch their penises with his hands and perform oral sex on them.307 Warren also said he was anally raped more than 20 times by one of the staff while other staff members restrained him.308 He said that the staff would withhold his medication unless he performed sexual acts on them.309 Warren was supposed to take his medication in the morning and at night. He told us that the sexual abuse would often occur in the morning, and Warren would be required to perform sexual acts on the staff or on himself while they watched, before they would give him his medication.310 He recalled that such abuse happened to him more than 50 times during his time at Ashley Youth Detention Centre.311 He also told us that if he did not submit to sexual acts, ‘the guards would arrange for my family to be hurt’ or that they would ‘arrange for older and bigger inmates to bash me’.312

Warren said that staff would also physically abuse him by pinning his arms behind his back, hurting his shoulders and ramming his head against the walls.313

He said that the staff who abused him were consistently on the same shifts, working together.314 Warren recalled that the abuse continued throughout his admissions to the Centre until after he turned 18.315

Warren said he did not tell anyone what was happening to him at the time.316 He said that the staff threatened to tell other young people in detention that Warren was informing on them if he disclosed the abuse. He said they also made threats against his family to prevent him from disclosing the abuse.317

Warren recalled: ‘They would tell me that no one would believe me anyway because I was just a little criminal. I didn’t want to say anything because I was afraid of what they could do’.318

Warren stated that nobody ever really complained at Ashley Youth Detention Centre because the staff would receive the complaints and tell each other about them.319 At the time, he did not know of anyone outside the Centre to whom he could complain.320

1. After Ashley Youth Detention Centre

Warren said that since leaving the Centre he has had ‘very few achievements’ in his life and has struggled with drug use and mental health issues.321 Warren has also been in and out of prison and has attempted suicide.322 He said that many of his problems were exacerbated by the abuse he experienced at the Centre.323

He said he was almost 30 years old before he began to discuss his experiences at Ashley Youth Detention Centre with his family. He said he has recently engaged with the redress process and counselling, which he has found helpful.324

In relation to the impact of his abuse at Ashley Youth Detention Centre, Warren said: ‘I have a hard time trusting people. This makes it really hard for me to keep relationships and friendships. I tend to keep to myself and distance myself from people’.325

1. Improving youth detention

Warren told us that many incidents of abuse at Ashley Youth Detention Centre happened in areas that were not covered by closed-circuit television cameras.326 He thinks that the Centre, or any facility that replaces it, needs more cameras.327

Warren also said that the staff need to treat young people in detention better, be better trained and not take their problems out on the people in detention.328 He said that he never had the same problems with staff in adult prisons that he had with staff at Ashley Youth Detention Centre.329

Warren said there needs to be a safe way for young people in the Centre to make complaints, including having someone to speak with who visits from outside the Centre.330

1. Case example: Charlotte

1. Before Ashley Youth Detention Centre

Charlotte (a pseudonym) was 12 years old when she first arrived at Ashley Youth Detention Centre in the early 2000s.331 At the time, Charlotte’s family was ‘very broken’.332 Her parents were in jail and Charlotte was living with their friends.333 Feeling abandoned and alone, Charlotte began running away and fell in with the wrong crowd.334 She started shoplifting and stealing cars.335

1. Alleged abuse by Ashley Youth Detention Centre staff

Charlotte described her first admission to Ashley Youth Detention Centre as ‘the worst time of my life’.336

During her first admission, Charlotte said she encountered a staff member, Edwin (a pseudonym), whom she knew from the community.337 Charlotte described Edwin as ‘very sleazy’.338 She told us that he would often touch her legs under the table and watch her while she showered.339 Edwin told Charlotte how pretty she was and that he would ‘love it if [she] were a bit older’.340 Charlotte said that Edwin’s behaviour made her ‘feel yuck’ but that she was too scared to report him because she thought her father might hurt Edwin and be sent to jail again.341 She was also concerned about what Edwin might do if she told anyone about his behaviour.342

Charlotte told us that another male staff member at Ashley Youth Detention Centre would also speak and act inappropriately towards her and a friend of hers, who was also in detention. Charlotte said that this staff member would be ‘really sleazy, touching our breasts and stuff like that’.343 She said that on one occasion, he wrote the words ‘bite me’ across her friend’s chest.344 A female staff member witnessed the incident and reported it.345 Charlotte wanted to speak to the team leader at Ashley Youth Detention Centre about what had happened, but it was several days before she and her friend could. The team leader shrugged the matter off and responded that the male staff member was no longer at the Centre.346 Charlotte told us she later found out that the staff member had not been fired. The staff member who had witnessed the assault confirmed to Charlotte that nothing had been done.347 Charlotte said neither she nor her friend heard anything more about the matter from the Centre’s management or the police.348 Charlotte said she was hurt by the lack of response. She recalled: ‘We went to tell someone what happened and nobody cared. We were only little kids’.349

Charlotte said that her first admission at Ashley Youth Detention Centre had a significant effect on her.350 When she was released, Charlotte went to live with friends who had also been detained at the Centre.351 She began using speed regularly and drinking heavily.352 She was worried that Edwin would hurt her if she said anything about what had happened at Ashley Youth Detention Centre.353

When Charlotte returned to Ashley Youth Detention Centre a second time, Edwin’s behaviour was much worse.354 Charlotte recalled that, on several occasions, Edwin told her that he ‘couldn’t wait’ to go offsite with Charlotte so he could ‘do some good things to [her]’.355

Charlotte described Edwin as being ‘very close’ with the male detainees and said that he was known for turning a blind eye to their behaviour.356 Charlotte recalled that Edwin would regularly bring in cannabis and cigarettes for young people in detention.357

On one occasion, Charlotte recalled that Edwin and other staff at the Centre left Charlotte unsupervised with several young people, including older boys.358 This was not an isolated occurrence. Charlotte recalled that she was regularly left unsupervised with older boys for more than an hour at a time.359 She told us that, on this occasion, she was sexually abused by an older boy.360

Charlotte felt unable to report the abuse because she was sure that friends of the older boy who assaulted her would harm her if she did.361 Charlotte also felt that even if she did report it, nothing would be done because the young person was a long-term detainee and favoured by staff.362 Charlotte also said that the staff member responsible for supervision at the time she was detained ‘was known to turn a blind eye to pretty much anything’.363 To keep herself safe, Charlotte isolated herself in her room and her unit.364 She was depressed and regularly self-harmed.365

Charlotte told us she was sexually abused a second time by an older boy from the Centre during an excursion away from the premises.366 These excursions were common near the end of a young person’s sentence and often took place in very remote outdoor places.367 On this occasion, Charlotte was the only girl in a group of six male young people and supervised only by Edwin.368 Charlotte said she tried to scream when she was being abused, but no one came to help her.369 Charlotte did not report the abuse. She explained:

I just had to leave it like that because, if I said anything, [the older boy] would have got other girls in there to bash me that were in there, and if I said anything to Centre staff, obviously nothing was working anyway, so I just had to keep it to myself.370

Charlotte was in her mid to late teens when she was admitted to Ashley Youth Detention Centre a third time.371 On one occasion during her third admission, staff locked Charlotte and other girls in their cells because they were misbehaving.372 Staff demanded that Charlotte hand over a lighter that she had, threatening to strip search her if she did not hand it over.373 Charlotte said she had been strip searched before and was scared about it happening again, so she set fire to her cell and cut her wrists.374 The fire was ultimately extinguished by the building’s sprinkler system.375 Charlotte said that even though the staff could see her covered in blood in the shower (through a viewing panel in the door), they left her alone in her room for four days in her wet clothes, with no bedding and little food.376

Eventually, Charlotte was given new clothes and locked down for another week.377 Upset and confused, Charlotte attempted suicide again.378 Charlotte told us that a staff member came into her room after her suicide attempt and slammed her head against the bed base, cutting her scalp.379 Charlotte told us the staff member said that Charlotte ‘deserved it’, that she was ‘a little bitch that needed a flogging’ and that she was ‘making more paperwork’ for the staff.380

1. After Ashley Youth Detention Centre

Charlotte said that, upon exiting the Centre after her third admission, she reported some of her experiences to her probation officer.381 Charlotte left Tasmania soon after and, as far as she is aware, her reports were never addressed.382

Charlotte has struggled with anxiety, depression and drug use throughout her teenage years and adult life.383 She is uncomfortable around men and often reacts with fear when somebody touches her.384 Charlotte attributes these difficulties to the abuse she suffered at Ashley Youth Detention Centre. She explained:

If it wasn’t for how they treated me, I wouldn’t be where I am today; using drugs to cover up how I feel and try to forget what happened.

So many times, I’ve tried to kill myself because of what happened at Ashley. I have lost count.385

1. Improving youth detention

Charlotte thinks that more support should be available to children in detention, including giving young people access to somebody to speak to.386 She feels that she received more support of this kind in adult prisons than she ever received as a 12-year-old at Ashley Youth Detention Centre.387

Charlotte thinks that more cultural support for Aboriginal children, like her, would have made a difference.388

Charlotte also noted the lack of educational support she received at Ashley Youth Detention Centre, stating that she still struggles to read and write.389

1. Case example: Fred

1. Before Ashley Youth Detention Centre

Fred (a pseudonym) told us he had a tumultuous childhood. He recalled that his father was abusive and physically assaulted Fred and his siblings.390 Fred’s parents separated before he was 10 years old, and he then spent several years moving around the country living with various family members.391

Fred had substance abuse issues from his early teens.392 He told us that, when he was in his mid-teens, his stepfather took out a family violence order against him, and Fred had to move out of the house. Fred became homeless.393

1. Admissions to Ashley Youth Detention Centre

Fred was in his late teens when he was first admitted to Ashley Youth Detention Centre in the mid-2000s.

He was charged with stealing a car and remanded in custody because he was homeless and, therefore, could not give the court a fixed bail address.394 Fred spent three months on remand in the Centre. He was then given bail and released for six months to an independent living placement organised by Ashley Youth Detention Centre.395 Fred was eventually sentenced to serve another three months’ detention on the same charges. Despite having turned 18 by this time, Fred was sent back to the Centre because he had been charged when he was a child.396

Fred was placed in the Franklin Unit at Ashley Youth Detention Centre, which he said housed the young people whom the staff had the most trouble controlling.397 While Fred was not violent, he believes that he was housed in the Franklin Unit because he would ‘push the guard’s buttons’.398

1. Alleged abuse at Ashley Youth Detention Centre

Fred told us he was subjected to numerous strip searches on each of his admissions to Ashley Youth Detention Centre. For every strip search, Fred recalled that he had to strip completely naked. Fred told us that he was often restrained by staff during these searches and subjected to intrusive physical search techniques.399 Fred recalled three or four staff holding him down, putting their knees on him, running their fingers along his buttocks and genitals, taking off his clothing and asking him to ‘squat and cough’ as part of searches.400

Fred described being strip searched when staff suspected that he had received drugs during a visit, although nothing was found.401 Fred recalled that the staff began threatening him in an attempt to make him hand over the contraband and comply with the search, with one staff member saying, ‘I know where your parents live’ and ‘we’ll make your time harder’.402 Fred said that the strip searches made him feel belittled and disgusting; he described them as ‘harrowing’.403

Fred told us that violence between the young people at the Centre occurred daily in the Franklin Unit and that it was often encouraged by staff at the Centre, who did little to stop the fights that broke out.404 Fred said that the young people in the Franklin Unit called the unit the ‘gladiator pit’ because it felt like the staff treated fights between them as a sport.405 In Fred’s experience, the Franklin Unit staff waited until a fight was almost over, or until there were more staff present, before taking any action to stop the fighting.406

Fred said that on at least two separate occasions he was violently abused by other young people while staff stood by and watched. He said staff then punished him, although he was the victim of the abuse, because he was ‘an annoyance to the unit’.407

Fred told us he was also subjected to physical abuse by the staff. He said the staff, who were physically bigger than Fred and most other young people in the Centre, would hit Fred on the back of his head, push him and jump on him.408 Fred recalled that once, when some young people from Fred’s activity group escaped from the Centre, staff handcuffed him and screamed at him to ‘interrogate’ him for information about the other boys’ whereabouts. He said this reminded him of interrogations shown in films.409

Fred told us he witnessed physical and sexual abuse perpetrated against other young people at the Centre. He said he saw a young person at the Centre being raped by another young person, a young person being bashed by other young people, and a staff member dragging a female young person naked from the shower by her hair before placing her on the ground and cuffing her.410 Fred said that staff generally treated the young people in the Centre roughly, including the younger children who were detained.411

1. Reporting abuse by Ashley Youth Detention Centre staff

While he was at the Centre, Fred made two written complaints about the misconduct of staff. He said the process for making a written complaint was to ask for a complaint form, fill it out and then slide the complaint under his cell door for a passing staff member to collect.412 Fred told us that neither of his complaints were acknowledged by Ashley Youth Detention Centre staff or gave rise to any follow-up action. Fred said that, after he slid the complaints under his door, he never saw nor heard about the complaints again.413

Fred said that he learned he should not speak out or complain because, if he did say something, staff and other young people at the Centre would ‘come after him’.414 Shortly after he made his second complaint, Fred was moved from Ashley Youth Detention Centre to Risdon Prison. Fred said that staff at the Centre told him that being sent to Risdon was his 18th birthday present.415

1. After Ashley Youth Detention Centre

The effect of the abuse Fred endured at Ashley Youth Detention Centre has been significant and ongoing. Fred said he suffers from poor mental health in the form of post-traumatic stress disorder, as well as panic attacks. He feels that his experiences caused him to lose trust in authority figures such as police, prison guards and alcohol and drug counsellors.416 Fred believes that the physical and sexual abuse he and others suffered at Ashley Youth Detention Centre should not happen to any child:

The things that happened to me at Ashley and the things I saw have affected my mental health. I have flashbacks. These things shouldn’t happen to kids, regardless of how naughty we were or how tough we acted. Especially kids that were younger than me.417

Fred believes that his time at Ashley Youth Detention Centre and in the youth justice system failed to address his behaviours. Instead, he said his experiences contributed to him falling into a life of crime: ‘They never addressed my behaviours. All I did at Ashley was learn how to be a criminal and meet people who led me further down the wrong track’.418

1. Improving youth detention

Fred thinks that the Tasmanian Government should move towards a model of managing offending behaviour in children through rehabilitation rather than punitive incarceration.419 He notes that Tasmania has the highest rate of recidivism among young people in youth detention in Australia and he has no doubt this is due, at least in part, to how Ashley Youth Detention Centre treats its young offenders.420

Fred firmly believes that Ashley Youth Detention Centre must be closed:

[The Government should] just close this place down and start again, because it’s not—it’s systemic, it’s grown in that environment. You won’t ever get rid of it by putting in new staff members or changing things: tear the place down and start again, the memories are too— just appalling.421

1. Case example: Oscar

1. Admission to Ashley Youth Detention Centre

Oscar (a pseudonym) first went to Ashley Youth Detention Centre on remand for a few months in the mid-2000s when he was 14 or 15 years old.422 He spent another three months on remand at the Centre about a year after his first admission.423

1. Alleged harmful sexual behaviours at Ashley Youth Detention Centre

During his first admission to the Centre, Oscar was initially placed with boys he knew from the community.424 He was then moved to a unit with boys he did not know.425 Oscar recalled that on his second day in the new unit, he went to do some laundry and was physically and sexually abused by five boys.426 Oscar said that a staff member at the Centre was present and watched the abuse.427 When Oscar asked for the staff member’s help, Oscar recalled that the staff member ‘just laughed’.428 Eventually, the boys stopped abusing Oscar. Oscar said the staff member did not say anything about the abuse that had just occurred; he just told Oscar to go back to his room.429

Oscar remained in the unit with the same boys.430 They continued to bully him, hit him when no one was looking and take his canteen food. Oscar explained that he felt like he ‘was walking on eggshells all the time. The guards were aware of what was happening but would just turn a blind eye’.431

Oscar recalled that when the other boys in the unit found out he was receiving a visitor, they pressured him to have drugs and money brought into the Centre for them.432 Oscar said that they threatened that if he didn’t do this, ‘they would bash the shit out of [him]’.433

Oscar said that he never spoke to anyone about the abuse he suffered from other young people detained at the Centre, and he never made a complaint: ‘I didn’t know how to make a complaint and was worried about what would happen if I did. I also didn’t want to be a snitch’.434

1. Alleged abuse by Ashley Youth Detention Centre staff

At a visit during his first admission at the Centre, Oscar was given $20, which staff found after Oscar had initially denied being given anything after he left the visitation room.435 After they found the $20, Oscar told staff that he had not been given anything else during the visit; however, he said they replied: ‘We know you’re lying to us and you’ve got other stuff’.436 Oscar said that staff indicated that they thought Oscar had something hidden in his anus.437 He recalled that he was then locked in a room near the visitation area that only had a bucket and a desk in it, and he was left there all day:

At end of the day, they came in and asked me if I’d taken a shit in the bucket. I said I wouldn’t go in the bucket. After I refused, they scruffed me and held me down. Then one of the workers who had a glove on stuck his finger up my arse. He said ‘I know you’ve got something in here’. Afterwards, they took me back to my room and locked me in there for the rest of the night and the next day.438

Oscar said that he was ‘upset and pissed off’ after the incident and that he knew the way he had been treated was wrong.439 Oscar did not want to make a complaint because he ‘didn’t know who [he] could trust’ and was worried what would happen to him if he told the ‘wrong’ person, because the same staff would always be on the same shifts together.440 At the time of giving his evidence to our Commission of Inquiry, Oscar still did not want to name the staff involved in that, or any other, incident.441

Oscar recalled being regularly strip searched during his time at Ashley Youth Detention Centre, including at admission and after court and visits.442 The searches would be done in the admissions area, with two staff members watching Oscar: one in front of him and one behind.443 Oscar also recalled that staff would search his room if they thought he was hiding something.444 If they did not find anything, they would strip search Oscar in his room’s shower bay.445 Oscar said that during these searches, staff members would sometimes ask him to move his genitals; at other times they would do it themselves.446 Oscar said that he ‘thought it was wrong for them to touch [him]’.447 Oscar thought he was strip searched in his room like this four or five times while he was at the Centre.448

Oscar also recalled being locked in his room on two occasions as punishment for fighting.449 He said staff would lock him in his room all day and night, only allowing him out once to make a phone call and then making him go to bed at 5.30 pm.450

1. After Ashley Youth Detention Centre

Looking back on his experience at the Centre, Oscar said that he does not trust or get along with many people because of the way he was treated there.451 Oscar said he tries not to think about what happened to him because it upsets him, and he does not like to talk about it; he is trying to get on with his life.452

1. Improving youth detention

Oscar said there needs to be better background checks on people who are hired to work at Ashley Youth Detention Centre.453 He said he believes that some of the staff at the Centre should not have been looking after kids.454 Oscar said he was always worried about what staff members would do if he complained or spoke up about what happened there.455

Oscar said he thinks that places such as Ashley Youth Detention Centre should focus on rehabilitation rather than punishment:

Kids that are in trouble need help to change their behaviours and get a start in life. They should be put into programs and helped to get a job. They shouldn’t just be locked up in an institution. Being at Ashley didn’t help me in any way. It didn’t teach me anything or help me change my behaviours one bit. If anything it made me worse due to the things that happened there and the people I was in with.456

1. Case example: Simon

1. Admissions to Ashley Youth Detention Centre

Simon (a pseudonym) was admitted to Ashley Youth Detention Centre seven or eight times from the early to mid-2000s.457 Simon was only 10 years old when he was first admitted, on remand for stealing.458

On the first and each later admission, Simon was detained at the Centre because he was denied bail, remanded in custody and sentenced while he was at the Centre.459

1. Alleged abuse by Ashley Youth Detention Centre staff

Simon told us that strip searches were regularly conducted at the Centre—every time he was admitted, every time he went to and from court, and during random searches of his room.460 He said that during these searches he had to be naked in front of the staff searching him.461

Simon said that, during one search, after he had removed his clothes as requested, the staff asked him to pull his buttocks apart and told him that they would need to hold him down to search him.462 Simon said he refused and asked the staff to perform a ‘normal’ search instead.463 He said that three staff members then came into the room, wrestled him to the ground and spread his buttocks, before putting him in an observation room known as ‘the fish tank’.464 Simon told us that, decades later, he still thinks about that search, how it made him feel abused and how it should never have happened to a child.465

Simon said that he was regularly physically abused by Ashley Youth Detention Centre staff, often for minor transgressions such as refusing to go back to his room.466 Simon told us that staff often responded disproportionately to the actions of the young people in detention; for example, not going to bed on time or ‘slipping up [and] doing something simple like a kid does’ would lead them to be ‘smashed up’.467 He recalled that staff regularly left him with bruises and grazes.468 He said that, as well as physically abusing him, staff often called him names such as ‘little cunt’, which distressed him.469 Simon told us that he was subjected to verbal abuse ‘all the time’ while at Ashley Youth Detention Centre.470

Simon further recalled staff acting inappropriately towards other young people detained at the Centre. For example, he said that an older staff member would regularly sit and watch young people shower through a viewing panel intended for suicide prevention.471 Simon said that the staff member became so notorious for this behaviour that he earned the nickname ‘dirty old dog’ from some young people.472

Simon said he was placed in isolation at the Centre two or three times.473 He recalled being put into isolation as punishment, sometimes for minor transgressions.474 Simon said he remembers the experience as ‘the coldest thing in [his] life that [he has] ever been through’, and that it was so cold that it ‘felt like it was snowing’.475 He was only given a horse blanket for warmth.476 He recalled that, on one occasion, he spent two and a half weeks in isolation.477

Simon said he generally did not complain about poor conditions and poor treatment while he was in the Centre because he was afraid that the staff might physically abuse him if he did.478 He said that, on the occasions he did complain about things the staff did to him, he felt he was not believed because he was a ‘criminal’ going up against the State.479

When Simon was aged 17, he was remanded for robbing a house.480 When he was told that he was going back to Ashley Youth Detention Centre, he asked to be sent to Risdon Prison instead because he believed he would receive better treatment there.481 Simon is now in his 30s and has spent more than 15 years of his life in the youth justice and prison system.482

1. After Ashley Youth Detention Centre

Simon said that his experiences at Ashley Youth Detention Centre have affected him into adulthood and he feels they have contributed to his long history of incarceration. He told us that the young people detained at the Centre could not defend or protect themselves and were not appropriately supported to improve themselves. He explained:

We were only kids and we couldn’t stick up for ourselves. The guards and workers at Ashley were disgusting. I’ve been in [and] out of jail all my life. I was never taught right or wrong to help me change. I was just abused. I don’t want what happened to me happening to another kid.483

1. Improving youth detention

Simon said he believes that children and young people who get into trouble should be helped and educated, not punished.484 He said:

There needs to be a better place for kids who get in trouble to be sent. A place where the kids actually get help to change their behaviour. Somewhere that makes them realise there are better things out there in life. Kids can’t stick up for themselves and should be helped …485

Simon said that Ashley Youth Detention Centre could introduce courses and programs to help young people rehabilitate and he believes that he might not be stuck in the prison system now if he had been given that opportunity—he would have had a chance to lead a ‘normal’ life.486

He said Ashley Youth Detention Centre should not be converted into an adult prison after its planned closure, because there is a significant number of adults in prison who spent time at the Centre when they were younger and were assaulted or sexually abused there.487 Simon said he is concerned that if those adults were sent to a prison on the same site, it could trigger past trauma. He worries that: ‘They will put their head down on their pillow at night and think about what happened to them as kids. They will have flashbacks. The whole place should just go’.488

Simon said he thinks the Centre should close as soon as possible to avoid causing trauma to more children. He explained: ‘I want them to realise they can’t treat kids like they did. I don’t want other kids to be put [through] what I went [through]. I think the place should be shut down now’.489

1. Case example: Erin

1. Admissions to Ashley Youth Detention Centre

When Erin (a pseudonym) was 14 years old, she was living in a women’s shelter after acting up at school and becoming estranged from her mother.490 Erin’s behaviour escalated quickly; she was arrested for stealing and remanded at Hobart Remand Centre (now Hobart Reception Prison) in the mid-2010s.491 She recalled that the court ‘didn’t know what to do’ with her; a placement in foster care, in a shelter or living with her parents were not seen as suitable options for Erin.492 After two days at the Hobart Remand Centre, Erin was sent to Ashley Youth Detention Centre on remand for three months.493

Erin told us that she was initially comforted by the idea of leaving the Hobart Remand Centre and going to the Centre. She said: ‘I was relieved. I thought going there would provide me with some security. I thought Ashley would be better, but it turned out to be worse’.494

After her first admission, Erin was admitted to Ashley Youth Detention Centre another three times.

1. Alleged abuse by Ashley Youth Detention Centre staff

Erin said she was strip searched by male staff on her arrival and placed in the female unit.495 The male detainees yelled at her and banged on her windows.496 She said she later learned that the males in detention could watch her through the staff office that separated the girls’ unit from the boys’ unit.497

Erin told us that ‘if the guards didn’t like you, they would do things like leave you in your cell on the weekend’.498 She said she was once ‘unit bound’ for a week and only allowed out for an hour or two a day.499 She stated that this experience has left her traumatised.500

Erin recalled frequent strip searches by male staff, during which she would be naked.501 Erin said she was strip searched each time she was admitted to Ashley Youth Detention Centre and before and after going to court.502 She said she was also subjected to random strip searches.503 Erin said she was often strip searched by multiple male staff, who told her they all had to be there for her safety, but Erin felt they treated the strip searches ‘like a show’.504 She described the experience as ‘totally violating’.505 Erin said that she was never given the option of being strip searched by female staff.506 Erin said that at the time she thought the strip search procedure was normal because she had had the same experience at the Hobart Remand Centre.507

Erin described the environment at the Centre as ‘hostile’.508 She said she regularly saw staff physically abuse male detainees.509 Erin described staff members’ attitudes and behaviours towards her as more ‘manipulative’.510 She recalled that staff members would intentionally cause her to miss meals, leave her in her cell on the weekends and regularly make offensive or inappropriate comments about her body.511 Erin described being ‘treated like an object’ by staff.512 She said that during her detention she was never provided with a bra, was not allowed tampons and was only provided with a certain number of sanitary pads at a time.513 Erin reflected that ‘[t]here were no rights or dignity. It was disgusting’.514

Erin told us that, about a month after arriving at the Centre, she was feeling unwell and was worried she had appendicitis.515 She said she told a male staff member and asked to see the nurse.516 Instead of arranging access to a nurse, she said the male staff member told her to lift her top up, felt around her lower abdomen and drew a shape near her hip, telling Erin it was a ‘happy appendix’.517 Feeling violated and that his actions were ‘creepy’, Erin reported the incident to a female staff member, who advised Erin to report it to the Ombudsman.518

Erin told us that the same male staff member entered her room to collect sheets while she was showering, despite Erin’s request that he send a female staff member to collect the sheets, or that he waited until she finished showering.519

Erin reported these incidents to the Ombudsman, who responded by letter two weeks later, stating that the matter would be resolved by Ashley Youth Detention Centre management.520 An internal investigation by management found that the male staff member had not displayed ‘inappropriate intent’ in either case, but that he should have known his actions might make Erin ‘feel uncomfortable and even potentially unsafe’.521

Erin said nobody at the Centre spoke to her about her complaint, she did not receive any counselling or other supports, and she was not notified of any outcomes.522 Erin said that she heard from another staff member that the male staff member was placed on two weeks’ paid leave as a result of her complaint, but that this was never confirmed for her by the Ombudsman or by the Centre’s management. We discuss the management of Erin’s complaint to the Ombudsman further in Case study 7.523

Erin told us that when the male staff member returned from leave, she had to continue engaging with him and that he was ‘never nice to [her] again’.524 She said that other staff were angry at her for reporting the incidents, calling her a ‘dog’ and a ‘drama queen’.525 This made Erin feel as though complaining only created problems:

After this I felt like it was pointless making complaints or speaking up. I learned that you don’t say anything in Ashley, it was more trouble than what it was worth. I would describe the staff at Ashley as being like a pack of animals. Some of them had been working there for 30 years. They all went to school together. They were all from Deloraine, which was a small country town. They all looked after each other.526

1. Alleged harmful sexual behaviours at Ashley Youth Detention Centre

There were few girls at Ashley Youth Detention Centre when Erin was detained. She said that this meant she was often in the company of males in detention when taking part in educational or therapeutic programs.527 Erin said that, on one occasion, she was left unsupervised in a room with 10 males in detention and was sexually abused.528 She said that it ‘was probably only 2 or 3 minutes but it was enough time for them to do significant damage’.529

Erin said she shared what happened to her with another young woman in detention, who then told a female staff member.530 Erin said that although she asked the staff member not to tell anyone, the staff member reported the incident to management.531 Erin said she was not offered counselling support or medical treatment, and no one else from the Centre spoke to her about the incident.532 Instead, she was released a few days later.533

Erin returned to Ashley Youth Detention Centre some weeks later on a charge of stealing.534 She said she was told that the boy who had been predominantly responsible for the sexual abuse during her previous admission had gotten into trouble.535 Once Erin arrived, the boy’s friends began threatening her and she was confined to her room for her safety.536 She said she also felt targeted by the staff members who had been reprimanded for allowing the incident to occur.537 She said this treatment reinforced her view that it was better to stay silent. Erin reflected:

I wasn’t offered any support or protection to help me deal with all of this. There was no-one there to support me. This again confirmed to me that you don’t say anything at Ashley. If things happen you don’t talk, you just go along with it.538

Erin was admitted to Ashley Youth Detention Centre two more times, each time for breaching her bail conditions.539 She said that sexual abuse by male detainees continued during these admissions.540 Erin told us that staff were aware of what was occurring but that ‘they just accepted it’, enabling the boys to get away with what they wanted.541 Erin recalled that she was regularly forced to perform sexual acts on males in detention during scheduled programs while staff members watched.542 Erin said that eventually she was placed on the contraceptive pill and recalled that she visited the nurse’s office each day to receive it.543

Erin said she never tried to report sexual abuse again:

I went along with doing these things because I just thought it was easier. I believed that if I didn’t, I would get my head kicked in. It was easier to comply. I didn’t make complaints to the staff because I knew if I did things would get worse. Again, I was fearful of being physically assaulted.544

1. After Ashley Youth Detention Centre

Erin said that, after leaving the Centre, she tried to forget her experiences by using alcohol and drugs.545 Erin has post-traumatic stress disorder, anxiety, depression and low self-esteem. She struggles to trust men, which affects her personal relationships and her children.546

Erin said she attributes her poor mental health and wellbeing to the way she was sexualised and sexually abused at Ashley Youth Detention Centre.547 Reflecting on the impact of her abuse, Erin stated:

Ashley made me feel like it was normal and it was okay for men to treat me like that. It made me believe that it was what I was used for. I have had horrendous things happen to me that I have just thought I deserved. I believed that it was normal for these things to happen because that’s how I was treated at such a young age. Before I went to Ashley, I was never exposed to sexual abuse.548

1. Improving youth detention

Erin expressed her view that Ashley Youth Detention Centre would be much safer for young women in detention if they were kept separate from males in detention, if there were more female staff, and if staff were better trained.549

Erin said that children should not be detained for minor offences and that alternative options to institutional detention, such as home detention, are needed.550

She also said that a commitment to therapeutic-based systems must be more than mere words; it needs to be evident in the systems and processes in place at Ashley Youth Detention Centre or any new youth justice facility.551 She recalled that Ashley Youth Detention Centre was said to be operating a ‘therapeutic model’ when she suffered abuse there.552 She said: ‘Building a new centre and putting a ribbon on it isn’t going to change anything. They need to break it right down and make sure it changes’.553

1. Case example: Jane

1. Before Ashley Youth Detention Centre

Jane’s youngest daughter Ada (both pseudonyms) was bubbly, outgoing and well liked for most of her primary school education.554 Jane told us that Ada became uncontrollable soon after she started her schooling in Tasmania in the late 1990s, aged 11.555 Ada spent much of her time trying to fit in with older kids, smoking, drinking and not attending school.556

Jane reached out to the Department of Education for assistance, hoping they could encourage Ada to go to school.557 However, Jane said that the departmental employees sent to speak with her and Ada told Ada to ‘not worry about schooling’ and to ‘focus on [her other] problems instead’.558

Jane became concerned that she could no longer keep Ada safe and in school.559 She described feeling ‘betrayed’ after she sought help from the Department of Education and two social workers who visited told Ada not to worry about school and to focus on addressing other problems.560 She was later told by the Department of Education that the social workers were students and that the Department considered Ada’s non-attendance a serious concern.561 Jane recalled that, after finding Ada’s behaviour uncontrollable and fearing for her safety, she decided to ‘get welfare involved’.562 She described being assisted to put together an application and ultimately applied to make Ada a ward of the State when Ada was aged 12.563 At around this time, a psychological assessment found that Ada’s behaviour was consistent with that of a primary alcoholic.564

1. Admissions to Ashley Youth Detention Centre

The same year, while she was a ward of the State, Ada was admitted to hospital with severe alcohol poisoning.565 Jane said that, after five days in hospital, Ada’s behaviour was deemed too problematic for the hospital to manage, and Child and Family Services approved Ada’s transfer to Ashley Youth Detention Centre.566 While Jane told us that Ada was admitted to Ashley Youth Detention Centre, we understood her to mean that Ada was admitted to the former Ashley Home for Boys (which was the relevant institution at this time). Jane recalled that Ada’s Child and Family Services’ case workers agreed that this transfer ‘wasn’t right’ but explained to Jane that Ada had been moved to the Centre because there was nowhere else for her to stay while they considered what to do with her.567

The Department told us Ada was admitted to the Centre under section 39(7) of the Child Welfare Act 1960.568 We were told the decision to admit Ada was made to address her complex behavioural and medical needs, was based on expert recommendations and was not a decision that was taken lightly.569

Jane told us that Ada resisted being transported to Ashley Youth Detention Centre and was therefore restrained during the trip.570 Jane said that, once at the Centre, Ada was placed in a single cell with other young people. Jane’s recollection was that Ada was subjected to the same rules, such as rules relating to isolation and searches, despite not having been charged with any crime.571 We were told that Ada was the only female young person detained at Ashley Youth Detention Centre at the time.572

Ada was detained at the Centre on and off in the late 1990s and 2000s. Her first admission lasted around two and a half months.573 Jane told us that, eventually, Ada was transported every day from Ashley Youth Detention Centre to a house, where she was cared for by a case worker or a foster carer. She was then transported back to the Centre every night.574 Jane recalled she was not allowed to visit Ada during her first admission but visited her at the day home.575

Ada was placed with a foster family full-time.576 A couple of weeks into that placement, Ada ran away for several days until Jane tracked her down and convinced her to go back to the foster home.577 In response to her running away, Child and Family Services decided that Ada would be detained at Ashley Youth Detention Centre again each night for two weeks and returned to her foster family during the day.578

After Ada left Ashley Youth Detention Centre, she returned to Jane’s care. Ada was later charged with burglary offences and put on a probation order, with conditions that included not drinking alcohol.579 The only support the State offered Ada for her alcoholism was counselling. However, Jane stated that Ada, then 13 years old, was left to decide whether she would access counselling.580 Ada soon breached her probation and was sentenced to a few months’ detention.581

Jane believes the State set Ada up for failure by neglecting to give her the tools she needed to comply with her probation order. Jane said: ‘[Ada] had a major drinking problem and they didn’t put anything else in place to help her stop. All of these rules had been set up that she would never be able to comply with’.582

Jane believes what happened to Ada at Ashley Youth Detention Centre is Ada’s story to share, not Jane’s.583 While Jane does not know all the details, Ada has told Jane she had some ‘bad times’ at the Centre, that she had to be ‘tough’ when she was there, and that she had to ‘fend off some older boys’, including males over the age of 18.584 Ada also told Jane that the increasing number of older people being detained, especially people over the age of 18, created a ‘hierarchy’ based on age groups and resulted in the older kids causing trouble.585 While Jane thinks there was more supervision for Ada because she was the only girl at Ashley Youth Detention Centre, she believes the Centre was an entirely unsuitable place for a vulnerable child.586

1. Out of home care

Jane told us the State’s decisions for Ada were often inconsistent and poorly communicated to Ada.587 Jane described one instance where Child and Family Services told Ada she would be placed in independent living on release from Ashley Youth Detention Centre. Jane told us Child and Family Services then changed its mind a week before Ada was released and instead transferred Ada to a women’s shelter.588 Jane said these changes were confusing for Ada, would cause Ada to get angry or upset, and in Jane’s opinion, set Ada back.589

Jane thinks Ada was not supported well enough as a ward of the State. She described how, on one occasion, when Ada was released from youth detention at the age of 14, Ada had to make her own arrangements to be picked up from the Centre because Child and Family Services had not put any transit arrangements in place for her.590

Jane also feels there was poor communication and coordination between the different services with which Ada interacted, including Child and Family Services, the Department of Education, the Department of Justice and police.591 Jane was particularly frustrated by the State’s failure to support Ada in her education:

They just didn’t have the facilities to deal with kids like [Ada] and as a result the system was failing them. There was never a push to get [Ada] back into school. The education department had told her to sort her issues out and not worry about school. There was no education under the care of [Child and Family Services] and as a result [Ada] didn’t complete primary school.592

Jane recalled that Child and Family Services allowed Ada to do things that Jane and Ada’s foster carers would not, given her young age.593 For example, Jane was aware that Child and Family Services would buy cigarettes for Ada when she was in her early teens.594 On one occasion, Jane told us that Child and Family Services gave Ada permission and spending money to go on a two-day trip with a female and three males who were much older than her.595 When Jane confronted Child and Family Services about this, she was told that the trip had been approved because one of the males, a 19-year-old, had a driver’s licence.596 Jane felt that Child and Family Services failed to listen to or consult her about Ada’s care, and let Ada do things that she didn’t have the maturity to do.597

1. Improving youth detention and out of home care

Jane thought that by making Ada a ward of the State, Ada would be safe and educated.598 Looking back, Jane feels betrayed by Child and Family Services’ decisions to treat Ada like a detainee even though, for much of her time at Ashley Youth Detention Centre, she had not been charged with any crime.599 Ada now battles an addiction to methamphetamine, which Jane attributes to Ada being caught up in ‘the system’ and spending time at Ashley Youth Detention Centre.600

Jane wants the Tasmanian Government to reduce its reliance on the criminal justice system to work with young people who have complex needs, in favour of alternative interventions and prioritising education.601 Jane would also like the Government to focus on addressing the cause of youth offending, such as treating Ada’s alcoholism.602

Jane also believes the various Tasmanian Government departments responsible for children and the out of home care, education and youth justice systems must work together in a child-centred way. She said:

… these are youth that need help, you know, but [through] a combination of all the services working together and [communicating] … [Ada] didn’t finish primary school and she hasn’t got an education, and she was extremely bright but she just didn’t get that education that I would have liked for her and I think there could have been a lot more done about that.603

1. Case example: Otis

1. Admissions to Ashley Youth Detention Centre

Otis (a pseudonym) was detained at Ashley Youth Detention Centre twice in the early 2010s.604 He was 16 or 17 years old when he was first detained and 17 years old when he was detained a second time. In total, he was detained for several months.605

1. Alleged abuse by Ashley Youth Detention Centre staff

Otis recalled being regularly strip searched at the Centre—on each admission and before and after leaving the Centre’s premises.606 During searches, Otis said staff required him to be naked and instructed him to squat or ‘stand like [he was] riding a motorbike’.607 Otis recalled that staff would then perform an intrusive cavity search, including putting their fingers in his anus.608 Otis said that if he did not comply with instructions, the staff would hold him down to perform the search and that they sometimes deliberately made it more painful and more sexual.609 It appeared to Otis that some staff enjoyed strip searching him.610 Otis recalled that because the strip searches occurred so regularly at the Centre, ‘[at] the time I just thought the searches were part of what goes on. I thought it was normal. I didn’t realise it was illegal like I do now’.611

Otis said that, on his second admission to the Centre, he was placed in a unit with young people who were afforded more privileges than most because they were well behaved.612 These young people were offered extra comforts such as DVD players in their rooms and more exercise time.613 The unit was not as heavily supervised as other units, and it received more funding.614 At the start of Otis’s admission, the unit did not have any closed-circuit television cameras.615

Otis told us that his first experience of sexual abuse was from staff working in that unit, after he opted to stay in his room instead of going to a class, to avoid problems he was having with other young people.616 Otis said that a staff member entered Otis’ room and told him that he would need to do the staff member ‘a favour’ for letting him stay out of class.617 Otis said that the staff member then made Otis perform oral sex on him and told Otis that ‘it was a secret and he’d look after [Otis] if [Otis] kept it a secret’.618 Otis recalled that the staff member also told him that if he did not keep it a secret, the staff member would tell the other young people in detention that Otis had ‘dobbed’ on the other boys.619

Otis told us that, after this first incident, he experienced further sexual abuse at the hands of other staff at the Centre.620 He recalled being made to perform sexual acts on staff and engage in sexual intercourse with staff in his room, in a storeroom, during relaxation therapy group sessions and outside his unit on the Centre’s grounds.621 Otis said that usually, when he was sexually abused, it was just him and the abusing staff member.622 Otis also recalled a ‘gang of perpetrators’ that he described as having a ‘gang mentality’.623

Otis also recalled being sexually abused by Ashley Youth Detention Centre staff during weekly excursions away from the Centre, and witnessing staff sexually abusing other young people in detention during these excursions.624 Otis said that the abuse started happening outside their rooms, in storerooms or on excursions once cameras were installed in the unit where he was detained.625

On some occasions, Otis and other young people were taken off the Centre’s grounds to perform community service.626 Otis said that the staff member accompanying them took advantage of this time to sexually abuse them.627 He told us that, when he was taken off site during the early 2010s, he would be separated from the group, held in a car and sexually abused.628 He said because there was no oversight, staff ‘would get away with an extreme amount of shit’.629 Otis described yelling out to another staff member for help following an incident of sexual abuse when he was left alone with one particular staff member when off site.630 Otis told us that, in response, this staff member physically assaulted Otis and urinated on him.631 Otis said that staff would also threaten to leave a young person off the grounds or to tell the Centre’s management that the young person had ‘run away’ if they did not submit to the abuse.632

Otis said that he and other young people in detention were bribed with cigarettes and alcohol to stay quiet, and they were physically abused if they complained about the sexual abuse.633 Otis said that it was well known among the young people in detention that going ‘off-property’ would mean being sexually abused, but that they would come back with cigarettes for everyone.634

Otis recalled being sexually abused almost every time he was taken off-property.635

1. Reporting abuse at Ashley Youth Detention Centre

Otis said he felt he could not share the details of his abuse with anyone at the Centre because it would affect his living conditions; the staff who sexually abused him were in control of his television time, his bedtime and his life.636 He told us that he wanted to stay in his more relaxed unit at the Centre and he was aware that, because he was aged 17 at the time, he had to be well behaved to avoid being transferred to the adult Risdon Prison.637 Otis said that, when the staff were not content with the sexual acts he was performing, they became physically violent and threatened to take away his bedding or his canteen privileges.638 Otis believed that his fear of retribution and, in turn, his lack of retaliation, caused staff to continue to sexually abuse him.639

Otis said he had heard that young people in detention at Ashley Youth Detention Centre were suffering sexual abuse long before he was admitted to the Centre.640 He said that sexual abuse was embedded in the everyday behaviour of the place.641 He said that the young people in detention knew not to ‘dob’ on anyone:

We … had a code in Ashley that you don’t dob anyone in. The [staff] knew that we had this code, so they knew that we wouldn’t speak up. I think they treated us the way they did to show us that they had all the power, and that we had none.642

Otis said he eventually reported the abuse to a psychologist at the Centre, although he did not share all the details of his sexual abuse.643 Otis recalled that the psychologist did not believe him and accused him of being a compulsive liar.644 He said the psychologist told him not to tell his family about his abuse.645

At the time, Otis did not tell his family about the abuse. Otis said: ‘I couldn’t tell mum about what was happening, and I still haven’t been able to tell her some stuff to this day. I got myself into Ashley because I wanted to be a cool kid and do crime. I just didn’t expect this stuff to happen’.646

1. After Ashley Youth Detention Centre

Otis said that after being sexually abused at the Centre, he has been confused about his sexuality because he felt that he ‘accepted’ the abuse from male staff.647 For example, Otis would sometimes offer himself up to go off-property or to the storeroom, where he knew he would be sexually abused, in the place of a younger person who had not been at Ashley Youth Detention Centre before.648 Otis said he was prepared to endure the abuse rather than watch others go through it.649

Otis said he also continues to feel distressed by the death of a fellow young person in detention at the Centre.650 Otis said the Centre did not offer any counselling or support to other young people in detention following the death.651 Otis told us that the circumstances before and after the young person’s death were ‘handled atrociously’ by staff at the Centre.652 He said the incident ‘still haunts’ him.653

Reflecting on his mental health issues following his time at the Centre, Otis said:

I was in detention because I did the wrong thing. That should have been my punishment, not the abuse that I had to endure. It’s changed who I am as a person. My self-esteem and personality have been affected. It’s impacted my mental health. I’ve lost faith in people. I was failed hard. I’m still suffering to this day for the things that happened to me.654

1. Improving youth detention

Otis said that the sexual abuse of young people in detention was allowed to happen in Ashley Youth Detention Centre because of a lack of oversight.655 He told us that, in contrast with adult prison, where a strict system of approvals and bookings applies, Ashley Youth Detention Centre staff were allowed to put detained young people in a car and drive them wherever they wanted, with no checks and balances.656 Otis said he believes the Centre should be run in a more organised manner, where everything requires approval, such as occurs in an adult prison.657 Otis told us that he wants young people to be accompanied by at least two staff members at all times when going off-property and for proper approval processes accompanying such trips to be introduced at Ashley Youth Detention Centre.658

Otis said that, in the past, he has not been comfortable speaking about his experiences of sexual abuse at the Centre.659 However, he said that, with the assistance of a counsellor, he has reached a point in his life where he wants to talk about what happened, so others are not subjected to similar abuse.660 Otis said: ‘I want to know who allowed these things to happen. I don’t care about money. Money doesn’t solve problems ... I worry about what will happen if my kids end up in detention like I did’.661

1. Case example: Brett

1. Before Ashley Youth Detention Centre

Brett was taken into the care of the Department when he was in his first year of high school because of his father’s mental health issues.662 However, he regularly ran away from his placements because of his experiences, trying to find a way back to live with his father.663 In Chapter 8, we discuss Brett’s experiences of abuse in out of home care. He said he ended up sleeping rough and stole to survive because he had no income.664

1. Admission to Ashley Youth Detention Centre

Brett had just turned 14 when he arrived at Ashley Youth Detention Centre in the late 2000s.665 He was remanded to the Centre after being charged for an armed robbery he said he committed to finance a plane ticket to the mainland.666

1. Alleged abuse by Ashley Youth Detention Centre staff

Brett said he was strip searched by a staff member on admission, and when Brett resisted taking off his boxer shorts, the worker physically abused him. Forcibly removing Brett’s shorts, Brett recalled that the staff member then inserted his finger in Brett’s anus, saying, ‘Welcome to Ashley, boy, you do as you’re told’.667

Brett said he went to Ashley Youth Detention Centre six times between the ages of 14 and 17.668 Brett described his treatment by staff during his time at the Centre as ‘horrible’.669 He recalled constant belittling comments such as being called a ‘drug baby’ and being told that he wasn’t wanted, as well as physical abuse such as being hogtied for minor infractions such as not moving fast enough back to his room.670 Brett described being kept in isolation in his room, under what was termed an ‘Individual Support Program’, for up to six weeks at a time.671

1. Reporting allegations of abuse at Ashley Youth Detention Centre

Brett described trying to complain to staff about his treatment in youth detention but stopped because ‘it made it 100 times worse’ when staff responded by making life even harder. He said was not aware that he could complain to the Ombudsman at that time.672

1. After Ashley Youth Detention Centre

Brett said that his experiences at Ashley Youth Detention Centre led him to distrust the justice system and police—‘the ones that are supposed to help are the ones you’re trying to escape from’.673

Brett said he has been incarcerated multiple times as an adult.674 He said that he has used drugs to try to ‘escape from it all’ and attempted suicide.675

1. Improving Ashley Youth Detention Centre

Brett expressed the desire for improved safety at Ashley Youth Detention Centre because of the impact that the experience has had on his life, stating, ‘it’s wrong … it’s destroyed my life and it’s destroyed many other lives that I know’.676 He recommended more cameras in Ashley Youth Detention Centre and that the Centre employ staff ‘who understand how to work with children’.677 He wants children to get help before they get to youth detention.678

1. Common themes

The accounts of abuse we have outlined here predominantly occurred between the early 2000s and the early 2020s (except in relation to Ada, who was detained at Ashley Home for Boys in the late 1990s and then at the renamed Ashley Youth Detention Centre in the early 2000s). Yet, we observed commonalities in the allegations of abuse made by these victim-survivors and their families, as well as in the allegations made through the Abuse in State Care Program, Abuse in State Care Support Service, National Redress Scheme, civil claims and other complaints. We describe some of the common themes from these accounts below. We urge the Tasmanian Government to reflect on these themes when responding to current and future allegations of abuse, and when planning and implementing reforms relevant to youth detention.

More than two-thirds of victim-survivors in the accounts we have documented were under the age of 14 when they were first detained at Ashley Youth Detention Centre. One of the victim-survivors, Simon, was only 10 years old on his first admission.679 Most of these children were initially detained at the Centre on remand for relatively minor charges, and some of them were never detained under sentence. In the case of Ada, who was only 12 years old when she was first admitted to the then Ashley Home for Boys, her mother Jane recalled that she was not subject to any criminal charges, although the Department told us she was there on specialist advice. Many of the victim-survivors were on remand, and some told us that the lack of an adequate bail address was the reason they were remanded to Ashley Youth Detention Centre.

All victim-survivors described being subjected to sexual, physical and other abuse by staff at the Centre or older detainees, or both. We summarise themes in the accounts of alleged abuse by staff below, including in relation to sexual abuse (including through personal searches) and the humiliation and belittling of children and young people. In Case study 3, we closely examine isolation practices at Ashley Youth Detention Centre, including individual accounts of this practice. In Case study 4, we summarise individual accounts of the use of force by staff towards children and young people in the Centre.

Some victim-survivors told us they were forced to share a unit with, or were left unsupervised in the company of, older boys detained at the Centre, despite some pleading with staff that they were not safe. They were subsequently sexually abused, sometimes by groups of older boys. We summarise the accounts of harmful sexual behaviours in Case study 2.

It is incomprehensible to us that children were exposed to such abuse while in the care of the State.

Most of the victim-survivors whose accounts we have reported told us they had experienced trauma before being detained, which contributed to their contact with the justice system and may have made them more vulnerable to sexual abuse once in detention. We heard that victim-survivors came from unsettled, tumultuous and broken family situations. One young person was living in a shelter before her detention at Ashley Youth Detention Centre; another was homeless and two were in out of home care.680 Victim-survivors spoke of physical abuse in their familial settings and of mental health issues that were triggered or exacerbated by their traumatic circumstances. It makes no sense to us that children and young people living under these pressures were not assessed for, and provided with, support services, rather than being detained, especially in circumstances where they had not been said to have committed an offence. In Chapter 9 of our volume on out of home care and in Chapter 12 of this volume, we discuss the need to support, and advocate for, at-risk children, and to ensure detention is imposed as a last resort.

Many victim-survivors told us that their abuse by staff, or their subjection to the harmful sexual behaviours of other detainees, began as soon as they were admitted to Ashley Youth Detention Centre. As described by Ben, Simon and Erin, when young people first arrived at the Centre, they would undergo an admission process that could involve a period of isolation ranging from a few hours to a week.681 We were told by Ben and another former detainee whose account is not recorded here that, in addition to the inherently humiliating experience of being strip searched and isolated, there was also a practice of applying scabies cream to young people’s naked bodies, causing a burning sensation.682 We understand that this practice occurred from the mid to late 1980s until the early 2000s.683 A staff member described the practice in a statement he made in 2020 to the Department:

The kids would come in, they would be showered and they would be de-liced … and you would have to paint their bodies with scabies cream … The process involved painting just about every inch of their body, including genitals … The cream would get applied with a paintbrush. Most of the time staff would apply most of it, including to the genital area …684

We received evidence from another former detainee of Ashley Youth Detention Centre that, when he was first admitted to the Centre at the age of 13 in the late 1990s, it was midnight, and he was strip searched and ‘painted head to toe in anti-scabies lotion’ in what he referred to as ‘punishment on top of punishment’.685 He also described a further incident involving the application of scabies cream as follows:

Once, they said there was an outbreak of scabies, so they line[d] us all up and they painted us all again. The stuff gets left on you, till 3.00 pm the next day when you can shower. It stung, and it’s genital torture. It wasn’t diagnosed by a doctor, it wasn’t completed by a nurse, just a staff member.686

Centre staff using strip searches as a tool of control, and as an opportunity to sexually abuse children and young people, was a common theme across the accounts of victim-survivors. We heard that victim-survivors were subjected to aggressive and ‘harrowing’ strip searches on numerous occasions during their time at Ashley Youth Detention Centre.687 The mother of one victim-survivor told us that her son asked her to stop visiting him in detention because of the strip searches he had to endure before and after her visits.688 As a result, her son was further isolated from the support he needed.

Others described being restrained while strip searched, and several victim-survivors detailed being sexually assaulted during ‘cavity’ searches, including through digital penetration. We also received evidence of male guards performing cavity searches on female detainees by inserting their fingers into detainees’ vaginas.689 Erin described how she was regularly strip searched by male staff members and never provided the option to be searched by female staff.690

Some victim-survivors described being stripped naked by staff, verbally abused and left in locked rooms for extended periods as punishment for any number of actual or perceived infractions.

Many, if not all, of these accounts of strip searches are allegations of child sexual abuse by staff.

Female victim-survivors described staff targeting them for humiliation. For example, Charlotte described staff trying to see down her top, making comments about her body and touching her inappropriately.691 Erin recounted that staff controlled her access to basic amenities such as a bra and sanitary products.692

We are particularly concerned by reports that female detainees, who were often alone or in the minority among male detainees at Ashley Youth Detention Centre (and thus especially vulnerable while in detention), said they were targeted for sexual harassment and abuse arising from their gender. We also heard that older boys would harm younger boys.

Several victim-survivors told us that sexual abuse by Centre staff was often perpetrated off site or in areas of the Centre that did not have closed-circuit television, so the abuse was less likely to be detected. Victim-survivors further recalled that if they attempted to avoid off site ‘excursions’, they were met with reprisals, including having food withheld.693

We were told that staff provided children with cigarettes and other privileges, such as more television time, if they submitted to abuse, both on- and off-premises.694 We heard that this level of manipulation has had lifelong adverse effects on victim-survivors’ understanding of their sexuality, their intimate relationships and their capacity to trust, because they believed that accepting such incentives meant they accepted the abuse.695

Victim-survivors who spoke to our Commission of Inquiry described being subjected to many forms of humiliating, belittling and threatening conduct at Ashley Youth Detention Centre. We heard evidence that being the target of staff members’ derogatory language and verbal threats often happened in conjunction with admission processes, strip searches, isolation and during the perpetration of physical and sexual abuse on Centre premises and off site. Many of the incidents described to us are likely to constitute human rights abuses under instruments such as the United Nations Convention on the Rights of the Child.

One common way that young people described being humiliated and sexually violated at the Centre was being watched by staff while they were showering. Showers at the Centre were visible through observation panels, which were designed so staff could open the panel and check the location and wellbeing of young people, especially if they were at risk of suicide or self-harm.696 Young people told us that this design was abused.697

We also received accounts of young people having insufficient access to toilet facilities while in isolation, including being given only a bucket to use or otherwise being forced to urinate and defecate on their cell floor.698 The Department told us that none of the rooms at Ashley Youth Detention Centre had toilets until refurbishments in the early 2000s.699 The Department advised that when a toilet was otherwise unavailable, access to toilet facilities occurred at the request of a detainee while they were in isolation.700

Alysha (a pseudonym), former Clinical Practice Consultant, Ashley Youth Detention Centre, told us that, during her employment at Ashley Youth Detention Centre between late 2019 and mid-2020, staff made direct threats of physical violence against detainees.701 She described a staff member threatening to turn a young person ‘into an owl’ if they did not change their behaviour. She recalled being told that this meant the staff member would ‘cave the child’s face in’.702 We also received evidence from Alysha of young people being teased about their weight and called names such as ‘fat fuck’ by staff while being strip searched.703

If this conduct did occur, it involves using degrading language to demean the young person and to frighten them as a means of securing their compliance and exercising power and control. The Youth Justice Act 1997 prohibits any form of psychological pressure intended to intimidate or humiliate children and young people in detention, as well as any form of physical or emotional abuse, or any kind of discriminatory treatment.704 Young people in detention are entitled to, and deserve, humane treatment and the maintenance of their dignity. Every child has the right not to be humiliated, belittled or threatened.705

The sense of utter helplessness that anything could be done about the ways in which young people were treated in detention was palpable across the accounts by victim-survivors, who commonly stated that, after initial attempts to report abuse, things often got worse rather than better for them. Therefore, they learned never to complain again. Victim-survivors told us that reprisals for reporting the abuse included severe violence from staff and other detainees. Consequently, some young people stopped disclosing sexual and physical abuse to other staff members, their parents, community visitors and statutory authorities, such as the Commissioner for Children and Young People.

We are deeply saddened to report that one of the most common themes to emerge from the accounts we have documented was the devastating ongoing trauma that the abuse at Ashley Youth Detention Centre has had on victim-survivors’ mental and physical health. We heard that many victim-survivors have attempted suicide, struggle with significant mental health conditions and addictions to drugs and alcohol, and have been incarcerated during their adult lives.

Ben provided a particularly evocative reflection on how the violent sexual abuse that he told us he experienced at Ashley Youth Detention Centre eventually broke him, and his realisation that using violence himself was the only way to survive.706 His account provides just one illustration of the failure of Ashley Youth Detention Centre to fulfil a core purpose of youth justice—rehabilitation. Instead, through a culture of humiliation, denigration, control, violence and abuse, Ashley Youth Detention Centre seems to have contributed to the antithesis of rehabilitation—further criminalising young people.

Many of the victim-survivors and their family members told us what they wanted to see happen at Ashley Youth Detention Centre and in relation to the youth justice system more broadly. Most commonly, they said they want proper mental health and other supports—not remand—for children when they start offending, and for the Government to reduce its reliance on detaining children and young people overall. They also told us that they want:

• an acknowledgment from the Government about what has happened to them
• a prohibition on staff who have abused children in detention from ever working with children again
• comprehensive background checks on anyone seeking employment at a youth justice facility
• a rehabilitative facility for young people that is more centrally located and ensures detainees have access to a full education
• closed-circuit television throughout a new facility
• female and male young people to be housed separately in detention facilities, with girls to be supervised only by female staff
• a safe and effective process for children to make complaints about their treatment when detained
• more cultural support for Aboriginal young people in detention.

1. Management recognition of the scale of the abuse

Despite a large number of claims and allegations filtering through various redress programs and civil claims, we heard it was only relatively recently that the full scale of allegations—and that many allegations were against current staff—became apparent to senior managers in the Department.

It started to become generally understood in the Department in late 2020 that many of the allegations through redress programs and schemes, civil claims and other sources related to current staff at Ashley Youth Detention Centre. We discuss this development in more detail in Case study 7.

Although he knew about the existence of the Abuse in State Care Program from 2014, Secretary Pervan told us it was in late 2020 that he became aware a significant number of current Ashley Youth Detention Centre staff were named in those records and other redress claims:707

There was a lot of activity in a very short period of time. It would have been towards the end of 2020 where we became aware of the extent of the number of current employees who were implicated from the various redress programs … and the severity of the allegations.708

A former Acting Executive Director, People and Culture in the then Department of Communities, explained to us that the ‘true picture … as to what may have occurred at Ashley’ only came to be understood at the time that various pieces of information (from civil claims, National Redress Scheme applications and Abuse in State Care Program applications) were put together and viewed as a whole.709

We were told that when reviewing this information together, it became clear there was a pattern of alleged abuse occurring at Ashley Youth Detention Centre over a lengthy period, and that many allegations related to current employees.710 At hearings, the former Acting Executive Director, People and Culture described her realisation of the extent of the allegations of abuse around August or September 2020 (soon after she joined the Department) once the various sources of information were viewed in totality:

Probably up until that point [the point at which she viewed the totality of claims together] I’d only read a few applications, maybe one or two letters of demand, but when you have, I believe, in excess of 300 applications that have come through detailing acts of abuse, and you can see the same names and the same types of abuse, and you can pick up themes and— it’s quite confronting.

…

… there is probably too much commonality in some of the methods of abuse, if I may call it that, or the allegations; that, for people that have spanned so many different years, to not believe that they’re— it’s not a matter of belief, but some of the themes have just repeated so much that it does definitely cause a lot of concern, and I think I’ve been quite specific in my statement as to a couple of those areas where I think that we see themes coming through now in terms of almost opportunities for abuse when they occurred, such as strip searches; that’s probably the main one coming through.

…

But you do have, again, these themes that just continue and again going back to the strip searching one, and it’s just how it’s described in these applications … a lot of the people didn’t even see what happened to them in terms of a cavity search as being a sexual abuse; it was almost like it was an intimidation tactic, and that’s how they describe it in their applications, and some of them are so detailed that they are very concerning.711

Mandy Clarke, former Deputy Secretary, Children, Youth and Families in the then Department of Communities (between September 2019 to February 2022), told us she was alerted to the possibility of a history of claims made relating to serving staff after a meeting she had with an external lawyer on 31 August 2020 that prompted her (and others) to begin to cross-check records against serving staff.712 In her statement to us, Ms Clarke said she was shocked and confronted by the allegations and never anticipated that the Department would need to respond to so many historical allegations of abuse involving current employees.713

Under questioning at hearings, Pamela Honan, Director, Strategic Youth Services in the then Department of Communities, conceded that there were abusive patterns of behaviour exhibited by Centre staff towards detainees.

Q [Counsel Assisting]: … [W]ould you accept from the materials that you’ve reviewed that it’s been a place where children have been physically abused? Not all children, but quite a lot?

A [Ms Honan]: There’s— absolutely, yep.

Q: That there’s been an ongoing pattern of what I would call emotional abuse or disregard in the way in which children have been treated by at least some workers?

A: Yes.

Q: And would you also accept that there’s clearly been an ongoing pattern of sexual abuse of some residents by some workers?

A: I would agree.714

Ms Honan also conceded ongoing problems with harmful sexual behaviours being displayed by detainees against other detainees.715

Secretary Pervan also accepted Counsel Assisting’s proposition that it is open to our Inquiry to find that there has been an ongoing pattern of sexual abuse of some detainees by some staff members over the past 20 years.716 At hearings, Secretary Pervan conceded this in response to questioning by Counsel Assisting:

Q [Counsel Assisting]: … [W]ould you agree that, having regard to all of the evidence that’s available, it’s open to the Commission to find that there has been ongoing sexual abuse of some detainees by some officials at Ashley over the last 20 years?

A [Secretary Pervan]: Yes, I would.

Q: And that, whether we describe it as a ‘pattern’ or ‘repeated conduct’ or whatever, nevertheless it’s clear that it’s not isolated incidents; would you accept that?

A: Yes.717

Stuart Watson, Manager, Custodial Youth Justice (‘Centre Manager’), acknowledged that Ashley Youth Detention Centre had a ‘dark past’.718 He noted it was not for him to draw conclusions about the truthfulness of some allegations made against staff but acknowledged that his reference to a ‘dark past’ necessarily involved wrongdoing by staff towards detainees.719

We note that, in recent times, as discussed in Case Study 7, the Department has conducted some misconduct investigations in response to allegations of abuse at Ashley Youth Detention Centre. However, the Department did not take disciplinary action in respect of the Abuse in State Care Program allegations until late 2020 at the earliest and, in some cases, much later (and only after other allegations had been raised against staff members). As a result of the time span over which allegations were made against some staff, we can only conclude that some alleged abusers continued to work at the Centre for many years after allegations were first made against them and, as a consequence, had access and opportunity to continue to abuse children and young people in detention during this time.

1. The broader context

The allegations of abuse need to be understood in context, including a longstanding corrosive staff culture, the beliefs of some staff that children and young people in Ashley Youth Detention Centre sometimes or often deserved punishment and make false allegations, and the fact that the Centre is isolated, physically and operationally from the department that oversees its.

1. A longstanding corrosive staff culture

It is clear to us that a significant proportion of staff members have worked at Ashley Youth Detention Centre for many years. Victim-survivor Erin, who was at the Centre in the mid to late 2010s and whose experiences we have outlined above, told us that she encountered staff who had worked at the Centre for 30 years.720 Staff members Ira, Lester and Stan (all pseudonyms), against whom a number of serious complaints of abuse were made (discussed in Case study 7), all began work when the Centre was the Ashley Home for Boys.721

In a May 2016 Minute to the Secretary, it was noted that many staff had been working at the Centre for more than 15 years.722

Ms Clarke confirmed that a large cohort of the Centre’s total staff have worked at the Centre for a very long time and that such staff continually describing ‘the old days’ could make it challenging for Centre management to redefine the culture in line with a more therapeutic approach.723 She reflected on this further in hearings, adding:

… some staff that perhaps dominated decision making that had been there for some time, and that perhaps new staff who brought fresh ideas and new ideas and new way of thinking, their thoughts were not always reflective in that decision; in fact, sometimes they just weren’t even being heard …724

Information provided in the accounts of victim-survivors, as well as evidence from others, further suggests that the personal connections of staff members at Ashley Youth Detention Centre, beyond their common employment, meant that staff ‘looked after each other’ and that it was challenging for individual staff members to raise concerns about the misconduct of their colleagues.725

A participant in one of our sessions with a Commissioner, who asked to remain anonymous, told us that:

Most of the staff [at Ashley Youth Detention Centre] were farmhands from around the Deloraine area. Nobody had qualifications. There was a bit of a joke: if you’re a member of [a particular club], you’ve got a job at Ashley. They were all connected through the … club.726

Ben, who was first detained at the Centre in the early 2000s, similarly stated that when he was at Ashley Youth Detention Centre it was ‘run’ by a group of families who would employ other family members and their friends to work there.727 When he was released from detention, Ben recalled seeing a photo at a club in the local area and could identify more than 50 per cent of the club members in the photo as people connected to Ashley Youth Detention Centre.728

As documented throughout this case study, we heard evidence from multiple sources about staff members working together to manipulate, control and abuse children. Warren, who was at the Centre for various periods between 2004 and 2009, described being raped on numerous occasions by different staff members while other staff restrained him and subjected him to verbal abuse.729 Erin recounted to us that male staff members watched as she was sexually abused by a group of older male detainees.730 Otis, who was admitted to the Centre in the early 2010s, referred to staff as having a ‘gang mentality’.731 Fred, who was first detained at the Centre in the early 2000s, told us that staff treated violence between young people in detention ‘like a sport’, either provoking violence or encouraging it when it broke out, rather than stepping in to de-escalate a situation.732 Max described multiple occasions where a number of staff physically or sexually abused him.733

Otis, who told us that he began to ‘offer’ himself to staff members when he realised that they were targeting younger children to abuse, suggested that sexual abuse at Ashley Youth Detention Centre was not uncommon, at least during the early 2010s when Otis was detained there.734 We were also told of staff withholding essential medication unless young people submitted to sexual acts, despite repeated requests by young people to staff that they needed this medication.735 Several accounts allege that physical and sexual abuse was perpetrated by two or more staff acting together. Some victim-survivors stated that other staff saw or heard physical and sexual abuse take place. There were multiple accounts of children’s attempts to make reports to staff.

There were also striking similarities in some of the ways that victim-survivors told us they were abused at Ashley Youth Detention Centre, with accounts naming multiple staff over decades using the same tactics, such as abuses perpetrated under the guise of strip searching.

In a submission to our Commission of Inquiry, Ms Sdrinis, who represents more than 300 victims of abuse seeking compensation from the Tasmanian Government (150 of whom relate to Ashley Youth Detention Centre), raised concerns about ‘collusion’ among staff at Ashley Youth Detention Centre:736

Numerous clients have described a sense of collusion between staff at [Ashley Youth Detention Centre] that inhibited reporting of abuse. Clients report there were numerous husband/wife teams working as guards … gang members working as security, and security personnel referring friends for shifts at [the Centre].

This created a perceived sense of solidarity between the guards, and an ‘us vs them’ attitude for staff and residents. This combination of circumstances allowed perpetrators to continue offending for many years, effectively unchecked.737

Alysha, who reported allegations against a staff member, Lester, in January 2020 (discussed in Case study 7), told us that:

Due to the, at times, nepotistic recruitment practices and Tasmania being a small place, speaking up often carries additional considerations such as being friends, community members or parents of children at the same school as someone acting inappropriately. With the Centre being in such a remote location, this issue is additionally compounded as the majority of the staff group live in a small town together. Not only is there fear of professional consequences such as failing to be considered for promotions or being bullied at work, but there are also social considerations that would leave staff ostracized or possibly in danger of reprisal in their own community.738

It is further apparent from the accounts of victim-survivors and their families that some new staff were drawn into a culture of degrading children and young people detained at the Centre or ignored the abuse happening around them. While we heard that some staff members who witnessed abuse made attempts to report it, we also heard that some new staff who may have ‘started off well’ would ‘turn into the same as the other ones’.739

Ben told us that:

The hardest thing for me to accept about this abuse is that all of the other staff that weren’t doing it to us had to have known. There were times when we did get to leave Ashley to go places and do fun things, but there was always a process. We would have to fill out paperwork. The times we were abused there was no process. We were just told that we were going fishing or caving or something like that, and then just taken off site.740

He also told us that staff who did not want to take part in the abuse were sidelined for ‘not toeing the line’. He said that these staff, who could have made a difference, were ‘continually pushed out’.741

In a panel at hearings, Professor Donald Palmer and Dr Michael Guerzoni—both experts in organisational misconduct—described how an organisation’s dynamics can foster such indoctrination. Dr Guerzoni, who teaches in the field of criminology (including youth justice), has examined many of the reports into Ashley Youth Detention Centre.742

Dr Guerzoni spoke of formal and informal aspects to the socialisation of staff, describing informal components including:

… the so-called water cooler conversations, lunchtime conversations, barbecue chats and that kind of thing where informal tips on how to do the job or ways of seeing problems and situations which arise within an organisational setting and how to respond to those.743

Dr Guerzoni further reflected:

… it is my understanding that the evidence suggests that new workers at Ashley Youth Detention Centre have been socialised into a punitive culture that is informed by a view that the children in their care are bad people who do not deserve to be treated well.744

Dr Guerzoni went on to note that even though Ashley Youth Detention Centre has introduced a range of policies and procedures designed to improve safety, the desired change does not seem to have achieved the intended effect.745

Speaking more broadly about cultures within youth detention settings, Professor Palmer said:

People who become guards in a detention facility very quickly learn from their peers what the culture of that organisation is and it may be; for example, never trust a child and what they say. That might not have been a view that they held before they took the job as a guard in a juvenile detention facility.746

Samantha Crompvoets, a sociologist who has examined misconduct in the armed forces, described risks of negative socialisation and misconduct in ‘closed’ organisations or those that are ‘in isolated parts of a network’ where distinct norms and behaviours can emerge among a group:

… when you enter an organisation, you take cues from everyone around you regarding … what is normal and what is not. Part of this is the natural human desire to conform and assimilate. So for organisations or parts of organisations that are closed, it is important that there are checks and balances in place to prevent new employees conforming to the behaviours of the rest of the group.747

It seems unlikely that persistent incidents of abuse like this could have happened without some level of staff awareness or collaboration. It also seems unlikely that abuse of this nature and to this extent could have occurred without some other staff knowing about it, or at least harbouring concerns or suspicions.

1. A culture of disbelieving detainee complaints

In addition to the broader culture that we heard worked to dehumanise children and young people, we observed a view held by many staff, management and even some external agencies that detainees were sometimes or often unreliable witnesses and concocted false allegations of abuse for monetary gain or retribution against staff.

A youth worker at the Centre, Sarah Spencer, said that she had observed some detainees make statements about their intentions to falsify complaints for redress purposes:

The government gave these young people, ex-residents whether they went to Risdon, payouts when they said, ‘Oh, so and so interfered with me or did this’. No investigation, just gave them 10 grand there, 20 grand there, 30 grand there. We knew about it because they told us all the time. They would leave the Centre saying, ‘I’m going to say this when I leave, so and so got this much money for saying this’. Constantly we’ve lost valuable workers through a lot of unproven allegations with no investigations whatsoever.

…

It just doesn’t make— it’s horrific, because they just kept handing them money with no investigation, and now we’ve got this flood of allegations, and there would be a percentage, I’m not diminishing that, but all of these false allegations take away from the legitimate ones.748

Ms Spencer also told us that she believed all young people who reported abuse to her and appropriately escalated all reports of abuse she received.749

Fiona Atkins, Assistant Manager, Ashley Youth Detention Centre, told us that staffing levels at the Centre were affected in part by ‘the perception of threats from young people about the making of false claims against staff’.750 In our public hearings, she said:

Q [Counsel Assisting]: Do you mean that people are worried that they’ll be falsely accused of physical or sexual abuse?

A [Ms Atkins]: Some young people have actually voiced that they will say, you know, ‘You touched me’ or whatever, so that they can get a payout. I have heard that.

Q: And it’s your assumption that, if a young person said that, it wouldn’t be truthful?

A: Not when they’re smiling and laughing in front of me, no.751

Mr Watson agreed with Counsel Assisting’s proposition that ‘a lot of staff’ would hold the view that many allegations made by detainees are false.752 Mr Watson pointed to one factor leading him to this conclusion about such a view among staff:

Often these people have worked with each other for a long period of time, and I guess, you know, it is the example of, do you really know your neighbour and do you really know what they do?753

In reflecting on his opinion of the views of staff later in oral evidence, Mr Watson felt there would likely be mixed views among staff about detainee accusations of abuse, with some thinking that suspensions of staff because of some of these complaints were ‘timely’.754

Former detainees Max and Warren shared with us that staff told them that reporting abuses was futile because no one would believe them.755 Otis disclosed some of his abuse to a psychologist at the Centre and told us that he was not believed.756

Both the Commissioner for Children and Young People, Leanne McLean, and the Ombudsman, Richard Connock, agreed with Counsel Assisting’s proposition that many young people may not have reported their abuse to oversight bodies partly due to fear of not being believed.757 Mark Morrissey, a former Commissioner for Children and Young People, told us he believed children at the Centre did not have confidence that their reports or concerns would be adequately responded to.758

The abuse of children at the Centre became normalised—so much so that some young people at the Centre understood the violence and abuse by staff against them as ‘normal’ treatment.759

We received evidence to suggest that this scepticism of detainee complaints was not confined to the Centre and Department, but also extended to some external agencies. In Case study 7, we discuss attitudes inside Tasmania Police that were dismissive of allegations of abuse at Ashley Youth Detention Centre.760

As we have made clear, it was not possible for our Commission of Inquiry to test the veracity of accounts given to us by detainees or to determine the prevalence of any false complaints. We do consider, given the patterns and consistency in allegations over decades, that at least a proportion of these allegations are likely to have occurred. We consider the prevailing views and attitudes of Centre staff, and bodies tasked with protecting children at the Centre, to be relevant to understanding how longstanding and systematic abuses at the Centre were not identified and addressed.

1. Isolation of Ashley Youth Detention Centre

It is clear to us that the risk of abuse at Ashley Youth Detention Centre (and the likelihood that it would go unchecked and unreported) was heightened, in part, due to the physical isolation of the Centre, and because of breakdowns in communication and leadership between those working at the site and those in the Department. Ms Honan described her immediate impression of the Centre when she began her role in October 2019:

[The Centre] operated independently to the broader Division of Children, Youth and Family Services (CFS) and Department of Communities. It was highly autonomous, inward facing and lacked strategic leadership. My impression was that there was also a high degree of mistrust and selectivity in what and how information was reported by the Manager up to the executive to ensure the operating of the centre was positively regarded. The relationship with independent statutory bodies appeared to be wary and uncooperative.761

At hearings, Ms Honan elaborated on the relationship between the Centre’s management and the broader Department, telling us that the Centre operated as a ‘satellite’ and that it was ‘very closed, very wary, and very defensive’.762 She told us: ‘I think what I was being told, but then what I was hearing and seeing on site suggested something quite different’.763 She also observed that the relationship had ‘changed significantly’ since 2020 due to many factors, including her weekly physical presence at the Centre and the ‘functional alignment’ of certain positions that are physically based at the Centre but are also ‘professionally supported and interface outside the centre’.764

Ms Clarke agreed with Ms Honan’s observations that the Centre was operating in a closed environment without a clear passageway to the executive when she began working at the Department in 2019.765

In response to questioning at hearings, Secretary Pervan also agreed that the Centre was disconnected from the broader Department and characterised by an insular and inward-looking culture.766 When we asked him about the cause of the Centre’s self-isolation from the rest of the Department, Secretary Pervan said:

I think it’s a broader reflection of cultural norms and history in that there’s been a facility on that farm—and Ashley does sit on the edge of a farm that’s owned by the Crown—for around 100 years. It was like a lot of our not-good past, a shameful past you might say, that no regard was given to young people …767

Secretary Pervan reflected on his role as Secretary and the role of the executive in allowing the self-isolation of the Centre to occur:

Q [Counsel Assisting]: Doesn’t that reflect on the management above Ashley in the hierarchy up to and including you if, if up to 2019 the Ashley management had been permitted to isolate themselves and not participate properly as part of the Department?

A [Secretary Pervan]: There is a reflection there, I’ll own that; I was also running the Tasmanian Health System, so it wasn’t as if I wasn’t aware of the issues at Ashley, and I very much depended on a succession of Deputy Secretaries to be informing me, as I was those conversations with the Commissioner for Children and Young People as to what was happening at Ashley and what I needed to do to remedy it …

It was very difficult to find out exactly what the situation was at Ashley other than noting that it was a facility that was isolated and had isolated itself over a considerable period of time. As with the Deputy Secretary and Director level, there was a succession of Centre managers, and getting to grips with not only what was the problem but what we could actually do about it was incredibly challenging.

Q: And so the practical effect of that … was that it appears that over a series of years the self-isolation of Ashley from the scrutiny that might be best practice in terms of an open line of communication up through the Director of Custodial Justice and up through the Deputy Secretary to you, that was able to continue so that it was still in place in October 2019?

A: Yes.768

It is clear from the Department’s evidence that senior members of the Department were aware of the inadequate scrutiny and supervision that occurred due to the Centre’s physical location and a culture in which it could self-isolate from the broader Department. We consider this evidence is relevant in understanding how abuses at the Centre continued over a long period without adequate responses from the Department.

1. Observations

Children and young people were supposedly sent to Ashley Youth Detention Centre for rehabilitation from the complex factors that contributed to their offending. In doing so, they entered a highly controlled environment that was largely closed off from the community. They become wholly dependent on staff to care for them, meet their basic needs and protect them from harm. The experiences victim-survivors shared with us paint a harrowing and heartbreaking picture of systematic mistreatment over years—mistreatment that included physical abuse, sexual abuse, verbal abuse, denigration, humiliation, bullying, threats, intimidation, use of isolation and other likely human rights abuses.

While we acknowledge the evidence we received from some staff about the propensity of detainees to falsify claims (or at least state an intention to do so), we can only say that the accounts that we heard from current and former detainees were consistent in terms of the individuals and patterns they described over different periods and varied in ways that suggest a lack of collusion between detainees. Their accounts often were measured and nuanced—particularly in recognising the existence of staff who were not complicit in the behaviour and who recognised their plight for what it was. Many of their accounts, particularly around the culture and dynamics at the Centre, echo the recollections of staff, former staff, some senior managers and oversight agencies. Taken together, all the descriptions of Ashley Youth Detention Centre reveal a toxic and callous environment—a very far stretch from a therapeutic place of rehabilitation and recovery.

Finding—For decades, some children and young people detained at Ashley Youth Detention Centre experienced systematic harm and abuse

Considering all the evidence from victim-survivors and their families, current and former Centre staff, senior management in the Department, the many prior reports and investigations into the Centre, the allegations made through civil and redress scheme claims, the matters considered in Case study 7, and the insight of relevant experts into organisational misconduct, we consider that many children and young people were systematically dehumanised, brutalised and degraded while at Ashley Youth Detention Centre. We do not accept that the mistreatment of detainees occurred only as rare or isolated incidents, or that it always occurred in a highly concealed fashion. We consider it reflected a widespread and, at times, methodical practice, albeit to varying degrees. In this sense, the abuse, including sexual abuse, was systematic.

The broader dynamics at Ashley Youth Detention Centre contributed to a perfect storm that enabled abuses, including sexual abuse, to be perpetrated over a long period. We consider there are complex and varied motivations among staff who harmed children, or who contributed to or ignored harms. We consider at least some staff members were motivated abusers with an abiding sexual interest in children and young people, while other staff members were opportunistic in their abuses, and others again perpetrated abuse as a means of exerting power and dominance over detainees. We also consider it likely some staff felt peer pressure to conform to the poor practices of others (for example, when performing strip searches) and participated reluctantly on this basis, but also to avoid becoming targets for abusive or bullying behaviour from colleagues. We consider some of this behaviour reflects a highly traumatised and dysfunctional workforce.

We accept that not all staff engaged in problematic practices, but we consider many would have been aware of the poor treatment of detainees. As discussed in Chapter 3, cognitive biases (such as wilful blindness) may have contributed to such staff minimising the nature and scale of the behaviour occurring around them, alongside the gradual normalisation of such callous brutality, which operated to erode normal human reactions. Also, a sense that reporting the conduct would be futile—or worse, place them at risk in some way—may have contributed to inaction or people simply leaving their roles.

We acknowledge that some staff did seek to investigate and report abuses, and to escalate such alleged abuses to their superiors, despite feeling discouraged from doing so.

We consider a range of factors are relevant to the culture that enabled systematic abuse of detainees, which includes the following:

• As discussed in Chapter 10, the highly pressured, stressful and occasionally frightening conditions in which staff sometimes had to work, coupled with inadequate professional training and development for some staff, made it more likely for staff to deviate from best practice when seeking to manage the behaviour of detainees. We also consider it likely that difficult—and at times violent—behaviours exhibited by detainees contributed to staff holding negative attitudes towards them.
• Familial and personal connections between some staff created strong social disincentives to challenge, question or report poor behaviour of staff towards detainees.
• The often-longstanding tenure of staff contributed to entrenching problematic attitudes and normalising the poor treatment of detainees. New starters were socialised into this environment, and efforts to promote change towards therapeutic approaches were resisted.
• Staff (and broader community) attitudes that diminished the humanity and credibility of detainees worked to reduce empathy and compassion for them; it heightened scepticism of any complaints or concerns they may have raised in the Centre and beyond.
• While they felt violated, detainees were not always aware that abusive practices likely contravened law, policy or human rights conventions.
• Detainees were disinclined to speak out about abuses for reasons including the stigma and a lack of confidence in reporting processes, the normalisation of their mistreatment and genuine fears for their safety and the safety of their families.

We also consider that the broader context of Ashley Youth Detention Centre contributed to this abuse going unidentified and unaddressed. The physical isolation of the Centre and the culture in which it operated as a ‘satellite’ from the broader Department enabled conditions in which abuse could be perpetrated and not reported, resulting in delays in action from the Department and an unacceptable level of risk to children. The closed nature of Ashley Youth Detention Centre—and the vulnerability of detainees at the Centre—made it especially necessary for the Department to maintain close supervision over the Centre. Instead, the inadequate scrutiny and apparent inability to address the cultural and physical conditions in which a closed environment was able to flourish meant that inherent risks went unchecked by the executive and abuse could continue.

Case study 2: Harmful sexual behaviours

1. Overview

Over the course of our Commission of Inquiry, we heard from many victim-survivors about their exposure to and experiences of harmful sexual behaviours, often by older male detainees, at Ashley Youth Detention Centre. In this case study, we summarise allegations of harmful sexual behaviours over many years at the Centre. We also consider the Centre’s and the Department’s responses to these allegations. We recount allegations that staff sometimes actively used the fear of harmful behaviours of children and young people to control other children.

We outline detainees’ personal accounts of experiencing harmful sexual behaviours, drawing from the accounts we present in Case study 1. We then focus on a series of incidents involving three young people, Max, Henry and Ray (all pseudonyms), between 2018 and 2022.769 First, we outline the law and policies during this period. Then, we provide a timeline of incidents involving these three young people. The timeline begins when Max was first admitted to Ashley Youth Detention Centre. It follows the responses of the Centre and the Department to some of the harmful behaviours, including harmful sexual behaviours, of young people in Tasmania’s youth justice system.

Throughout this discussion, we highlight specific and systemic failings in the management of Max, Henry and Ray—as well as the children and young people who were displaying harmful sexual behaviours. At the end of the timeline, we highlight some of the systemic problems that were common to the incidents, including:

• staff tensions
• an absence of risk assessments
• a lack of capacity to respond to complex behaviours of children and young people
• the importance of critical incident investigatory skills.

We are particularly concerned about the disrespect and disregard apparently shown to staff who endeavoured to raise or address the risks to young people at Ashley Youth Detention Centre. We received information about unprofessional conduct, silencing in meetings and written complaints being ignored or deflected. We are concerned about apparent efforts to undermine the status and expertise of those professionals raising concerns.

This chapter covers a series of concerning allegations regarding the responses of Ashley Youth Detention Centre staff to harmful sexual behaviours displayed by some young people at the Centre. We acknowledge there have been and are staff at Ashley Youth Detention Centre who have sought to do their jobs lawfully and appropriately. References to ‘staff’ in this case study are not intended as a reference to all staff at Ashley Youth Detention Centre, unless explicitly stated in a specific context.

In the final section of this case study, we provide our general observations about systemic and operational deficiencies at Ashley Youth Detention Centre, which we consider have contributed to young people being exposed to or experiencing sexual harm by other detainees.

We identify that, over many years, some staff had knowledge of the harmful behaviour, including harmful sexual behaviour, of children and young people against other children. There was often an inadequate response to the risk that such behaviour could occur, as well as inadequate responses when it did occur. Children and young people in detention have too often been exposed to serious harm, including sexual harm, by other children and young people in detention. Some staff have not taken enough steps to protect them.

1. What we heard from victim-survivors about harmful sexual behaviours

In Case study 1, we outline personal accounts of young people’s allegations of harmful sexual behaviours at Ashley Youth Detention Centre, including the following:

• In the early 2000s, 11-year-old Ben (a pseudonym) told us he was placed with much older boys who physically and sexually abused him on numerous occasions during his first admission.770 He had multiple admissions to Ashley Youth Detention Centre and said he was frequently sexually abused by older boys.771 He said his abuse occurred in the Centre and on outings, where there was less supervision.772 He told us that, when he told staff early on about the abuse, they essentially blamed him for putting himself in such a position.773 At other times, he said he was punished for speaking up.774
• Charlotte (a pseudonym) told us she was sexually abused by boys at Ashley Youth Detention Centre on several occasions in the mid-2000s when she was in her mid-teens.775 She told us staff were aware she had a history of experiencing sexual abuse, but she was left alone with groups of boys and was sexually abused more than once.776 She said she reported the abuse after leaving Ashley Youth Detention Centre but heard nothing more.777
• Fred (a pseudonym) told us he was in his late teens in the mid-2000s when he witnessed a detainee raping another boy and was himself physically abused by other boys at Ashley Youth Detention Centre.778 He said he learned not to speak up because he experienced retribution from staff and residents.779
• Oscar (a pseudonym) told us he was in his mid-teens when he was first admitted to Ashley Youth Detention Centre in the middle of the 2000s.780 He said older boys sexually abused him within days of his admission while a staff member watched on and laughed.781 He said other boys regularly physically abused him but did not disclose for fear of being labelled ‘a snitch’.782
• Erin (a pseudonym) first came to Ashley Youth Detention Centre in the mid-2010s.783 She told us she was left unsupervised with a group of 10 boys, where she was sexually abused.784 After disclosing the abuse, she said she did not receive any support.785 Instead, she said she felt shunned by staff who had been reprimanded for allowing it to occur, and was subsequently and targeted and sexually abused by other boys.786 She said staff witnessed the harmful sexual behaviours and did nothing but put her on the contraceptive pill.787
• In the late 2010s, Max was repeatedly placed in units with older boys who posed a risk of harmful sexual behaviours.788 Consequently, he told us he was physically abused on numerous occasions, threatened with sexual abuse and then sexually abused with a table tennis bat.789 He said his behaviour became more challenging as he sought to protect himself from other residents and he displayed harmful sexual behaviours himself.790 Professional services staff came into conflict with operational staff about responding to incidents and protecting Max from harm.791 We discuss Max’s account in more detail in the next section.

As we have made clear, it was not possible for our Commission of Inquiry to test the veracity of all the individual allegations outlined in victim-survivors’ accounts. However, we were struck by the many common themes across these accounts. While we do not make findings in relation to any individual allegation, we note the similarities across accounts.

In many of these accounts, younger children were placed with older children who had previously displayed harmful sexual behaviours and received no therapeutic intervention.792 Although girls were generally placed in separate units from boys, the harmful sexual behaviours they told us about occurred when they were left unsupervised and outnumbered by boys in the Centre.793

Victim-survivors told us that some Centre staff were aware of incidents of harmful sexual behaviours but responded in ways that apparently condoned the behaviour—such as dismissing the damage caused by harmful sexual behaviours or responding passively or punishing children and young people for complaining about the harmful sexual behaviour of another child.794 Victim-survivors told us these responses discouraged them from subsequently reporting harmful sexual behaviours they experienced or witnessed.795

1. The exposure to harm of vulnerable children and young people in detention, 2018–22

In this section, we focus on the specific experiences of Max, Henry and Ray from 2018 to 2022. We outline Ashley Youth Detention Centre’s response to these young people’s vulnerabilities to harmful sexual behaviours (and other harmful behaviours by young people) at the Centre.

Max, Henry and Ray have much in common. Each was detained at Ashley Youth Detention Centre in the past five years and some of their time there overlapped. Each of these three young people were particularly vulnerable to harmful behaviours from other detainees because of their age, experiences of trauma, mental health problems or more than one of these vulnerabilities. At some point during their detention, Max, Henry and Ray were housed in the Centre’s Franklin Unit despite protests from several staff and the young people themselves that this unit was not safe for them. All three young people were put at risk of or experienced harmful sexual behaviours by one or both of two detainees in the Franklin Unit, Albert and Finn (both pseudonyms).796 It is our view that Ashley Youth Detention Centre failed to protect Max, Henry and Ray from harmful behaviours, including harmful sexual behaviours, of other young people. We discuss non-sexual harmful behaviours in this case study because harmful sexual behaviours can be one part of a spectrum of harmful behaviours.

We discuss other experiences that Max says he had in Ashley Youth Detention Centre elsewhere in this report (refer to Case study 1 and Case study 6). In this case study, we consider only those aspects of Max’s evidence, and the relevant evidence of others, that relate to his accounts of harmful sexual behaviours and the responses to those behaviours by Centre management and the Department.

First, we discuss the laws, policies and practices relevant to the 2018–22 period. We then outline several incidents of harmful sexual behaviours relevant to Max, Henry and Ray, as well as the varied responses of Centre staff to these incidents at the time.

1. The law, policies and practices

In this section, we provide some relevant context about:

• the laws and standards that prohibit bullying and physical and verbal abuse of children and young people in detention
• how decisions were made about where to place young people within Ashley Youth Detention Centre, including what we heard from former staff members about placing young people in the Franklin Unit
• the use of ‘Very Close Supervision’ orders at Ashley Youth Detention Centre to manage young people whose behaviour is considered a risk to others or to the security of the Centre
• how incidents involving harmful sexual behaviours are reported and investigated at the Centre.

1. Laws and standards

The Youth Justice Act 1997 (‘Youth Justice Act’) prohibits using:

• any form of psychological pressure intended to ‘intimidate or humiliate’ a child or young person in detention
• any form of physical or emotional abuse
• discriminatory treatment.797

It also provides that a child or young person in detention is entitled to have their developmental needs met.798 In addition, the Inspection Standards for Youth Custodial Centres in Tasmania includes several standards designed to protect vulnerable young people from verbal or physical abuse and bullying.799

1. Managing children and young people in detention through placement and supervision

Placement decisions

In Chapter 10, we detail how, prior to 31 May 2022, Ashley Youth Detention Centre staff decided the unit within which to place children and young people at the Centre.800 To summarise:

• The Centre Support Team generally made week-to-week placement decisions, although these could be changed daily, based on operational factors.801
• Placement decisions considered some or all the following factors:
  • age
  • gender
  • safety and security
  • legal status and length of sentence
  • individual needs
  • behavioural issues
  • relationship dynamics between young people and staff
  • the views of staff.802
• Due to operational challenges, including staffing numbers, placement decisions sometimes amounted to ‘choosing the best out of a poor range of options’.803
• Young people could make a formal request for a unit transfer, which the Centre Support Team would consider.804

Franklin Unit

Until recently, the Franklin Unit was the most secure unit at Ashley Youth Detention Centre, housing ‘the most high risk or dangerous young offenders’.805 Mr Watson told us that before the Centre’s redevelopment in 2022, the Franklin Unit was the only unit with a secure courtyard. It also had concrete (instead of plaster) ceilings.806 He explained that certain children and young people in detention, such as those who presented an escape risk, were placed there.807 Mr Watson told us that now all units at Ashley Youth Detention Centre have secure courtyards.808 We understood his comments to mean Centre staff now have more flexibility in housing children and young people in detention who pose an escape risk.

Madeleine Gardiner, former Manager, Professional Services and Policy, Ashley Youth Detention Centre, recalled that, ‘on occasion’, youth workers or Centre Support Team members would comment that ‘placing certain detainees with other detainees was helpful to manage the behaviour of detainees’.809 She told us the chair of the Centre Support Team said this was inappropriate and the ‘general consensus of the [Centre Support Team] would not support this’.810 Alysha (a pseudonym), a former Clinical Practice Consultant at Ashley Youth Detention Centre, believes young people were regularly placed in the Franklin Unit to ‘manage and punish behaviour that was considered disruptive by Operations staff’.811 Her opinion is that staff relied on the reputation of the Franklin Unit and the fear of what happened to young people there ‘to essentially “scare them into line”’.812

Alysha believes the Franklin Unit was operated very differently from other units, specifically in terms of how it was staffed.813 She said:

There were ‘Franklin staff’, whereas [staff in the other units] all seemed to rotate a little unless there was a particular issue for a staff member. None of the staff rotated as they ought to, but the Franklin staff appeared to dictate the rules under which they worked. They would ‘refuse’ to work in any other units.814

Alysha’s concern echoes matters departmental staff identified in a 2016 Minute to the Secretary with the subject line ‘AYDC–Commissioner for Children letter and emerging concerns’ (refer to Case study 3 for more detail).815 This Minute noted serious concerns about human rights abuses and, among other things, that the Tasmanian Government had previously agreed ‘staff at Ashley Youth Detention Centre were to work across teams when requested to do so rather than working solely in the allocated smaller team groups’.816 We note one of the recent reforms we discuss further in this case study (in response to the 7 August 2019 incident) was to regularly rotate staff through all units.817

We asked several past and present Ashley Youth Detention Centre staff about placing young people in the Franklin Unit. The general response was there was no policy or practice (informal or otherwise) of using some detainees as a threat to influence or punish the conduct of other children and young people in detention.818 We were instead told placement decisions were made according to a range of factors such as age, individual needs and security.

Very Close Supervision

We are aware it is sometimes necessary to place young people in units where staff anticipate incidents might occur.819 In such situations, a Very Close Supervision order may be applied to the young person.820

In August 2019, Standard Operating Procedure No. 8: Supervision and Movement of Young People outlined the requirements for Very Close Supervision at Ashley Youth Detention Centre.821 It stated:

Very Close Supervision (VCS) is used if a higher level of risk is presented by an individual young person.

Approval for a young person to be placed on and taken off VCS status can only be given by the Centre Support Team (CST), Operations Manager or On Call Manager based on information provided by operational and/or professional staff.

A young person may be classified as requiring VCS if it is assessed they are a serious safety and/or security risk due to:

• Aggressive, subversive and/or inappropriate behaviour.
• The risk of assault or harm from other young people.
• Escape or threat of escape.
• Any other reasons identified by staff that require a higher level of supervision.

The supervising Youth Worker will ensure the young person on VCS remains within five metres at all times whenever the young person is outside of a locked building.822

It is unclear from the wording of this Standard Operating Procedure whether a youth worker is required to be within a certain distance of the young person on Very Close Supervision while the young person is inside a building, or if the terms of the supervision only apply outside a locked building. We are aware that some young people have been placed under Very Close Supervision inside and outside a unit.823

The Department’s Serious Events Review Team (described further in this case study and in Chapter 9) received evidence from a staff member that in practice, Very Close Supervision may not ‘guarantee’ that a young person would receive one-on-one supervision.824 Rather, it was suggested that Very Close Supervision was considered more of an ‘alert’ to staff to be watchful for potential problems, as opposed to a direction to increase supervision itself.825 The review concluded that Very Close Supervision ‘is problematic and difficult to achieve’ even when in use, given the insufficient staffing numbers and the lack of understanding among Ashley Youth Detention Centre staff on how Very Close Supervision operates.826

As discussed in the timeline below, Ray was subject to a Very Close Supervision order during a period of his detention at Ashley Youth Detention Centre. However, it does not appear that Albert and Finn were placed on Very Close Supervision orders in response to the incidents outlined below, despite staff being aware of their ongoing sexualised behaviours towards younger detainees.

1. Incident reporting, referrals and review

Incident reporting, detention offences and conferences

Staff at Ashley Youth Detention Centre must record and report any incident arising from the behaviour of a young person or young people.827 As discussed in Chapter 10, incident reporting at the Centre occurs in line with the AYDC Incident Reporting Procedure (‘Incident Reporting Procedure’) and the incident report template.828 The Incident Reporting Procedure came into effect on 1 July 2018.829 We understand it is still used today.830 We were told that staff receive incident reporting training during their induction and periodically during refresher training.831

The Incident Reporting Procedure states that the aims of incident reporting include to:

• record ‘thorough, accurate and objective information’ about an incident, including injuries
• provide ‘impartial and responsible assessment processes’ that ensure the seriousness of an incident is appropriately classified
• ‘encourage mutual accountability between young people and staff’ for their behaviours and actions
• support consistent decision making
• ensure incident reports are appropriately escalated through management, the Department’s executive and Minister, as required
• support ‘independent and external oversight of incident management’.832

As outlined in Chapter 10, the reporting staff member must also recommend a ‘level of seriousness’ for the incident for each young person involved against one of the following categories:

• recorded incident
• minor incident
• detention offence.

The Operations Coordinator must sign off on all incident reports, noting any alternative recommendations.833 There is also a requirement for a ‘Management Assessment’, which involves the Centre Support Team considering:

• the level of seriousness of the incident
• identifying whether the police, Child Safety Services or a young person’s parents should be notified
• whether any other actions, such as an independent investigation, should take place.834

Where an incident involves a detention offence or isolation, or the Centre Support Team cannot reach a decision in relation to the seriousness of the incident, the Centre Manager must then review the circumstances of the incident and complete the relevant parts of the Management Assessment, including considering whether any notifications or further actions are required.835 The Director, Strategic Youth Services, must decide whether any independent investigation of an incident is required.836

Under section 140 of the Youth Justice Act, the Secretary must be notified of any detention offences that the offender admits committing. The Secretary must then confer with the offender and any other relevant person before determining how the offence should be dealt with. As outlined in Chapter 10, the Secretary may deal with the offence by:

• taking no action, ‘on the undertaking of the offender to be of good behaviour for a period not exceeding 2 months’
• cautioning the offender
• delaying the offender’s release from youth detention by no more than three days
• filing a complaint against the offender.837

We note that in March 2022, Michael Pervan, the then Secretary of the Department of Health and Human Services (and later the Department of Communities), delegated his functions for dealing with a detention offence to the holders of several other roles, including the:

• Deputy Secretary, Children, Youth and Families
• Director, Youth and Family Violence Services
• Ashley Youth Detention Centre Manager
• Ashley Youth Detention Centre Assistant Manager
• Operations Manager (to a more limited extent)
• Coordinator, Training and Admissions (to a more limited extent).838

While we have not received an exhaustive record of previous delegations of these functions, we note that similar delegations were in place (at least in practice) for many years before this.

The Youth Justice Act requires that a conference is held, where practicable, with a young person who has committed a detention offence.839 Standard Operating Procedure No. 24: Conferencing describes conferencing as ‘an opportunity for both the offender and victim to enter a restorative discourse and for the offender to take responsibility for their behaviour and to make appropriate reparation’.840 Standard Operating Procedure No. 24 also provides that sanctions may result from a conference, such as a ‘good behaviour bond’.841

We understand that for a conference to be held, the offender must admit to the offence and agree to take part in the conference.842 If possible, the conference should involve the victim, a support person, a guardian and appropriate staff representatives.843

As noted throughout the timeline and other sections in this case study, Centre management and staff allocated different levels of seriousness to the incidents involving Max, Henry, Ray, Albert and Finn. Despite detention offences being recorded against Albert and Finn, it is unclear whether conferencing took place.

Senior Quality and Practice Advisor

In line with Ashley Youth Detention Centre’s Referral to a Senior Quality and Practice Advisor Procedure, clinical staff could seek the advice of a Senior Quality and Practice Advisor from the Department’s Children and Youth Services division after an incident had occurred and about managing the behaviours of a detainee.844 As outlined in Chapter 9 in relation to out of home care, specialised Senior Quality and Practice Advisors, and the Quality Improvement and Workforce Development Team they were in, were abolished during the Strong Families, Safe Kids redesign, which began in 2019.845 Secretary Pervan told us these roles were substantively replaced with new roles performing similar functions, with the Senior Quality and Practice Advisor functions substantively transitioning to the Senior Development Manager role.846

The purpose of making a referral to a Senior Quality and Practice Advisor was to ‘access an independent and impartial resource’ that would ‘provide guidance in relation to ethical considerations and practice, and provide objective, evidence-based recommendations’.847

The Referral to a Senior Quality and Practice Advisor Procedure required that:

• a referral was made by the Clinical Practice Support Officer or the Multi-Disciplinary Team
• the Multi-Disciplinary Team considered referring complex and critical cases to the Clinical Practice Support Officer in the first instance
• if the Multi-Disciplinary Team considered the matter to be unsuitable for referral to the Clinical Practice Support Officer (due to urgency, complexity or a requirement for independent investigation), the referral could be made to the Senior Quality and Practice Advisor
• the referral had to be endorsed by the Centre Manager
• the referral had to be approved by the Director, Strategic Youth Services.848

As we discuss later in this chapter, a referral was made to a Senior Quality and Practice Advisor after an incident involving Ray, Albert and Finn.

Serious Events Review Team

The Serious Events Review Team mentioned throughout this part is:

… a small team of senior practitioners who undertake reviews when a child [or] young person … known to Children and Youth Services (CYS) has experienced a serious event, such as death, serious injury or ‘near miss’.849

As described in Chapter 9, Ginna Webster, former Deputy Secretary, Children and Families, Department of Health and Human Services, established the Serious Events Review Team in 2017.850 We were told this team was established in consultation with then Secretary Pervan.851

It is our understanding the Serious Events Review Team was disbanded in May or June 2020, but can be brought together on an ad hoc basis if required (refer to discussion in Chapter 9).852 The team’s former manager explained that its reviews usually involved the following process:

• The Children and Families Executive referred a matter to the Serious Events Review Team for review, along with the terms of reference of the review.853
• A Serious Events Review Team reviewer would undertake a comprehensive review of the matter in line with the terms of reference.854 Their review would include desktop analysis of all relevant data as well as interviews with relevant staff.855
• The reviewer would prepare a draft review report, which was provided to a ‘Moderation Group’ for discussion.856 The Moderation Group comprised the Manager, Workforce Development; the Manager, Clinical Practice Consultants and Educators; and the Manager, Policy and Director Service Deployment.857 The Moderation Group was intended to run ‘fresh eyes’ over all aspects of the report, including editing and analysis.858
• The final report would be provided to the Executive of the Department and the Serious Events Review Committee, which comprised representatives internal and external to the Department.859
• The Serious Events Review Committee would consider the report and prepare advice to the Secretary.860

The former manager also explained the team’s role ‘was complete upon delivery of the final review reports’.861 The Children and Youth Services Executive was responsible for implementing any recommendations.862

1. Max, Henry and Ray

Timeline of Responses to Harmful Sexual Behaviours at Ashley Youth Detention Centre, 2018-2022

1. Summary

Over an 18-month period in 2018 and 2019, there were at least six reported incidents where Albert or Finn had engaged in sexualised behaviours. These included:

• making sexualised comments
• discussing sexual activities with staff
• simulating sexual acts on other young people
• forcing residents to touch each other’s genitals
• exposing their genitals and anus to other young people
• forcibly exposing the genitals and anus of other young people
• placing their hands down their pants in front of other young people.863

All but one of these incidents was recorded as a detention offence.864 Max, Henry and Ray were all placed in the Franklin Unit with Albert or Finn at various times, exposing them to the risk of harm.

We received evidence that Finn’s behaviours were serious enough to consider a transfer from Ashley Youth Detention Centre into the adult prison system. A transfer application was drafted in early 2019.865 That application identified that Finn ‘require[d] a high level of secure care because he represents a high risk to the security and safety of himself, other detainees, staff’ and the Centre’s operations.866 The application noted ‘numerous incidents of inappropriate sexual behaviour’ with other residents and other instances of violence and intimidating behaviours while at the Centre.867 The application also identified that Finn’s mental health difficulties contributed to his risk of offending generally.868 A report prepared by the Centre’s psychologist (and included with the draft application) stated that Finn posed ‘a High risk of future violence’.869 The application acknowledged that the Centre did not have the resources to support Finn to address his behaviours, such as access to full-time mental health specialists.870 We are unaware if the application to transfer Finn was ever lodged. It appears that Finn stayed at Ashley Youth Detention Centre at least until mid-2020 (whether as one uninterrupted admission or on multiple admissions).871 We discuss the appropriateness of sending young people to adult prison below in relation to Max, but note this detail here because it indicates the Centre was aware of Finn’s behaviours.

Max was only 12 years old when he was first admitted to Ashley Youth Detention Centre in the late 2010s.872 We note that we have received evidence, from Centre staff and Max himself, that Max’s behaviour during his ‘lengthy history at the centre’ could be complex and challenging.873 Ms Gardiner told us she considered the decision by other staff to place Max in ‘a unit with two detainees who had been observed to use sexualised behaviour’ may have been made on the basis that ‘[s]ome staff found [Max] difficult to manage, and I am aware some staff did not like [Max]’.874 Alysha gave evidence that Max was ‘one of the most disliked children by the staff group’.875

Max told us he believes the harmful behaviours he experienced when he was first detained at Ashley Youth Detention Centre have had a lasting impact on his behaviour. He said: ‘The abuse and how much they could have stopped it but didn’t, is the main thing that has caused my behaviour problems’.876

On 6 August 2019, Henry was placed in the Franklin Unit with Albert and Finn.877 Although Henry was technically a few months older than both Albert and Finn, we understand he may have been vulnerable in other ways. We have seen evidence that some Ashley Youth Detention Centre staff expressed concerns about his ability to process and retain information and noted that he was ‘[e]asily influenced by negative peers’.878

Henry was housed with Albert and Finn despite their behaviours being known to managers and staff at the Centre and despite Henry’s care plan stating that he was ‘vulnerable when with older boys and unable to be safe’, as well as identifying that Henry had been the victim of an earlier incident in the Franklin Unit.879 The care plan further stated that Henry was ‘not to reside with [Albert] or [Finn]’.880 Staff later reported that Henry was placed in the Franklin Unit ‘because [Albert] and [Finn] would keep him in line’.881 On 8 August 2019, Henry requested that he ‘move units please anywhere’.882

Ray was first admitted to Ashley Youth Detention Centre in the late 2010s.883 Ray had an extensive history of serious mental illness.884 We are aware of multiple incidents and concerns during Ray’s time in the Centre. In this case study, we focus on Ray’s first admission to the Centre because the harmful behaviour he experienced was similar to that of Max and Henry.

When Ray first arrived at Ashley Youth Detention Centre, the Centre’s psychologist emailed Operations Management staff with critical information about Ray.885 The psychologist explained:

The stability of [Ray’s] mental health and the effectiveness of his care and management will strongly depend on his sense of safety and mitigation of stress. Thus, it will be important not only to carefully consider his unit and program placement, but also as far as possible to limit changes to his unit and group placements. Whilst I understand the operational difficulties arising from managing a group of youth all with their own set of complex needs, [Ray is] at a high risk of harm to himself and others.886

The psychologist identified that Ray experienced cognitive difficulties, suicidal ideation, hypervigilance, verbal and physical aggression and a ‘vulnerability to the influence of others’.887 To assist Ray during his time at the Centre, the psychologist made several recommendations to Operations Management, which were noted on Ray’s care plan.888 These recommendations included that Ray should be assisted with simple visual checklists outlining his daily schedule, that activities should be broken down so he did not get overwhelmed, and that he responded well to praise for good behaviour and gentle redirection if he was exhibiting signs of distress.889 The psychologist shared her view that Ray would be suited to placement with a particular young person, and that his interactions would need to be closely monitored because they may rapidly deteriorate.890

During his detention, Ray was involved in numerous incidents that involved violence from and against other young people. Some professional services staff at the Centre tried to stop Ray being placed in the Franklin Unit because they considered other young people in that unit posed a significant risk to Ray.891 Despite this, Ray was placed in the Franklin Unit. After a violent altercation with Albert and Finn, Ray tried to escape from the Centre.892

In late 2019, the Centre’s psychologist emailed the Centre Manager to advise of a young person in detention disclosing to her that staff had threatened to transfer him to the Franklin Unit, that he felt unsafe, and that he had stated that detainees get ‘stood-over, abused and raped’ in the Franklin Unit.893 The identity of the young person who disclosed these concerns to the psychologist is not revealed in the documents, but those concerns related to Albert’s and Finn’s behaviours.894

1. 2018—Max is placed with older detainees and experiences harmful sexual behaviours

Max recounted to us that on his first admission to Ashley Youth Detention Centre he was placed in a unit with three older detainees, including Floyd (a pseudonym) and Ned (a pseudonym).895 Max told us he warned staff that he would be abused if placed with those detainees, but he was placed in the unit anyway.896 When the three detainees returned to the unit from the day’s activities, Floyd threatened Max.897

Max said that once the single staff member supervising the unit walked away into an office, Floyd exposed his penis to Max and told him ‘you’re going to be sucking this’.898 When Max refused, Max told us that Ned began slapping him, at which point Max punched Ned.899 Ned then began punching Max, knocking him to the ground, before jumping on his head.900 Max recalled that the supervising staff member shouted at the detainees and called for assistance but otherwise did not intervene to stop the abuse until other staff arrived.901

After the abuse, Max recalled he was moved to another unit. But Max was still placed with two detainees who were older and bigger than him, and he recalled that he was bullied and physically and sexually abused further, with the older detainees hitting him and pinching his buttocks.902 Max recalls that one of the detainees was Arlo (a pseudonym).903 He could not recall the name of the other detainee, but we know from other evidence available to us, including a Serious Events Review Team report, that the other detainee in the unit with Max and Arlo was Albert.904

About a week after he was moved to that unit, Arlo and Albert confronted Max, at which time Max says Arlo sexually abused him with a table tennis bat.905 We understand that Albert was also involved.906 Max told us nothing was immediately done to keep him safe after that incident. He remained in the unit with Arlo until he was eventually moved to a different unit for unrelated reasons.907 An incident report was prepared three days after the incident occurred, but it is not clear to us whether any staff were aware of the incident earlier than this because staff were outside the room responding to a request for help at the time it occurred.908 The incident report states it was prepared based on CCTV footage. It is also unclear to us how staff became aware of the incident and the existence of the CCTV footage.909

On his next admission to Ashley Youth Detention Centre, Max was again placed in a unit with Floyd, the detainee who had sexually abused him previously:

Before I got taken to the unit, I asked the youth workers who I was going to be with. They told me that it was someone from the North West that I wouldn’t know. When I got to the unit I saw that the other person was [Floyd]. [Floyd] was the only other resident in there. I dropped all of my stuff and lost my shit and started screaming ‘what’s going on here’. The staff called a code black and while they were trying to restrain me, I assaulted one of the staff members. I was saying to the staff ‘why the fuck are you putting me back in here when he tried to rape me’. They said that I was exaggerating. They told me that if I didn’t calm down I would be put in isolation. After I calmed down, they told me that there was nowhere else I could go so I’d have to stay with [Floyd] in Bronte west.910

While Max notes that Floyd apologised to him, Max was still scared and decided that he ‘would do something that would get [him] moved from the unit’.911 Max damaged the ceiling in his room and was moved to another unit.912

It is unclear to us how meaningfully Centre staff considered Max’s concerns about his unit placement at the time of the previously mentioned incidents. However, we have received evidence that suggests the Multi-Disciplinary Team discussed Max’s relationship with Floyd as an issue relevant to his unit placement in August and September 2018 (after the Serious Events Review Team completed its review, referred to in the next section). At that time, the Multi-Disciplinary Team recommended that Max and Floyd not be placed in the same unit or program group, noting that Max’s desire to move units was likely related to his interactions with Floyd and that Max ‘does not operate well when housed with’ Floyd.913

1. June 2018—The Serious Events Review Team reviews harmful sexual behaviours experienced by Max

The Serious Events Review Team carried out a review into the two instances of harmful sexual behaviours Max experienced. This review was prompted by notifications from Child Safety Services in March and April 2018 following a report from Max’s solicitor to Tasmania Police alleging that Ned had sexually abused Max at Ashley Youth Detention Centre.914 The Serious Events Review Team’s report covered the incident involving Floyd and Ned, as well as the incident involving Arlo and Albert.

In relation to the incident involving Floyd and Ned, the Serious Events Review Team investigated it as the ‘alleged “rape” of [Max] by [Ned]’ because the incident was notified to police in those terms by Max’s solicitor.915 The Serious Events Review Team broadly found that no rape or sexual abuse had occurred.916

The Serious Events Review Team’s report stated that Max told the investigator that Ned commanded Max to perform oral sex on him before Ned physically abused Max.917 We note that this is slightly inconsistent with Max’s evidence to us that it was Floyd who gave this command while exposing his penis to Max before Ned hit Max. Regardless, the report contained no detailed analysis of the sexualised behaviour and abuse experienced by Max, instead focusing on whether the notified allegation of a rape was substantiated. Indeed, Max’s experience of harmful sexual behaviour was met with no significant comment from the investigator other than the finding that ‘no sexual assault of [Max] by [Ned] has occurred at [Ashley Youth Detention Centre] on the information available’.918 We note that the Serious Events Review Team report did not mention Floyd’s involvement.919

The Serious Events Review Team’s report notes that the material the investigator reviewed ‘shows a response to the incident as consistent with the current [Centre] procedures’, including providing medical care for Max, conversations with Max encouraging him to report the matter to police, involving Max’s parents and conferencing with Ned once Max declined to make a formal complaint.920

Regarding the incident involving Arlo and Albert, the Serious Events Review Team found a significant issue in the original incident report. The incident report, which was written with reference to the CCTV footage of the incident, stated the following:

• Supervising staff left the three young people unsupervised in the unit after staff attended to a code black emergency in another part of the Centre.
• Arlo and Albert then harassed and abused Max, with Albert jumping on Max’s back and making sexually suggestive motions.
• Albert pulled Max’s pants down before Max pulled them back up.
• Albert continued to intimidate Max, approaching him with his hand down his pants.
• Arlo removed his erect penis from his pants and encouraged Max to touch it, which Max did.
• Max was obviously upset and appeared to be crying.
• Arlo and Albert made comforting gestures to Max before staff returned to the unit.921

The incident report recorded that Arlo and Albert had both perpetrated abuse. Both were ‘conferenced’ in relation to ‘inappropriate sexual behaviour’, which meant they were required to meet and discuss the nature and impact of their actions with Centre staff.922

The investigator reviewed the CCTV footage as part of preparing the Serious Events Review Team report, finding the following:

• The footage showed staff leaving the young people unsupervised in the unit, Albert jumping on Max’s back, Arlo and Albert harassing Max and Albert seemingly comforting Max when he became upset.
• The footage did not show Albert making sexually suggestive motions while on Max’s back or Arlo removing his erect penis from his pants, but rather appeared to show him with a table tennis bat in his hand throughout the incident.923

The report noted that Arlo had ‘accepted full responsibility for the incident’ but denied the characterisation of the incident during conferencing, stating that it was a table tennis bat in his hand rather than his penis, and that this was consistent with the investigator’s review of the CCTV footage.924 This was also consistent with Max’s characterisation of the incident to the investigator when Max was interviewed, as well as his evidence to us, in that Arlo attempted to sexually abuse him with a ‘ping pong bat’.925 The report also noted Albert ‘agreed to having committed the offence’ as part of the conferencing process.926

The Serious Events Review Team found that neither Arlo nor Albert perpetrated a sexual abuse based on the information available to the investigator:

In conclusion, the CCTV footage of the incident does not clearly portray sexual motions by [Albert], nor does it clearly show the exposure of a penis by [Arlo]. [Max] now states that [Arlo] had a table tennis bat in his hand. This was also the claim made by [Arlo] during the Conferencing process. There is insufficient information to substantiate sexual assault based on the information available at this point in time.927

The investigator acknowledged the incident involving Albert and Arlo was ‘likely to be intimidating and frightening for [Max]’, but otherwise made no significant findings beyond the factual occurrence and characterisation of the incident.928

The limitations of the review were noted in the following comment from the investigator:

… [a] review of records at [Ashley Youth Detention Centre] found multiple Incident Records referencing ‘Inappropriate Sexual Behaviour’ involving youth detainees other than the three residents referenced in this Review. By nature of being a youth detention centre and the known pathway to offending behaviour resulting in detention, the residents of [Ashley Youth Detention Centre] are majority male, adolescent and are likely to have dysfunctional backgrounds including exposure to family violence, poor parenting, poor school attendance, interface with child protection services and general trauma history. The result of this can be poor social skills, impulsivity and skills in understanding the impact of behaviour on others. These factors can result in behaviours in a detention centre that are far from ideal within the community, but must be managed on a daily basis within a detention centre setting.929

The investigator went on to comment that:

It is outside the scope of [the Serious Events Review Team] to provide recommendations as to the response of [Ashley Youth Detention Centre] to such behaviours both at a Centre and individual resident level. However, it may be useful to consider expert review, advice and on-going consultation concerning this issue to support [the Centre] to assist residents to develop socially appropriate behaviours for transition to the community.930

The Serious Events Review Team’s report also stated that Centre management had ‘openly acknowledged the action of both Youth Workers leaving the residents unsupervised in the unit was in breach of procedure’ and the staff members involved had also acknowledged the error and its role in the incident occurring.931 Aside from the lack of staff supervision, the report noted that staff and management at the Centre ‘appear to have responded to this incident in a manner consistent with their procedures’.932

The report further noted that Max later raised concerns about being in a unit with Arlo and that the records reviewed showed ‘professional discussion and debate about this’ at the Centre.933 Minutes of a Centre Support Team meeting dated shortly after the incident involving Arlo and Albert and attached to the Serious Events Review Team’s report indicated that Max was upset by the incident but did not want to move units at that time.934 The minutes suggested staff were responding to Arlo and Albert’s harmful sexual behaviours and that Max would be offered counselling with the psychologist.935

Based on the evidence we received, we are concerned that Max was the victim of harmful sexual behaviours in the incident involving Albert and Arlo. Penetration, or attempted penetration, with a table tennis bat is a serious instance of harmful sexual behaviour. The Serious Events Review Team’s conclusion that because ‘sexually suggestive motions’ were not clearly visible on CCTV meant that harmful sexual behaviours did not occur is not, in our view, a sound one, particularly given the relevant incident report and the accounts from the young people involved supported a conclusion that harmful sexual behaviours involving a table tennis bat had occurred.

The choice of units in which Max was placed, in the context of his victimisation and subjection to harmful sexual behaviours by other young people in detention, continued to be an issue at the Centre for more than 12 months after the incident with Arlo and Albert. In this chapter, we further discuss Max’s subsequent subjection to other harmful sexual behaviours while detained in the Franklin Unit.

1. 6 August 2019—Henry is placed in the Franklin Unit

On 6 August 2019, Henry was placed in the Franklin Unit with Albert and Finn.936 As previously outlined, this was despite a care plan for Henry stating that he was ‘not to reside with [Albert] or [Finn]’, that Henry was not safe being housed with older boys and that Henry had been the victim of an earlier incident in the Franklin Unit.937

There was a lack of evidence to explain why Henry was moved to the Franklin Unit. Documents later prepared by Centre Manager Stuart Watson stated that no risk assessment or Centre Support Team process appeared to have taken place before or after Henry was moved to the Franklin Unit.938 Whatever the reason for the move, Pamela Honan, Director, Strategic Youth Services, acknowledged in her evidence that ‘the decision to place [Henry] into [the Franklin] unit was not properly considered or risk assessed’.939

1. 7 August 2019—Henry experiences harmful sexual behaviours

On 7 August 2019, an incident occurred involving Albert, Finn and Henry. We have reviewed the CCTV footage of this incident, which does not contain audio.940 The CCTV footage shows Henry seated in a common room in the Franklin Unit with Albert, Finn and another resident, Jonathan (a pseudonym).941 Henry was approached by Finn and Albert, who pulled Henry to the ground. During the incident, Finn and Albert pulled Henry’s pants down, exposing Henry’s buttocks and then Albert held a bottle near Henry’s exposed buttocks. After the incident, Albert and Finn left the room and Henry pulled his pants back up and retied the drawstrings. The incident lasted for approximately 20 seconds and staff members were not present. Jonathan remained in the room throughout the incident.

Finding—In August 2019, Henry (a pseudonym) was exposed to an unacceptable risk of harm and experienced preventable harm at Ashley Youth Detention Centre

Henry was placed in the Franklin Unit despite a care plan for Henry stating that he was ‘not to reside with [Albert] or [Finn]’, that Henry was not safe being housed with older boys and that Henry had been the victim of an earlier incident in the Franklin Unit.942

The behaviours Finn and Albert expressed towards Henry were non-mutual or non-consensual sexual behaviours involving force and fall within accepted definitions of harmful sexual behaviours. Albert and Finn’s harmful sexual behaviours towards Henry were preventable.

1. 8 August 2019—Staff at Ashley Youth Detention Centre become aware of harmful sexual behaviours Henry experienced

It appears staff were first alerted to the 7 August 2019 incident the following day when Finn, Albert and another young person at the Centre, Frank (a pseudonym), joked about an attempted rape of Henry with a water bottle.943 That conversation was not documented until 10 August 2019 (the relevant incident report is described in the next section). Staff identified the incident as likely having occurred on 7 August 2019 and that the matter should be notified to the Operations Coordinator at the Centre, Maude (a pseudonym).944

On 8 August 2019, Albert and Finn were involved in other incidents in the Franklin Unit in which they made sexualised gestures and appeared to try to engage other young people in sexualised acts.

On 8 August 2019, Henry asked that he ‘move units please anywhere’.945 A staff member documented at that time that ‘staff are keeping a close eye on interactions between the new residents and the three Franklin residents’ and that Henry was ‘very uncomfortable and a bit nervous’.946

1. 9 August 2019—The Centre Support Team discusses the harmful sexual behaviours Henry experienced

The first documented report about the 7 August 2019 incident was lodged on 9 August 2019. That report recorded that a staff member had heard Finn and Albert telling other residents: ‘[Henry] is a bitch, he won’t even come out of his room, we fucked him with a water bottle. He was resisting until we got his pants down’.947

An Interim Centre Support Team meeting took place on 9 August 2019. The minutes of this meeting stated:

Franklin staff noticed [Henry] removing himself from the general population and upon conversation with [Henry] he advised that during his time in Franklin he has been receiving unwanted attention from [Albert] and [Finn]. Footage for the times suggested in the conversation have been reviewed but this shows more attention towards [Jonathan] than to [Henry] as [Henry] is not present.948

The Centre Support Team determined that Henry and Jonathan should be immediately moved from the Franklin Unit and asked if they would like their parents notified.949 The minutes also noted that more information about behaviour and comments staff had heard or seen needed to be recorded before the next Centre Support Team meeting.950

Also on 9 August 2019, the Operations Coordinator, Maude, viewed the CCTV footage of the 7 August 2019 incident.951 Maude included the following description of the CCTV footage in another incident report relating to Albert, which she lodged on the same day:952

[Finn] walks toward [Henry] with [Albert] following. Both boys then grab [Henry] by the legs and pull him off his chair. [Henry] holding on firmly to his track pants, fights against [Finn] & [Albert] trying to pull his trackpants down. [Henry] ends up on his side. [Albert] reaches for the drink bottle and in a swooping manner brings it towards [Henry]’s buttocks. Both [Finn] & [Albert] quickly stand up and move towards the TV room entrance. [Henry] stands up and is seen to be pulling his track pants up which were clearly sitting below his buttocks at the back. During the ordeal it appears [Henry] holds onto the front of his trackpants. [Finn] has his back to the camera and is bent over the top of [Henry]. [Albert]’s face is [noticeable] to the camera and he is also bent over the top of [Henry].953

The incident report notes that the behaviour was not unusual or out of character for Albert.954 We were not provided with a copy of any corresponding incident report specific to Finn or Henry.

Maude recommended the incident be recorded as a detention offence for Albert and Finn.955 It is unclear whether Maude’s viewing of the CCTV footage or completion of the incident report occurred before or after the Centre Support Team meeting on 9 August 2019.

1. 10 August 2019—Another incident report is lodged about the harmful sexual behaviours Henry experienced

An incident report was lodged on 10 August 2019 about the conversation between Albert, Finn and Frank that staff overheard on 8 August 2019.956 The report noted the following:

• Albert said Henry had ‘put himself in his room because he was scared of being raped’ and Albert had told Henry that ‘he rapes little boys like him’.957 When the staff member asked whether Albert was joking, Albert laughed and said, ‘well yeah obviously—but not really’.958
• Frank told Clive (a pseudonym), a youth worker, that Henry had locked himself in his room because ‘we tried to rape him’.959 When asked whether he was joking around, Frank said: ‘No, we actually tried to’.960 We note that Frank was not present at the incident on 7 August 2019.
• Finn, Albert and Frank were talking about ‘pulling someone’s pants down, a bottle and holding someone down’.961
• Finn repeatedly said: ‘I don’t want to go to prison for rape—I hope they do not check the cameras’.962
• Finn stated the incident occurred while one staff member was in the toilet and the other was playing cards with another young person.963
• Frank told Clive about another incident of sexual behaviour between young people, stating: ‘I told [Finn] that I’d give him a coke if he touched me on the dick and he did’. Finn and Albert confirmed the incident happened as Frank described.964
• ‘In general, the sexualised talk in Franklin has escalated beyond normal “teenage boy” talk’ since Henry and Jonathan were moved to the Franklin Unit.965
• Finn told the staff members present: ‘Can you please stop putting small boys with long hair in this unit, we have been locked up a long time and we take out our sexual frustrations on them’.966

We are not aware of the reason for the two day delay in lodging this incident report.

1. 12 August 2019—The Centre Support Team discusses Albert’s and Finn’s harmful sexual behaviours

On 12 August 2019, the incident involving Albert and Finn on 7 August 2019, and the subsequent discussions between the young people in detention on 8 August 2019, were again discussed at a Centre Support Team meeting.

The minutes of this meeting stated that there would be ‘zero tolerance with this behaviour and talk’.967 The Centre Support Team was of the view that the level of seriousness of Albert’s and Finn’s behaviour warranted a ‘detention offence’ for each of them.968 It was recorded that conferences would be held with Albert and Finn and that neither would ‘progress further than orange [colour level under the behaviour management system] until they attend’.969 Albert (originally on the yellow colour level) and Finn (originally on the green colour level) were put down to the orange colour level, indicating disapproval of their behaviour under the behaviour management system.970 Under a section titled ‘Positive Words’ for each of Albert and Finn, it was commented that each ‘had [a] good week aside from their incident reports’.971

The minutes also recorded a discussion about Henry’s behaviour regarding an unrelated incident on 5 August 2019, but he was moved from the red colour level to the orange colour level and taken off being ‘unit bound’.972 There is no record of the impact of the 7 August 2019 incident on Henry. The only reference to Henry being subjected to harmful sexual behaviours was that ‘[Henry] was moved back to Bronte [Unit] due to some standover behaviour that [Henry] was subject to in Franklin’.973 We found the use of the phrase ‘standover behaviour’ surprising. We are concerned it may indicate a lack of appreciation of the seriousness of what occurred to Henry in the Franklin Unit, particularly because Operations Team staff had heard Finn and Albert talking about ‘raping’ Henry.974

The meeting minutes do not record any dissent in the decision to place Albert and Finn on the orange colour level.975 Ms Gardiner recalled, however, that she was present at that meeting and had made recommendations that were not followed.976 In our public hearings, Ms Gardiner told us she had disagreed with the decision to place Albert and Finn on the orange colour level, believing red was the most appropriate colour for this incident.977 Ms Gardiner further stated that the rationale at the meeting for not placing Albert and Finn on red was because ‘they would drop their bundle and that would cause some behaviour problems’, creating difficulties for Centre management.978

On 12 August 2019, Patrick Ryan, then Centre Manager, prepared and distributed a document titled AYDC Weekly Report.979 Referring to the 7 August 2019 incident, the report stated:

An incident involving sexualised behaviour in Franklin was considered on the 9 August 2019 and reconsidered at [the Centre Support Team meeting]. Appears to be silly behaviour but [detention offence] for conferencing.980

We don’t know who received this weekly report.

1. 13 August 2019—Staff voice their concerns to the Centre Manager about the management of Albert and Finn

On 13 August 2019, Ms Gardiner emailed Mr Ryan and some members of the Centre Support Team to reiterate her view that the Centre Support Team’s response to Albert and Finn’s behaviour was inappropriate. She voiced the following concerns:

• Moving Finn and Albert to the orange (not red) colour level was inconsistent with other Centre Support Team decisions and did not appropriately reflect the nature and seriousness of the offending.981
• The rationale for moving Albert and Finn to the orange (not red) colour level was inappropriately influenced by concerns about Albert’s and Finn’s response to the colour level, and not on Henry’s wellbeing. Ms Gardiner criticised the rationale, which she identified as being that ‘on Red colour these two residents will “drop their bundle” or similar’, that the Centre would struggle to manage Albert and Finn on red, and that Albert and Finn were long-term residents and would be experiencing some sexual frustration.982
• The Centre needed to notify Child Safety Services and the parents of the young people in detention, and to arrange support for all involved.983 She reminded Mr Ryan and the Centre Support Team that ‘in the community this would be [considered] a level of abuse, and we are mandatory reporters’.984
• Staff were minimising Finn and Albert’s behaviour and needed training in relation to harmful sexual behaviours.985

On the same day, the Health and Community Services Union delegate emailed Mr Ryan on behalf of members to raise concerns about Centre Support Team decision making.986 The email stated that ‘conferencing and a slap on the wrist will not be seen by either myself or [union] members as appropriate in this circumstance’.987 The later Serious Events Review Team report stated that the delegate also noted there were inconsistencies in the Centre Support Team decision making, such as ‘awarding more severe consequences for physical assault than were awarded for sexual assault’.988

In his response to the delegate, Mr Ryan questioned why the members had approached the union and had not considered using internal mechanisms to address their concerns in the first instance.989 We are unaware of the steps Mr Ryan took, if any, to address the union’s concerns.

1. 14 August 2019—The Centre Manager notifies the Director, Strategic Youth Services of the incident involving Henry

The Serious Events Review Team’s report regarding Henry dated 19 March 2020 recorded that, on 14 August 2019, Mr Ryan contacted Greg Brown, the then Director, Strategic Youth Services, via email to notify him of the incident and the differences in opinion among staff about the nature of the incident.990 The email (as extracted in the report) stated:

I have viewed the footage, and I do not view it as a sexual assault. But the centre is full of armchair critics and some [youth workers] have gone to their [Health and Community Services Union] delegate who has put his two cents worth in.991

We discuss Mr Ryan’s description of the incident below.

Henry also had an appointment with the Centre’s psychologist on 14 August 2019, during which he revealed he was feeling threatened and had isolated himself in his room for safety.992 After that appointment, Professional Services Team members noted that Henry was reluctant to talk about the incident, possibly due to fear of retribution.993 There is no clinical record indicating Henry attended any more individual sessions with the psychologist before his release from the Centre a few months later, but he attended group work, including sessions concerning healthy relationships.994

Evidence indicates Henry was offered an opportunity to make a complaint to police but he declined to do so.995 We do not know when that offer was made.

1. 19 August 2019—The Centre Support Team again discusses the behaviours of Albert and Finn

Another Interim Centre Support Team meeting occurred on 19 August 2019.996 The minutes of this meeting recorded that Albert and Finn were moved from orange to yellow colour under the behaviour management system.997 The rationale for this change was not explained in the minutes, but the minutes do record that Finn had ‘quickly improved his behaviour following last week’s incidents’.998

The minutes recorded that the Centre’s psychologist ‘feels that there is a pattern of behaviour over more than a day with [Finn] & [Albert] that needs to be addressed’.999 It was noted that the psychologist would continue to work with Albert, but that Finn did not engage with the psychologist.1000 There was no suggestion of alternative therapeutic supports for Finn. The minutes also stated that ‘careful consideration’ was to be given to any unit or program placements with Finn and Albert, acknowledging the pair tended to ‘buddy up’ and display problematic behaviours.1001

The minutes of this meeting also suggested that Albert and Finn’s sexualised behaviour was affecting other young people in the Franklin Unit. The minutes record that Frank, who remained in the Franklin Unit with Albert and Finn, had been ‘intimidated by [others’] behaviour in the unit, which may be why his comments around sexualised behaviour have increased’.1002

At this point, neither Albert nor Finn had attended a conference about the 7 August 2019 incident. The minutes acknowledged the need to prioritise conferencing in relation to the incident.1003

The Centre’s psychologist took her own notes from this meeting, which included the following observations:

Provided the members of the [Interim Centre Support Team] meeting with a summary of the incidents reviewed on the Franklin video footage. Raised concerns regarding: the seemingly organised nature of the intimidation behaviour; repeated sexualised behaviours including indecent exposure, sexualised harassment and bullying, assaultive behaviour with a threat/intimidation of sexual violence; and non-sexualised bullying/intimidation.1004

… Mr Ryan and [a staff member] disagreed with the seriousness of the incidents, describing the incidents as ‘horseplay’ and comparing them to behaviours observed in the community in various sporting teams. Furthermore, Mr Ryan, [a staff member] and [another staff member] appeared to affirm the risk management and the sanctions taken as proportionate to the nature of the incidents (CST meeting minutes 12/08/2019). However, [one staff member] conceded that should the victims involved in the incident have been female, the response to the incident would have been different, ‘would have unleashed a war’.1005

A further concern was raised that in the context of frequent and ongoing moves of residents between units the steps taken to ensure the immediate safety of the victims (i.e. moving them to another unit) may be insufficient to provide them with a perceived sense of and actual safety at [the Centre]. [One staff member] acknowledged the concerns, stating that selection of residents to be placed in a unit with either [Finn] or [Albert] would require special attention whereby younger and more vulnerable residents may be deemed to be at high risk of victimisation.1006

Mr Ryan denies describing the incidents as horseplay and comparing them to behaviours of sporting teams.1007

In the Ashley Youth Detention Centre Weekly Report, dated 19 August 2019, it was noted that:

… sexualised behaviour by some residents last week was re-visited this week. Residents have moved units as a practical response. CPR and case conferencing are also practical and theoretical responses.1008

The extent of any therapeutic intervention provided to Albert and Finn is unclear.1009 We do not know the extent to which Albert continued to engage with the psychologist. We are also unaware of what other supports the Centre offered Finn after he declined to engage with the psychologist.

1. 19 August 2019—Max is placed in the Franklin Unit

On or around 19 August 2019, Max was transferred to the Franklin Unit. Max’s placement in that unit raised concerns among the Centre’s professional services staff. These concerns appear to have arisen because of the presence of other detainees in that unit, namely Albert and Finn. As noted, this was the second time Max had been placed in a unit with Albert, who had previously been involved in an allegation of an incident of harmful sexual behaviour directed at him.

Notably, Max’s placement in the Franklin Unit with Albert and Finn occurred about two weeks after Albert and Finn had displayed harmful sexual behaviours towards Henry and at a time when the Centre’s management and staff were still considering the seriousness of that incident.1010

It is unclear to us why Max was placed in the Franklin Unit. The Centre Support Team meeting minutes from the day the decision was made to transfer Max do not reflect any discussion about his placement in the Franklin Unit.1011 Rather, those minutes state that Max was requesting a transfer and had been moved between different units (not Franklin) within the Centre.1012 We infer from this that the decision to place Max in the Franklin Unit was made after that meeting, likely by Operations Team staff without the direct input or consideration of the Centre Support Team.1013

1. 21 August 2019—Centre management responds to concerns over Max’s placement in the Franklin Unit

On 21 August 2019, Ms Gardiner emailed her concerns about Max’s placement in the Franklin Unit to Mr Ryan and the Operations Manager:

I am raising the serious risk to [Ashley Youth Detention Centre], [Max] and Franklin residents of the placement of [Max] in the Franklin unit with the current residents.

Recently there has been a number of incidents of serious sexually inappropriate behaviour from [Albert] and [Finn] to other residents.

[Max] has been the subject of [Serious Events Review Team] review of incidents where he has reported being sexually assaulted by other residents. One of these incidents was by [Albert].

This unit placement is very inappropriate. It places [Max] at risk of being exposed to further sexual incidents, which he already feels vulnerable to. As well as puts [Albert] and [Finn] in a position of risk of continuing this behaviour, as they have done this in the past.

The decision also put[s] [the Centre] at risk from a significantly concerning incident occurring regarding sexualised behaviour.

I cannot imagine [Max] would feel very safe in this unit – with one resident who has previously been the subject of sexually inappropriate behaviour towards him, and now he is with two residents for who there is evidence of sexually abusive behaviour.

I request this [unit] placement be [reviewed] asap to ensure the safety of residents.1014

In her statement to us, Ms Gardiner referred to the placement of Max in the Franklin Unit as an example of some operational staff failing to adequately consult other Centre staff about placements and making placement decisions outside the processes of the Centre Support Team.1015

In response to Ms Gardiner’s concerns about Max’s placement, the Operations Manager appears to have immediately recognised the risk and addressed the issue, transferring Max to another unit.1016 In his response to Ms Gardiner, the Operations Manager also noted that the decision to place Max in the Franklin Unit had been made by other staff two days prior, while he was on leave.1017

Ms Gardiner told us she also raised concerns with Mr Ryan about the risk posed by Operations Team staff making placement decisions without proper consultation. Ms Gardiner stated that Mr Ryan’s response was that she should ‘read the “Unit Moves” policy’.1018 Ms Gardiner said that, after reviewing that policy, she told Mr Ryan the policy, as applied in practice, placed young people at risk and needed to be reviewed.1019

Mr Ryan has provided us with his own file note of his initial conversation with Ms Gardiner, which records her objection to the placement decisions and processes.1020 It also records Mr Ryan explaining that the levels of ‘[Operations Coordinator] and up can use’ the relevant procedure to make unit placement decisions.1021 Mr Ryan’s note also records that:

[Ms Gardiner] suggested that staff need supervision, and to involve [Professional Services and Policy] in unit moves. I explained that an operational decision can be made, if it’s based on operations. Thus any discussion on concerns go to the [Operations Coordinator] and/or [the Operations Manager].1022

We understood Mr Ryan’s note to mean that some Operations Team staff could make decisions about unit moves if there was an operational reason to do so. An example of an operational reason for a unit move might be damage to unit infrastructure that required a young person to be moved to a different unit.

1. Observations—Placement decisions involving Max

We were concerned by the evidence that Max was placed in the Franklin Unit with Albert and Finn only a matter of weeks after these two young people had engaged in harmful sexual behaviours against Henry, and at a time when Centre management and staff were still considering the seriousness of that incident. We note that before Max’s placement in the Franklin Unit he had also been subjected to harmful sexual behaviours by Albert.

Ashley Youth Detention Centre was aware of concerns about Max’s safety. As previously outlined, Ms Gardiner had raised concerns soon after the decision was made to place Max in the Franklin Unit, making clear her disagreement with the decision considering Max’s vulnerability, the previous behaviour of Albert towards Max and the harmful sexual behaviours engaged in by Albert and Finn. A few days later, Ms Gardiner raised her concerns about Operations Team staff making placement decisions without proper consultation. We are concerned that operational matters were prioritised over protecting young people from the risk of harmful sexual behaviours.

While Max was ultimately placed in a different unit without incident, it appears that no Centre-wide steps were taken to ensure that Max or other vulnerable young people would not be placed in a unit with detainees who were known to engage in harmful sexual behaviours. There should be an integrated, consistent and trauma-informed approach to unit placements in youth detention.

Ms Gardiner’s diligence in identifying risks and advocating for Max’s safety is to be commended.

Finding—In August 2019, Max (a pseudonym) was exposed to an unacceptable risk of harm at Ashley Youth Detention Centre

Ashley Youth Detention Centre did not adequately consider the risk to Max of him being placed in the Franklin Unit, despite concerns being raised about Max’s safety. Max was exposed to an unacceptable risk of harm.

1. 22 August 2019—A staff member reports the harmful sexual behaviours Henry experienced to Child Safety Services

A week after expressing her view that Child Safety Services should be notified of the 7 August 2019 incident involving Henry, Ms Gardiner had received no response from the Centre Support Team or Mr Ryan, so she revisited the matter with Mr Ryan.1023 On 21 August 2019, Mr Ryan responded, stating there were ‘varying views on [the] level of seriousness of the matters’ and while he was not ‘convinced’ a Child Safety Services notification was necessary, he was ‘happy to take more argument on it’.1024 Ms Gardiner responded the next day, stating she would advise Child Safety Services of the incident and leave it to them to determine whether it was to be a notification that required further follow-up.1025

On 22 August 2019, Ms Gardiner reported the incident involving Henry to Child Safety Services’ Advice and Referral Line.1026 Advice and Referral Line records indicate Ms Gardiner reported that Albert and Finn were masturbating in the TV room before the incident with Henry.1027 Ms Gardiner also provided further information about an incident involving another young person on 8 August 2019 (where he was subjected to a resident ‘exposing himself and masturbating’) and lodged a care concern about Max in relation to his placement with Albert and Finn.1028

The records of Ms Gardiner’s call with the Advice and Referral Line also suggest there was a discussion about the need to notify police.1029 On 23 August 2019, Ms Gardiner emailed Mr Ryan, saying that Child Safety Services told her they would make a report to police.1030

Mr Ryan told us he had escalated the 7 August 2019 incident and Child Safety Services’ report to Mr Brown, who advised him to leave the matter to the police.1031 Mr Brown said he does not recall advising Mr Ryan to leave the matter to the police.1032

There appears to have been confusion, however, between Ashley Youth Detention Centre and Advice and Referral Line staff about who would notify police, with each entity believing the other would make the notification.1033 By early October 2019, no police notification had been made.1034 The Advice and Referral Line notified police of the incident on 3 October 2019 after an Ashley Youth Detention Centre staff member

informed them the Centre had not made a referral about the incident.1035 The Advice and Referral Line file of the incident was closed on 11 November 2019.1036

Police records confirm that police were first notified of the incident on referral from Child Safety Services. However, they did not proceed with an investigation because ‘no formal complaint’ had been made.1037 We note that the lack of a formal complaint should not be the sole reason for police inaction, particularly when there may be serious barriers for a victim-survivor making a formal complaint.

1. 22 August 2019—The Ashley Youth Detention Centre psychologist recommends risk management of harmful sexual behaviours

Also on 22 August 2019, the Centre’s psychologist emailed Ms Gardiner a spreadsheet she had prepared after reviewing footage of incidents in the Franklin Unit.1038 The spreadsheet summarised incidents of sexualised and non-sexualised threatening and harmful behaviours displayed by Albert and Finn, including the 7 August 2019 incident involving Henry.1039 The summary does not appear to address all matters or incidents identified in the various incident reports lodged on 9 and 10 August 2019.

In the email to Ms Gardiner, the psychologist noted disagreement about the ‘nature and the seriousness of the behaviours’ seen in the Franklin Unit.1040 The psychologist reasoned that this disagreement could be explained by differences in individual and work experience, the extent of staff training and a:

… general tendency [among Ashley Youth Detention Centre staff] to minimise or dismiss young people’s sexually abusive behaviour as experimentation or play, or as a ‘phase’ that will pass with age … which inadvertently perpetuates the cycle of abuse.1041

The psychologist’s view was that Finn and Albert had displayed ‘concerning and developmentally inappropriate sexual behaviours’.1042

The psychologist recommended the following responses:

• further investigation of the incidents
• urgent development of clear risk management strategies, such as increased supervision of the young people who displayed sexually abusive behaviours
• staff training
• more discussion about appropriate therapeutic interventions.1043

Ms Gardiner forwarded the psychologist’s advice to Mr Ryan on the same day, noting the Centre had ‘some work to do to upskill staff in this area. It is a significant risk otherwise’ and repeating a request for education/training from a sexual assault service.1044 Mr Ryan responded to Ms Gardiner, stating that he believed the Department of Education had booked training for Centre staff through the Sexual Assault Support Service for the 2019 school year and encouraged Ms Gardiner to engage the Sexual Assault Support Service for resident programs.1045 Mr Ryan directed Ms Gardiner to work with the Learning and Development Manager, Strategic Youth Services at the Department of Communities to arrange staff training.1046

Ms Gardiner told us she was particularly concerned that:

… staff in leadership positions were not aware of [harmful sexual behaviours] and this had created a situation of sexual abuse in the Centre, and would create more risk for young people in the future if this was not addressed.1047

Over an extended period, Ms Gardiner had contacted several senior staff at the Centre and in the Department to request group training on harmful sexual behaviours, but she said she received no response.1048

Mr Ryan provided information to our Commission of Inquiry that during the time he managed the Centre, a number of relevant training programs were provided for staff.1049 He also made repeated attempts to arrange for the Sexual Assault Support Service to deliver training for Centre staff in relation to harmful sexual behaviours.1050 He stated that in 2019 the program was implemented for detainees at Ashley School, with the support of the Principal.1051 However, training for staff was not implemented because, according to Mr Ryan, successive directors did not support the training and Ms Honan noted the request but took no further steps to implement training.1052

Mr Brown informed us that sometime between October 2018 and October 2019, at his recommendation, the Department agreed to review staff training programs, including in relation to harmful sexual behaviours, at the Centre.1053 It is not clear if this review was undertaken, or what the outcome of any such review was.

Ms Honan told us that training for recognising and responding to harmful sexual behaviours is now offered to staff.1054 Such training will need to be supported by a cultural change of attitudes towards harmful sexual behaviours (refer to Chapter 12).

1. 23 August 2019—The Centre Support Team again discusses the behaviours of Albert and Finn

On 23 August 2019, a further Interim Centre Support Team meeting was held. The meeting minutes reflect that Albert and Finn had progressed to the green colour level. There was no mention of the 7 August 2019 incident involving Henry, progress in relation to conferencing with Albert and Finn, or any actions to address their behaviour.1055

Despite the recommendation of the Centre Support Team that Albert and Finn be dealt with by conferencing, it appears that conferencing never took place because of the following factors:

• The Conference Convenor decided to pause the process until a Child Safety Services report was made and responded to.1056 The Conference Convenor also indicated that if police were notified, she would wait until the end of that process.1057
• Police were not notified until 3 October 2019.1058
• Henry was subsequently released from Ashley Youth Detention Centre in late October 2019.1059
• Child Safety Services did not close their investigation until 11 November 2019.1060

Moving Albert and Finn to a green colour level appears to contradict the Centre Support Team decision made on 12 August 2019 that Albert and Finn would not progress beyond orange until a conference had been completed.1061 While we hold serious concerns about the Behaviour Management System and particularly its use as a tool for punishment, which we discuss in Chapter 12, it is important that if in use it should be applied equally and consistently. It is important that any behaviour management process should be experienced by children and young people in detention as fair, equitable and predictable to support strong relationships between detainees and to promote their sense of security.

We are concerned that Albert and Finn did not appear to receive conferencing or any other therapeutic support for the behaviours they had exhibited. It is also important that the Centre sends a clear message to children and young people displaying or experiencing harmful sexual behaviours that such behaviour is not acceptable.

1. 9 September 2019—The Secretary is briefed about the 7 August 2019 incident involving Henry

In his written statement to us, Mr Ryan confirmed he reviewed the CCTV footage of the 7 August 2019 incident involving Henry.1062 He described the incident as ‘an attempt by two residents to remove the pants of a third resident’.1063 In a further written statement, Mr Ryan recalled that the footage showed an ‘attempt’ to pull Henry’s pants down and that Henry’s ‘trousers [were] pulled part way down but his underpants remained on’.1064 Mr Ryan states that he also showed the footage to Mr Brown, who ‘shared my view that it was appropriate to treat this as a sexualised incident, rather than a sexual assault’.1065

We asked Mr Brown about what information he received regarding this incident. He could not recall what information he received or when he received it and did not mention viewing the CCTV footage or his interpretation of it at the time.1066 He subsequently recalled viewing the CCTV footage but, aside from recalling that the footage was ’grainy’, he could not recall what it showed.1067 Mr Brown disputes that he and Mr Ryan shared a view as to how the incident should be described and treated.1068

On 2 September 2019, approximately one month after the 7 August 2019 incident involving Henry, Mr Ryan prepared an issues briefing for Michael Pervan, the then Secretary of the Department of Communities, about the incident.1069 The issues briefing was cleared through Mr Brown on 3 September 2019, then by Ms Honan, who at that time held the role of Acting Deputy Secretary, Children and Youth Services, on 6 September 2019.1070 The issues briefing confirms that Mr Brown had viewed the CCTV footage of the incident.1071

The issues briefing was titled ‘Sexualised incident between residents at the Ashley Youth Detention Centre’.1072 Its stated purpose was to brief the Secretary on the ‘sexualised incident’ on 7 August 2019 and the related referral to police about the alleged abuse.1073

The issues briefing referred to the incident as a ‘sexualised incident’ and a ‘potential sexual assault’.1074 It described the CCTV footage as showing:

… the four residents in the [common] room … [Finn] and [Albert] approach [Henry] and grab his legs, pulling him off his chair, and attempting to remove his track pants. [Henry] holds onto his pants and is able to keep them up. [Albert] reaches for a 600-millilitre water bottle and brings it towards [Henry’s] buttocks for two to three seconds. The incident then ends.1075

We note that Henry’s buttocks were exposed, which this description implies was not the case.

The issues briefing also stated:

• Henry had not made a complaint, but staff moved Henry from the Franklin Unit on 8 August 2019 as part of an ‘immediate operational response’ while an ‘inquiry’ continued.1076 Jonathan was also moved from the unit on 9 August 2019 because it was ‘considered prudent to do so’.1077
• Albert and Finn were reported for a detention offence and referred to the psychologist.1078 The briefing does not acknowledge that Finn declined to engage with the psychologist.
• Matters were and continued to be monitored via the Centre Support Team and Multi-Disciplinary Team processes.1079
• The Professional Services Team and the psychologist considered the incident. Ms Gardiner still ‘held concerns that the matter was an assault’ and referred the incident to the Advice and Referral Line.1080
• Representatives of the Advice and Referral Line agreed the incident was an alleged abuse and advised Centre staff to contact police.1081
• The incident had been referred to police.1082 We note this is incorrect—a police referral was not made until 3 October 2019, almost a month after the Secretary approved the issues briefing.
• To that date, police had ‘not been in contact’ with the Centre about this matter, ‘but historically do so upon receipt of such referrals’.1083
• ‘[N]o further complaints or issues [had] been raised or identified since 8 August 2019’.1084 We note that the issues briefing does not clarify that the psychologist and the Health and Community Services Union delegate had separately raised concerns about the incident with Mr Ryan.
• Police may charge Albert and/or Finn and the related detention offence reports had been filed pending the outcome of any charges.1085
• Various incidents had occurred between Henry, Albert and Finn over the period of 7–8 August 2019, which ‘could be described as wrestling and/or adolescent behaviour, or as unwanted attention’.1086 These incidents were recorded and considered.1087

The issues briefing did not invite the Secretary to take any action or make any decision. The Department did not take any further action in response to the issues briefing.

Mr Ryan denied his description in the issues briefing was inaccurate but accepted the description could have been worded better.1088 When asked about the issues briefing during our public hearings, Mr Ryan emphasised his lack of control over the final product that went before the Secretary. Mr Ryan said it was common that the contents of briefings were changed as they were considered and edited by his superiors, through whom briefings were approved.1089 He commented that what he ‘initially authored isn’t exactly what the recipient gets’.1090

Mr Ryan provided a draft of the relevant issues briefing, dated 30 August 2019.1091 The contents of this draft are similar to the final product. Some important differences are that Mr Ryan’s draft:

• stated that the allegation was referred to Child Safety Services, which had on-referred the matter to police to consider1092
• attached the referral advice provided to Child Safety Services, containing the opinion of its author, Ms Gardiner1093
• stated Mr Ryan had considered the incident and CCTV footage and ‘suggests the incident is sexualised behaviour, but not an Assault’.1094

The description of the incident contained in the draft and final briefing are the same. The two briefs indicate the matter is a ‘sexual incident’, but the original draft makes it clearer that Mr Ryan did not believe the matter to be ‘an Assault’.

The Director, Strategic Youth Services, who has since retired, could not recall many details of the 7 August 2019 incident or the issues briefing. He said:

I do not recall what information I received and when I received it in relation to this incident. I would be quite sure I would have initially received a phone call outlining basic details and possibly a follow up email. I would generally then receive the incident report and a follow up Issues Brief. I would advise the Deputy Secretary (generally verbally) then follow up with written details through email or an Issues Brief …

I do not recall whether I sought additional information or received additional information or not. In general practice, before clearing an Issues Briefing I would clarify any matters I was not sure about or felt required additional information. I am not sure if I did that on this occasion or not.1095

Ms Honan, as Acting Deputy Secretary, stated that she did not conduct any further investigation about the matter before approving the issues briefing.1096 Ms Honan noted that Mr Ryan and Mr Brown (both of whom had been involved in preparing the issues briefing) had seen the CCTV footage of the incident.1097 She also acknowledged that the matter had been referred to police and Child Safety Services, and that the young people had been referred to the psychologist about their behaviours.1098 She told us that, because of these actions, she had ‘no reason to doubt the content’ of the issues briefing.1099

In her statement to us, Ms Honan reflected that she considered the issues briefing of 9 September 2019 appeared to minimise the behaviour of Albert and Finn and did not, as noted in the Serious Events Review Team report, depict an accurate description of the 7 August 2019 incident, and was misleading.1100

Department Deputy Secretary Mandy Clarke also agreed the issues briefing minimised the incident and showed a lack of understanding of harmful sexual behaviours.1101

Secretary Pervan disagreed the issues briefing minimised the incident overall but acknowledged and accepted the later findings of the Serious Events Review Team that the briefing provided an inaccurate description of the incident.1102 Secretary Pervan considered that, in this respect, the issues briefing ‘painted the incident in a less severe light’.1103 Secretary Pervan gave evidence that if the issues briefing had been more accurate, he would have initiated the Serious Events Review Team’s review sooner.1104

It was not until Alysha raised concerns that Ms Honan may not have been fully informed about the incident that a Serious Events Review Team review began in December 2019.1105 We discuss this review further in this case study.

Finding—The issues briefing to the Secretary about the 7 August 2019 incident regarding Henry minimised the incident and was incomplete, which contributed to a delay in reviewing the incident

The following information was available to Ashley Youth Detention Centre and the Department:

• Albert and Finn forcibly removed Henry from his chair and held him down.
• Albert and Finn’s conduct was of a sexual nature.
• Henry’s pants were forcibly removed to the extent that his buttocks were exposed.
• Henry was isolating himself in his room, seemingly as a result of the incident and comments from Albert.
• Albert and Finn had discussed a sexual abuse of Henry with other detainees and staff.

This information should have made it clear that an incident of serious harmful sexual behaviour had occurred. It should have been reported as such to the Secretary.

As a result of an insufficient briefing, the Department was not appropriately informed of the severity of the incident and the potential risk to other young people at Ashley Youth Detention Centre. In turn, the incomplete issues briefing likely contributed to the Department delaying action to investigate or otherwise manage the incident.

1. 18 September 2019—The Ashley Youth Detention Centre psychologist alerts the Centre Manager of Henry’s exposure to a risk of harm

We were concerned by evidence that in the weeks following the incident, operational decisions meant Henry was again exposed to a risk of harm from Finn. On 18 September 2019, the psychologist raised concerns that Henry had been moved into a program group with Finn, despite the lack of any formal interventions and without consultation with the Multi-Disciplinary Team.1106 On 20 September 2019, the psychologist requested (via email) that Mr Ryan reverse this decision immediately.1107 In this email, she stated:

I believe that some of the reasons provided for the decision (this is secondary information as I was not at the morning meeting in person) were that the investigation is likely to be closed without any further actions due to the insignificant nature of the incident, and that [Henry] and [Finn] have since been in each other’s company (for example, in the dining hall) without any issues observed by the youth workers. As I am sure you can appreciate there are a number of issues with such rationale.1108

We understand the psychologist’s reference to an ‘investigation’ at this time refers to the internal consideration of the incident within the Centre and the Department, rather than an official investigation such as that subsequently undertaken by the Serious Events Review Team, as we have seen no evidence to suggest that a formal investigation started before December 2019 (discussed in a further section). It is unclear whether Henry was removed from the program with Finn.

Finding—In the weeks following the 7 August 2019 incident, Henry continued to be exposed to risk of harm at Ashley Youth Detention Centre despite widespread knowledge about these risks

Based on the evidence and findings covered in the Serious Events Review Team report into the incident, as well as our own viewing of the CCTV footage of the incident, it appears that Henry experienced serious harmful sexual behaviour on 7 August 2019.1109

Ashley Youth Detention Centre did not demonstrate an appreciation of the seriousness of the incident involving Henry on 7 August 2019. Some staff appeared to understand the seriousness of this incident. However, we were concerned that other staff described the matter as a ‘sexualised incident’.1110 This was despite multiple concerns being raised about this, including on:

• 10 August 2019, when another incident report was prepared about Albert and Finn discussing the incident and making further sexualised comments
• 12 August 2019, when the Centre Support Team discussed the sexualised behaviours of Albert and Finn
• 13 August 2019, when Ms Gardiner emailed Mr Ryan and other members of the Centre Support Team emphasising that Albert and Finn’s behaviours were inappropriate
• 19 August 2019, when the Centre Support Team again discussed Albert and Finn’s behaviour and the psychologist noted a pattern of behaviour that needed to be addressed
• 22 August 2019, when Ms Gardiner reported the incident involving Albert and Finn to Child Safety Services.

This minimisation of the incident resulted in:

• insufficient supports provided to Henry after the incident
• not taking immediate action to protect Henry’s safety
• failure to develop a program to address Albert and Finn’s behaviour
• delayed reporting to police and Child Safety Services.

We are concerned the advice of staff who had knowledge and understanding of harmful sexual behaviours and the management of such behaviours, appears not to have been given as much sway as the concerns and views of operational staff.

Consequently, young people continued to be placed with Albert and Finn for several months and were at continued risk of sexual harm. We are particularly concerned by evidence that Henry was placed in programs with Finn in the weeks following the 7 August 2019 incident.

1. September 2019—Ray is admitted to Ashley Youth Detention Centre

In September 2019, Ray was admitted to Ashley Youth Detention Centre. Soon after Ray’s admission, the Multi-Disciplinary Team recommended the Centre Support Team place Ray on a Very Close Supervision order until more was known about his history and current mental health.1111 It does not appear that Ray was placed on a Very Close Supervision order until towards the end of his third month at the Centre (as discussed further in this section).

Approximately one week after his admission, Ray abused another young person and was isolated for 50 minutes.1112 Ray continued to be involved in a range of physical incidents in the weeks following his admission. Ray was again isolated after at least one other incident.1113 Ray’s mental health difficulties were not reflected in incident forms completed following these incidents.1114 Conferences were held with Ray regarding some of these incidents.1115 Following these conferences, Ray was directed to continue to see the psychologist.1116 In at least two conferences, it was noted that Ray was ‘very insightful about his behaviour’.1117

A version of Ray’s care plan was updated approximately one month after his admission. The care plan noted a recommendation by the Multi-Disciplinary Team that ‘a “Key Worker” be identified at each shift to support and monitor [Ray] and to report any behaviour concerns’.1118 The intention was not ‘that a worker be specifically dedicated to [Ray], but rather has a consistent oversight’, to help Ray build relationships and create some stability in his environment.1119 Later emails sent between Professional Services and Operations Team members suggest this recommendation was, at least initially, received positively by at least one Operations Team member.1120

We note there were discrepancies in the various incident reports concerning Ray, including forms apparently filled out without reference to the actual events, and some forms that were not filled out appropriately or were incomplete.

1. 8 October 2019—The Ashley Youth Detention Centre psychologist reports harmful sexual behaviours to the Commissioner for Children and Young People

On 8 October 2019, the Ashley Youth Detention Centre’s psychologist contacted Leanne McLean, the Commissioner for Children and Young People, to advise her of the 7 August 2019 incident and another incident of harmful sexual behaviour in October 2019 by Albert and Finn.1121

1. 13–14 November 2019—The Ashley Youth Detention Centre psychologist raises more concerns with the Centre Manager about Albert and Finn

On 13 November 2019, the psychologist emailed Mr Ryan to advise of a young person in detention disclosing to her that staff had threatened to transfer him to the Franklin Unit, that he felt unsafe and stated that detainees get ‘stood-over, abused and raped’ in the Franklin Unit.1122 This conduct referred to Albert and Finn’s behaviours.1123 We are unaware of which young person expressed this concern but based on the timing it appears unlikely to be (but could be) Max, Henry or Ray.

Mr Ryan told us he ‘was taken aback by her assertions because they didn’t square with [his] understanding of how residents were being treated or the history of complaints which had been received prior’.1124 In response to this email, Mr Ryan told us he:

• spoke with Digby (a pseudonym), the co-manager of Professional Services (we note Ms Gardiner’s employment at the Centre ceased in mid-October 2019), and senior social workers
• convened a ‘special meeting’ of managers on 20 November 2019 to discuss Albert and Finn’s behaviour
• held regular weekly meetings for the remainder of 2019 and into February 2020 to monitor Albert and Finn’s behaviour and provide a ‘higher level of intervention’.1125

It is unclear to us what action was taken in response to the allegations that staff had threatened young people with a transfer to the Franklin Unit, separate from the response to the behaviours Albert and Finn exhibited.

In a meeting on 14 November 2019, the Multi-Disciplinary Team recommended that ‘no other residents will be placed in Franklin until a clear plan is in place’.1126

1. 15 November 2019—The Ashley Youth Detention Centre psychologist documents her concerns about Albert and Finn in a letter to the Centre Manager

With the support of her supervisors in the Department to raise concerns, the Centre’s psychologist sent a letter to Mr Ryan on 15 November 2019.1127 This letter was also copied to the Director of Nursing, Statewide Forensic Mental Health Services, Department of Health and Barry Nicholson, Group Director, Forensic Mental Health and Correctional Primary Health Services, who were senior health staff in the psychologist’s reporting line.1128

The letter summarised ‘previously voiced concerns’ and identified the following concerns associated with the management of Albert and Finn:1129

• There was a ‘[h]igh risk of harm and traumatisation to youth placed in the Franklin Unit, perpetrated by [Albert] and [Finn], on particularly younger residents, those smaller in physical stature and those with disabilities’.1130
• There was a ‘chronic sense of being unsafe and risk of vicarious trauma to [Centre] residents in general who are aware of the incidents of intimidation and sexualised behaviour in the Franklin Unit and who are also aware of the lack of sanctions associated with these incidents’.1131
• Current practice risked reinforcing to Albert, Finn and other young people that this kind of behaviour was an acceptable way ‘to get [one’s] needs met and is a successful strategy to keep one safe from the abuse of others’.1132
• There was ‘insufficient and [in]accurate documentation’ at the Centre that could lead to courts or community agencies receiving misleading information.1133
• There was a range of long-term risks, including ‘significant risk of physical and psychological harm, poor staff morale, and the corruption of the system entrusted with the care of some of the most vulnerable youth in the state’.1134

To mitigate those risks, the psychologist stated that ‘clear interventions and consistent enforceable sanctions’ were required as ‘a matter of priority’.1135 The psychologist identified a need to formally assess whether Ashley Youth Detention Centre was sufficiently resourced to address Albert and Finn’s specific needs and to prepare a management plan.1136

The psychologist also contended there was ‘evidence of lack of consultation and adherence to the decisions and recommendations made by the Centre Support Team and Multi-Disciplinary Team’.1137 She expressed her view that it was essential all professional disciplines across the Centre support implementing the management plan.1138

The psychologist recommended that, as an interim measure, other young people should not be placed in the Franklin Unit until safe measures had been implemented ‘to ensure their safety with regards to the abolishment of the clear pattern of “ganging-up” and victimisation’.1139

Mr Ryan gave evidence that the Director of Nursing and the Nurse Unit Manager had read the psychologist’s letter to him, dated 15 November 2019, and did not accept its assertions.1140

Emails sent in the week following 15 November 2019 indicate that the Director of Nursing and Mr Ryan spoke about the psychologist’s letter. In his statement, Mr Ryan noted an email he had sent to Piers (a pseudonym), who held a leadership role at Ashley Youth Detention Centre at the time, which reads in part that ‘[the Director of Nursing] states that he has been over [the psychologist’s] clinical notes, leading [the Director of Nursing] to state “I believe this to be an operational issue”’.1141

In evidence to us, the Nurse Unit Manager disagreed with Mr Ryan’s recollection that she reviewed the psychologist’s letter at the time, stating that she did not see the psychologist’s letter before 4 February 2020.1142 She did, however, recall a conversation with the Director of Nursing about ‘an alleged sexualised behaviour incident which occurred in early August’, but could not recall the exact date.1143 The Nurse Unit Manager told us that during this conversation, she expressed her opinion that she did not interpret the behaviours of Albert and Finn to be ‘a serious sexual assault’.1144 The Nurse Unit Manager told us she formed this opinion after she reviewed the CCTV footage and spoke with the young people in detention (including Henry), who she reported ‘all said that they were “just mucking around”, and that there was no intent to cause anybody harm’.1145 The Nurse Unit Manager said that, in hindsight, she believed ‘this was probably “bravado” and an attempt to deflect possible retaliation on [Henry’s] part’.1146 The Nurse Unit Manager stated that she would not have done anything differently, but had she been privy to all the information at the time, she could have supported the psychologist in monitoring Henry’s wellbeing.1147

The Director of Nursing also disagreed with Mr Ryan’s recollection, stating that he in fact agreed with the psychologist’s concerns.1148

Mr Brown could not recall the 7 August 2019 incident and retired from the Department in October 2019.1149

There is evidence to suggest that in response to the letter, Mr Ryan told the psychologist that a task team would be created to develop an intervention plan for Albert and Finn.1150

In an email to Piers on 22 November 2019, Mr Ryan noted that he had spoken with the psychologist on 21 November 2019 to discuss ‘action items’ and that ‘she appeared pleased’.1151

Mr Nicholson also told us the concerns the psychologist raised in her letter of 15 November 2019 were legitimate clinical concerns.1152 He stated that these concerns should have been taken seriously but were not.1153

We return to the discussion between the Department, the psychologist and the Centre below (refer to January 2020).

1. Early December 2019—Behaviour management programs are initiated for Albert and Finn

In late November 2019, the Multi-Disciplinary Team tasked Alysha and the psychologist with creating and implementing an intensive behaviour management program for Albert and Finn.1154 In early December 2019, the psychologist and Alysha conducted a review into Albert and Finn’s behaviour over the preceding 12 months.1155

Alysha told us that as part of their review she and the psychologist reviewed the CCTV footage of the incident and other incidents from 7 and 8 August 2019.1156 Their review indicated there were five other incidents of intimidating behaviours in that period, including sexualised behaviour.1157 Albert and Finn were involved in all these incidents.1158

Alysha recalled that she and the psychologist also identified a series of incident reports prepared by youth workers that noted conversations in which Finn discussed serious sexual abuse perpetrated by Finn and Albert against younger and smaller boys in the Franklin Unit.1159 Alysha told us that those incident reports were marked as ‘recorded incidents’ and left blank in a number of sections, including regarding notifications, CCTV footage, the involvement of other agencies and further action to be taken.1160 Among these incident reports were documents lodged on 9 and 10 August 2019 in which staff reported discussions between detainees about the 7 August 2019 incident, as well as other harmful sexual behaviours by Albert and Finn.1161 We understand those reports cover the same incidents as those described above.

Alysha told us that she and the psychologist immediately notified Mr Ryan and Piers about the numerous incidents involving Albert and Finn.1162 We understand this occurred on or around 6 December 2019.1163

Alysha’s view was that the ‘most urgent’ task was to ensure the safety of other children and young people in detention and provide intensive therapeutic interventions for Albert and Finn.1164 Alysha told us she was concerned the issues documented in the incident reports had not been reported to police and that children were still being placed in the same unit as Albert and Finn.1165

Alysha’s evidence was that Mr Ryan and Piers ended the review she and the psychologist were conducting.1166

We asked Digby, the former co-manager of Professional Services, about the response to concerns raised about Albert and Finn. He responded that he was aware the psychologist, Alysha and another member of staff ‘undertook to develop an appropriate tailored management plan to meet the needs of both boys’ but that to his knowledge, the plan was never finalised.1167

Piers told us that Alysha and the psychologist were restricted from accessing files on advice from Mr Ryan.1168 Piers recalled the reason for that advice to be:

Prior to this both staff were freely accessing said files without authority and in some cases, it appeared to have no immediate bearing on their workloads especially in relation to the role that Alysha was employed to do.

In the case of [the psychologist], she was employed by Forensic [Mental] Health and as such being a separate department, there was a protocol to accessing clients’ files.

However, to compensate for this, a daily information meeting was started between [the psychologist], Operations Manager and Operations Coordinator to brief on incidents or concerns from previous shifts. She did have unrestricted access to incident reports and [Centre Support Team meeting] minutes.

Both staff were able to move forward with access to any files that they considered important to their work, however they needed to seek authority from their manager to do so.1169

In relation to developing a behaviour management plan for Albert and Finn, Mr Ryan told us that although he was aware Alysha and the psychologist were tasked with undertaking a review of Albert and Finn’s behaviours, he was not aware they were accessing ‘any and every file they wished, against the parameters’ set by the managers of the Professional Services Team.1170 He told us:

I spoke with [the co-managers of the Professional Services Team] about the unfettered access to files. Both assured me that this was not agreed to with anyone, but that their office was to work with [the psychologist] in preparation of the Plan. Both [managers] felt that … [Alysha] granted access to any file or correspondence sought and that this was against their set parameters. Both indicated that they would speak with all parties involved.1171

Mr Ryan denied that he interfered with the development of a behaviour management plan for Albert and Finn.1172 We understood him to mean that he did not interfere unreasonably or without justification, noting that he did engage with the managers of the Professional Services Team to raise concerns about access to files outside of ‘set parameters’.1173

1. Early December 2019—Staff continue to raise concerns about Albert and Finn

Alysha told us that after speaking with Mr Ryan and Piers on 6 December 2019, she notified the Advice and Referral Line of all the incidents involving Albert and Finn.1174 The psychologist also made a mandatory report to Child Safety Services on 6 December 2019 about the 7 August 2019 incident involving Henry.1175 On the same day, the psychologist emailed Mr Ryan stating that, following the discovery of the incident reports—which contained allegations of attempted rape and verbal threats of rape, incidents of sexual favours performed for compensation, and that sexual frustration was being taken out on younger residents in the Franklin Unit—she had made mandatory reports to Child Safety Services and the Commissioner for Children and Young People.1176

By December 2019, Ms Honan had assumed the role of Director, Strategic Youth Services (now Director, Youth and Family Violence Services).1177 On 6 December 2019, Mr Ryan forwarded to Ms Honan the psychologist’s email about her report to Child Safety Services.1178 Mr Ryan told Ms Honan that he did not agree with the psychologist’s assertions.1179 He also told Ms Honan that he had urged the psychologist to be cautious until he had checked the Centre Support Team records, but that the psychologist ‘declined to wait and said she had no option but to report those findings to [Child Safety Services]’.1180 He concluded the email by writing that the psychologist had ‘strong, emotive opinion in respect to this matter’ and that the Director of Nursing and the Nurse Unit Manager had recently disagreed with the psychologist.1181

Alysha told us that, on both 5 and 6 December 2019, she called Ms Honan’s Executive Officer to tell her about the incident reports and Mr Ryan and Piers’ response.1182 Alysha recalled that she told the Executive Officer she wanted to contact police about the matter immediately, but the Executive Officer told her to wait and to speak with Ms Honan the following week.1183 On 6 December 2019, Alysha also emailed the Executive Officer, stating:

I have reached a point where if I lose my job for reporting practices in place, it will be worth it to shine a light on the issues and practices that are currently in place at Ashley. Someone would need to further examine all residents incident reports to get a full picture of the lack of adequate documentation, follow up and interventions put in place to support staff, victims and perpetrators of said incidents.

Please note that it is my understanding there is currently [paper-based] handover and incident reports at Ashley. There are only originals and no copies electronically or paper based.1184

Alysha sent photographs of the incident reports to the Executive Officer.1185

In her response of the same date, the Executive Officer stated that she appreciated Alysha giving Ms Honan ‘an opportunity to discreetly investigate this first before contacting external agencies’ and assured Alysha that Alysha had met her duty of care.1186

1. 6 December 2019—The Ashley Youth Detention Centre psychologist again reports harmful sexual behaviours to the Commissioner for Children and Young People

On 6 December 2019, the Centre’s psychologist again contacted Commissioner McLean after discovering the incident reports related to Henry.1187 The psychologist provided the Commissioner with the spreadsheet of incidents she had prepared in August 2019.1188 The psychologist was troubled that nothing had happened to manage Albert and Finn’s behaviours, despite her letter of 15 November 2019 to Mr Ryan outlining her concerns.1189

On the same day, Commissioner McLean contacted Ms Honan to discuss the psychologist’s disclosure.1190 Ms Honan confirmed she was aware of concerns but did not have all the information.1191 Ms Honan also confirmed that Mr Ryan had assured the immediate safety of all detainees over the weekend and that she would go to the Centre on the next business day to access information with a view to initiating a Serious Events Review Team review.1192

Commissioner McLean expressed support for Ms Honan’s approach during that conversation.1193 Commissioner McLean commented that it seemed to her that the motivation for examining unwanted sexual behaviours among children and young people in detention ‘was low’ and ‘perhaps influenced by a custodial environment’.1194 We understand this comment to mean Commissioner McLean was concerned that little attention was paid to harmful sexual behaviours at the Centre and that this attitude may have been influenced by a custodial rather than therapeutic attitude in the Centre.

1. 9–10 December 2019—The Director, Strategic Youth Services initiates a review into the 7 August 2019 incident involving Henry

Alysha told us she met with Ms Honan on 9 December 2019.1195 Alysha recalled that Ms Honan said the Department would conduct an internal investigation and report the matter to the police if necessary.1196

On the same day, Commissioner McLean followed up with Ms Honan, who confirmed there was a need for a Serious Events Review Team review.1197 Commissioner McLean supported initiating a review and advised Ms Honan she would write to the Department about the matter with the potential to refer it to the Custodial Inspector.1198

On 10 December 2019, Commissioner McLean wrote to Secretary Pervan to advise him of the psychologist’s concerns, enclosing the psychologist’s supporting material.1199 Commissioner McLean further advised of her contact with Ms Honan and of her support for an immediate review.1200 Commissioner McLean requested that she be kept up to date with the Serious Events Review Team process and advised that she may refer the matter to the Custodial Inspector.1201

We have received no evidence that the Custodial Inspector was notified of this incident or any other concerns the psychologist raised. During our public hearings, the Custodial Inspector, Richard Connock, told us he was not sure whether he had been informed at the time that the review was being conducted, but he agreed it was the kind of thing that would have been important for him to have been aware of.1202

We note that on 13 December 2019, there was an incident where three young people detained at Ashley Youth Detention Centre accessed a roof, there was a stand-off, and the three young people were subsequently ‘unit bound’, with allegations of staff falsifying isolation records (we discuss this incident and the Centre’s response in Case study 3).1203

1. Mid-December 2019—The Serious Events Review Team investigates the 7 August 2019 incident

The Serious Events Review Team’s investigation into the 7 August 2019 incident involving Henry began in December 2019.1204

The terms of reference for the review were as follows:

Background and Services History

Review the process applied in recording, investigating, assessing and referral to required services of the alleged incident of sexual assault upon [Henry] in [Ashley Youth Detention Centre] in August 2019.

Determine and comment on the post incident management of this incident both for the alleged perpetrators, victim and other residents’ safety and wellbeing.

Assessment

Consider and analyse the presence/absence and quality of recorded information and assessments which guided the decisions made with regard to the placement, safety, referral to police/[Tasmanian Health Services], case planning and post incident management of [Henry] and others allegedly involved in this matter.

Planning, Services and Communication

Describe and analyse the quality of communication between [Ashley Youth Detention Centre] and other key internal and external stakeholders/service providers in this case.

Make comment on case processes, planning, and service provision and how these have served (or otherwise) to protect and enhance [Henry]’s safety and well-being at this time and over time.

Compliance with Legislation and Policy

Determine whether [Ashley Youth Detention Centre] has fulfilled its responsibilities as articulated in the Youth Justice Act 1997, Standard Operating Procedures and agency policy.

Findings and Draft Recommendations

Articulate findings from this review and provide draft recommendations regarding any actions that should be taken to address issues identified in the review, as they relate to the above Terms of Reference.1205

Veronica Burton, a former Serious Events Review Team member, conducted the review and wrote the final report. We heard evidence about the difficulties that Ms Burton and others experienced when seeking to access records relevant to the review.

As part of the review, Ms Burton read a wide range of documentation, including electronic and paper files, email communication, meeting minutes and daily diaries, and watched CCTV footage.1206 She also considered relevant legislation, policies and procedures.1207 Interviews were conducted with past and current Centre staff, including management.1208 We note that Mr Ryan said he was unwell and on extended leave during the period Ms Burton carried out the review and was largely unable to participate or contribute to the review process.1209

Both Alysha and Ms Burton told us about an occasion during Ms Burton’s review where they said Piers prevented Ms Burton from accessing files stored in a filing cabinet and told her that he could not find other files she requested because they had been archived.1210 Ms Burton told us that some of these records were provided by Stuart Watson when he replaced Mr Ryan as Centre Manager.1211 Ms Burton recalled that during her review, she was prevented from speaking directly with Henry and therefore, never heard his version of the incident.1212

Piers could not recall the Serious Events Review Team attending the Centre to discuss the 7 August 2019 incident.1213 He said that ‘at no time would I have restricted them from accessing any files or reports and would have made available to them what was available to me’.1214

Ms Burton also told us that Piers provided her with incident reports about the 7 August 2019 incident.1215 She believed these reports were not originals and had been rewritten.1216 Ms Burton told us she received a second set of incident reports from Alysha.1217 Ms Burton recalled that second set included different details about the incident, including the length of time the detainees were left unsupervised, who the matter was reported to and the severity of the incident.1218 Ms Burton also told us the second set ‘minimis[ed] how the … bottle was used’.1219 Ms Burton told us that her usual practice was to scan any hard-copy paper files and save them to the secure file system for the Serious Events Review Team and to then file the hard copies.1220 She stated she does not have ‘a clear memory of exactly doing that with those documents, but that was the process that I followed, so I can say with … almost 100 per cent confidence that that’s what occurred’.1221 Ms Burton stated that she no longer had access to the Serious Events Review Team files after leaving the Department.1222 We have only received one version of the relevant incident report from the Department, which Ms Burton believed to be the version she received from Piers.1223

Commenting generally on her engagement with Ashley Youth Detention Centre staff when conducting reviews into incidents at the Centre, Ms Burton told us she depended on the cooperation of Centre management to gain access to records and interviewees.1224 Her experience was that it was sometimes difficult to access all the information she needed, including interviewing children, without staff assistance, saying ‘I couldn’t go anywhere in the centre unless somebody took me because every door is locked and I needed somebody to escort me wherever I needed to go’.1225

Ms Burton also observed that her access to children and young people in detention was limited because they were usually housed in secure units and so she would ‘often only get the staff version of events’.1226 She said she was often not provided personal information or history about the young people involved.1227 She expressed concerns to us about an approach at the Centre of a ‘clean slate’ philosophy that did not view children’s history of significant trauma as relevant, noting ‘[it] is no way to run a therapeutic service’.1228

Ms Burton noted that while the Centre had an electronic filing system, it was not in use and ‘pretty much everything was paper file’.1229 Ms Burton told us that she depended on the Centre’s management to make paper files available to her and noted that this was different from other agencies, such as Child Safety Services, where Ms Burton would have automatic access to all electronic records.1230 Ms Burton recalled that in her dealings with Ashley Youth Detention Centre, she often encountered issues of missing documents, a lack of records and, if records were provided, concerns about their accuracy.1231 For example, Ms Burton recalled that, ‘because … file-keeping was so poor’, she would often depend on management to identify which staff were rostered on during an incident under review.1232

1. December 2019—Ray is moved to the Franklin Unit

Towards the end of his third month at the Centre, Ray was transferred to the Franklin Unit because the unit he was in had to be evacuated.1233 At this time, Albert and Finn were still housed in the Franklin Unit.1234 Minutes of the Centre Support Team meeting held two days after Ray’s transfer to the Franklin Unit showed the team did not raise the possibility of transferring Ray out of the Franklin Unit after the incident that caused the transfer.1235

We note that at this point, there had been a Multi-Disciplinary Team recommendation that no young people be placed with Albert and Finn until both had received appropriate interventions. That recommendation was made about one month before Ray was placed in the Franklin Unit (on 14 November 2019). The Centre’s psychologist reiterated this recommendation following the placement of Henry in the Franklin Unit in the week before Ray’s transfer to the Franklin Unit. We also note, as outlined, that when Ray was admitted to the Centre, the psychologist had made a general recommendation about the need to ‘carefully consider’ Ray’s unit placement considering his mental health difficulties.1236

1. December 2019—The Multi-Disciplinary Team raises concerns about Ray’s transfer to the Franklin Unit

In the days following Ray’s transfer to the Franklin Unit, minutes of a Centre Support Team meeting recorded that Ray had ‘settled well into Franklin’.1237

Minutes of a Multi-Disciplinary Team meeting held two days later included the following comments, under the heading ‘What are we worried about?’:

• ‘Recent move to Franklin could be a concern for [Ray]’.
• ‘[Ray] is highly suggestible to external influences’.
• ‘There are concerns about the current mix of residents in Franklin’.1238

The following comments were made about the recommended next steps for Ray:

• ‘Ideally to be moved from Franklin due to [Ray] being easily coerced and his ongoing mental health symptom’.
• ‘Reside with peers who are not going to influence [Ray] in an adverse manner’.
• ‘Youth workers reporting dysregulation. It is recommended a unit move’.1239

Around this time, Ray was made subject to a Very Close Supervision order.1240 A subsequent issues briefing (discussed below) indicates that this decision was made ‘during Centre Support Team and/or [Interim Centre Support Team] meetings’, which appears to be backed up by Centre Support Team meeting minutes of this period.1241 Centre Support Team meeting minutes around this time indicate some discussion about Ray’s placement in the Franklin Unit, with a set of minutes noting:

Concerns regarding [Ray] being housed in Franklin were tabled, but staff felt that by putting [Ray] on [Very Close Supervision] this would eliminate the concerns raised around him possibly being influenced by others in the unit, particularly given his unsettled mental health.1242

We asked Mr Ryan about the decision to place Ray in the Franklin Unit. He responded it was a ‘difficult’ time at the Centre, that there were a ‘number of very challenging residents’ and that Ray’s behaviours were ‘extreme’.1243 He said the options following the Multi-Disciplinary Team’s recommendation that Ray be moved from the Franklin Unit were either to move Ray out of the Franklin Unit or to keep him in the Franklin Unit under Very Close Supervision.1244

Mr Ryan said that to move Ray from the Franklin Unit to a less secure unit would have had ‘ramifications for [Ray] and for other residents and staff’.1245 Mr Ryan described Ray’s continued placement in the Franklin Unit under Very Close Supervision as ‘the “least worst” option’.1246 Mr Ryan also said a separate incident that occurred two weeks after Ray’s transfer to the Franklin Unit meant it was ‘very difficult to safely move [Ray] from Franklin to a less secure unit’.1247

The Very Close Supervision order required a supervising youth worker to always be within five metres of Ray when he was outside a locked building.1248 We are unclear as to why, in this instance, the Very Close Supervision order seemingly applied only when Ray was outside, given he was likely at the same or increased risk of harm by other young people when inside a unit. However, it appears from the relevant procedure that this was standard practice.1249 The practice was perhaps directed at managing an escape risk rather than protecting young people from harm.

Minutes of a Centre Support Team meeting held after the Very Close Supervision order was made recorded that he was ‘travelling well in Franklin’ but that he did ‘keep to himself’.1250

1. 2 January 2020—An incident occurs involving Ray, Albert and Finn

Approximately three weeks after Ray was transferred to the Franklin Unit, he was involved in a verbal altercation with Albert, after which Ray initiated a physical altercation with Albert.1251 Finn also took part in this altercation and Ray received multiple punches to the head from Albert and Finn.1252 This incident occurred indoors.1253

Documents prepared in the days following the incident show that Alysha and the psychologist believed Ray was provoked to violence when Albert and Finn made light of Ray’s mental health difficulties.1254 The incident reporting form invited the reporting youth worker to select the option ‘the young person was incited/provoked by other young person/s’ under the heading ‘moderating factors’, but this was not selected.1255

We have reviewed the CCTV footage of this incident, which does not contain audio.1256 We consider the CCTV footage matches the account provided in the incident report prepared after the incident, except as noted next.

Immediately before the incident, Ray displayed signs of stress or anxiety. These included signs that the Centre’s psychologist had identified to Operations Management at the beginning of Ray’s admission.1257 The incident report stated that each of the three staff members present attempted to stop the incident by speaking to the three young people but that the incident did not end until three more staff members arrived after a ‘code black’ was called.1258 It is not apparent from the CCTV footage that any staff member attempted to de-escalate or redirect Ray—for example, by moving him away from other young people—as he began to show signs of distress before the incident. We accept, however, that it was difficult to understand any verbal de-escalation techniques staff might have used without audio available to us.

The arrival of extra staff members cannot be seen in the CCTV footage and appears to have happened outside the room. The CCTV shows that one of the three original staff members eventually intervened to redirect Ray out of the room and away from the incident. It is unclear from the footage why that staff member took several minutes to act in this way, especially when he appears to have finally acted without support or help from other staff. We were concerned to see that none of the original staff members present appeared to try to remove, restrain or redirect any of the three young people during lulls in the incident, including one instance where Albert left the room entirely (before returning to engage in the incident again). Alysha told us that immediately following the incident involving the three young people:

… I spoke to Patrick Ryan and [the then Acting Manager, Professional Services and Policy] about the need to report the assault to the police as well as the need to get Ray medically assessed. They insisted that it was a ‘fight’ between residents and that no police notification was required. He was not assessed by a doctor, nor was this attack reported to the police.1259

Alysha believed Ray was concussed, did not attend school due to the concussion and did not get medical care.1260

The Nurse Unit Manager’s notes from 2 January 2020 in relation to Ray indicate that ‘[n]il signs of concussion noted … and author advised [Ray] that if he experienced any of these symptoms to notify staff immediately’.1261 We are unclear whether Ray required any more help or got any further medical assistance.

The incident reports for each of Finn, Albert and Ray include a note that referral to police may be ‘pending’, but no further comments are made about when or if a referral would occur.1262 Ms Honan told us the incident was not reported to police ‘[d]ue to [Ray’s] mental health condition and that he was the instigator of this assault and other less serious unprovoked assaults towards detainees’.1263

Finding—Ray’s (a pseudonym) placement in the Franklin Unit at Ashley Youth Detention Centre in December 2019 was inappropriate and exposed him to preventable harm

Although there was no evidence before us that Ray was subjected to harmful sexual behaviours at Ashley Youth Detention Centre, he was involved in a physical altercation.

We are concerned that Ray was placed in the Franklin Unit in the first place and then not moved once concerns were raised. We hold these concerns because the Centre was aware of:

• Ray’s vulnerabilities as outlined by the Centre’s psychologist on Ray’s admission to the Centre
• concerns raised by the Multi-Disciplinary Team about the decision to place Ray in the Franklin Unit
• the harmful sexual behaviours of detainees in the Franklin Unit, particularly Albert and Finn, which at the time of Ray’s placement in the unit had not been properly addressed
• Ray ‘keeping to himself’ in the Franklin Unit, which could suggest Ray did not feel safe.

We acknowledge the evidence that Ray’s behaviour made him a risk to other detainees and that placing Ray in the Franklin Unit with Albert and Finn was the ‘least worst’ option. However, while we acknowledge that placement decisions at Ashley Youth Detention Centre likely involve a range of difficult decisions, we are not convinced that appropriate consideration was given to Ray’s ongoing safety in the Franklin Unit.

It is not apparent to us that the Centre considered transferring Ray to another unit under Very Close Supervision—the options appeared to be seen as Ray either being in a different unit or in the Franklin Unit under a Very Close Supervision order. We note that after the incident Ray was moved to another unit.

We are also not convinced that the Very Close Supervision order—which we understand to have related only to Ray’s movements in outdoor areas of the Centre—was enough to ensure Ray’s safety if he remained in the Franklin Unit. Having reviewed the CCTV footage of the incident between Ray, Albert and Finn, it does not appear that any youth worker was assigned to supervise Ray inside on that day. More appropriate supervision may have helped avoid the incident.

We are also concerned that Albert and Finn, who appeared to present similar threats to Ray, were not on Very Close Supervision orders.

At our public hearings, Ms Honan agreed the harm that Ray suffered in the incident was entirely preventable.1264 She also acknowledged there ‘could have been other strategies put in place to reduce the likelihood of [the incident] occurring’.1265 We agree and further consider that earlier de-escalation and intervention to stop the incident once it began would have minimised the degree of harm Ray suffered.

1. 3 January 2020—The Centre Support Team discusses the incident involving Ray, Albert and Finn

Staff logs and minutes of an Interim Centre Support Team meeting held the day after the 2 January 2020 incident say that Ray was moved to another unit on the night of the incident.1266 A later issues briefing to the Secretary stated that Ray was moved from the Franklin Unit on 2 January 2020 in response to a different incident of property damage the day before the incident.1267 According to the Ashley Youth Detention Centre daily roll, Ray was not moved to the new unit until a day later (3 January 2020), suggesting that

he spent another night in the Franklin Unit immediately after the incident.1268 We do not know the reason for the discrepancy in these records, but they appear to be an example of inconsistent and poor record keeping at the Centre.

The minutes of the 3 January 2020 Interim Centre Support Team meeting state:

• ‘Staff spoke to residents involved [in the incident in the Franklin Unit] and all agreed that it was over and they were happy to move forward’.
• ‘[Ray] stated that he wished to stay in [the new unit] and it was decided that he could stay on the terms that there were no problems otherwise he would return to Franklin’.
• ‘[Albert] and [Finn] both met with [Ray] separately for mediation … and they were all happy to move on from this’.
• Ray was told that ‘if he wished to move back to Franklin at any stage that he was welcome to do so’.1269

Albert, Finn and Ray’s involvement in the incident was classified as a detention offence and all three young people attended conferences in the days after the incident.1270 It is not clear to us whether the detainees’ individual circumstances, including Ray’s mental health condition, were considered when determining an outcome for these young people.

1. 3 January 2020—A staff member meets with the Director, Strategic Youth Services to discuss concerns about Ashley Youth Detention Centre

Alysha told us she met with Ms Honan again on 3 January 2020 to discuss her concerns about the Centre’s management of harmful sexual behaviours and Ray’s safety.1271 On 6 and 7 January, following this meeting, Alysha emailed Ms Honan copies of Multi-Disciplinary Team meeting minutes in which concerns about Franklin Unit placements were raised, along with a copy of the psychologist’s letter to Mr Ryan of November 2020 in which the psychologist highlighted the risk of placing vulnerable people in the Franklin Unit.1272

1. 5 January 2020—Ray attempts to escape from Ashley Youth Detention Centre

Three days after the incident involving Albert and Finn, Ray climbed an internal fence in an apparent attempt to escape from the Centre.1273 We understand that Ray was still the subject of a Very Close Supervision order at that time, requiring a youth worker to be within five metres of Ray while he was outside a locked building.1274

The Operations Coordinator on shift, Chester (a pseudonym), emailed the Operations Manager about the incident.1275 Chester reported that Ray was stopped, ‘walked back’ to his unit ‘unassisted’ and was placed in isolation for 30 minutes.1276 A decision was made to place Ray on ‘unit bound’ until the next day’s Centre Support Team meeting.1277 We discuss the practice of ‘unit bound’ in Case study 3. According to Chester’s email, this incident immediately followed an earlier one involving Ray, in which he attempted to steal something from an out-of-bounds area.1278

In response to a notice to produce, the Department provided us with a copy of what appears to be a complete bundle of all incident reports relating to Ray for the relevant period.1279 In that bundle, we received a copy of the incident report about the earlier incident.1280 We have not been provided with a copy of the incident report relating to the escape attempt or associated isolation documents. It is unclear why we did not receive a copy of the incident report and associated isolation documents relating to this incident. This is concerning because we received allegations that staff tackled and handcuffed Ray.1281

Alysha told us she spoke to Ray after he returned to the unit.1282 She recalled that Ray told her he had tried to escape because ‘no-one was keeping him safe’.1283

1. 6 January 2020—The Centre Support Team discusses the incident involving Ray, Albert and Finn

A Centre Support Team meeting was held four days after the 2 January 2020 incident involving Albert, Finn and Ray.1284 In relation to Ray, the minutes record that Ray ‘is always apologetic after incidents’ and notes that work was underway to refer Ray’s case to a Senior Quality and Practice Advisor.1285 The minutes note that Ray had been ‘unit bound’ since his escape attempt the day before but do not record a decision to remove him from ‘unit bound’ at that time.1286 In relation to Finn and Albert, the minutes record separately for both of them that ‘[he] has had a great week aside from the one incident that let his week down’.1287

The Centre’s psychologist was present at this meeting.1288 We have viewed an email sent by a Case Management Coordinator and a member of the Centre Support Team, in the days following this Centre Support Team meeting. In that email, the Case Management Coordinator raised his concerns about how the psychologist’s presence was managed.1289 We understand that some members of the Centre Support Team requested the psychologist’s presence because her expertise was required in relation to Ray in particular.1290 The email recorded that Maude initially declined to allow the psychologist to attend, but when Centre Support Team members ‘insisted’, Maude agreed on the condition that the psychologist only listen and not speak.1291 The email also recorded that Mr Ryan agreed with the approach.1292 Alysha’s evidence was also that the psychologist had been allowed to attend on the condition that she not contribute to the discussion.1293

We asked Maude for her response to the allegation that she prevented the psychologist from contributing to the Centre Support Team meeting.1294 Maude did not respond to our request for a statement.

1. 6 January 2020—A referral is prepared to engage a Senior Quality and Practice Advisor

Also on 6 January 2020, Mr Ryan requested that Ray be referred to a Senior Quality and Practice Advisor.1295 It appears that Ms Honan either approved or directed that a referral be prepared.1296

On the same day that Mr Ryan instructed the Case Management Coordinator to prepare a referral to the Senior Quality and Practice Advisor, Alysha emailed Ms Honan requesting a meeting to discuss the incident between Ray, Albert and Finn, and the associated response.1297 The email said the Multi-Disciplinary Team had ‘strongly advised against’ placing young people who were ‘highly vulnerable, suggestable and at risk’ in the Franklin Unit, ‘for their own safety’.1298 The email also notified Ms Honan of Ray’s escape attempt, which had occurred when Ray was under Very Close Supervision.1299 Alysha queried the value of making a referral to a Senior Quality and Practice Advisor when previous recommendations about Ray had not been followed.1300

Ms Honan’s response to Alysha was that Mr Ryan had asked Ms Honan for her ‘opinion about engaging a [Senior Quality and Practice Advisor] … because [staff] were at a loss as to how to manage [Ray]’.1301 Ms Honan suggested that a referral to the Senior Quality and Practice Advisor would ‘shine a light on the adverse responses to the advice of the Professional services staff to the [Operations] Managers’.1302 We understand Alysha also spoke with a member of the Senior Quality and Practice Advisor team, who shared a similar view to Ms Honan about how a referral could assist with the internal dynamics at the Centre.1303

In her emails with Ms Honan of that day, Alysha continually expressed her serious concerns about disregard for the advice of the Professional Services Team and the Multi-Disciplinary Team and failure to comply with policy, including the following:

• Staff were not following the Multi-Disciplinary and Professional Services Teams’ advice about how to manage Ray (contrary to the suggestion that staff were simply ‘at a loss’ about how to manage Ray).1304
• Decisions to place Ray and others in the Franklin Unit were directly contrary to advice, and the incident between Ray, Finn and Albert would not have occurred had Multi-Disciplinary Team recommendations been followed.1305
• Operational staff had failed to comply with the terms of the Very Close Supervision order, enabling Ray to attempt an escape in the days following the incident with Finn and Albert.1306
• The Centre’s psychologist had been instructed not to speak at the Centre Support Team meeting in relation to next steps for Ray.1307

We understand that the Centre’s psychologist reported the incident to Child Safety Services four days after the incident.1308 The report was made in conjunction with other reports the psychologist made involving Albert and Finn (as discussed earlier).1309 Specifically, the psychologist reported that Ray had significant mental health difficulties and was placed with Albert and Finn contrary to recommendations.1310 The psychologist also reported that the response from youth workers was ‘very delayed’ and that multiple workers were present during the incident but did not intervene.1311

The psychologist also raised the matter as part of a broader report of issues to her line manager in the Department (which we discuss further in this case study).

1. 7 January 2020—A management plan is developed for Ray

After the 2 January 2020 incident involving Ray, Albert and Finn, Ms Honan ‘formally instructed’ Mr Ryan to ask Alysha (in consultation with the psychologist) to ‘set out clear strategies to manage [Ray] and also develop some recommendations’.1312 This was to occur in conjunction with the referral to the Senior Quality and Practice Advisor.1313

On 7 January 2020, Mr Ryan instructed Digby, the Manager, Professional Services and Policy, to prepare a management plan for Ray.1314

Ray’s final management plan, prepared by Digby, provided that:

• Ray was to remain in a specified unit (not the Franklin Unit) ‘for the time being’ and that the psychologist and others were to be consulted ‘if practicable’ before a placement decision affecting Ray was made (such as adding others to his unit).1315
• Ray was to remain under Very Close Supervision ‘until determined otherwise by both [the Multi-Disciplinary Team] and [the Centre Support Team]’.1316
• Operations staff were ‘to be reminded of their responsibilities’ in relation to Very Close Supervision, given Ray’s escape attempt.1317
• Alysha was to prepare a referral to a Senior Quality and Practice Advisor and provide operational staff with ongoing clinical support.1318

Much of the management plan covered recommendations from the psychologist working directly with Ray, which had already been raised with Centre staff at the beginning of Ray’s admission and which were listed in his existing care plan.1319 The management plan also provided that a behaviour chart was to be developed—a task that the psychologist had undertaken to complete in the days following Ray’s admission.1320 We understand from minutes of a Multi-Disciplinary Team meeting approximately 10 weeks after Ray’s admission that the behaviour chart was to be ‘reintroduced’ for Ray, suggesting its use had been discontinued.1321 We are unclear about whether its use was intended for a short period or what kind of use Centre staff made of it.

We asked Digby about the 2 January 2020 incident and the responses to it, including the referral to the Senior Quality and Practice Advisor. He responded that he knew ‘nothing about this matter’.1322 This is surprising given his role in preparing the management plan in response to the incident.

1. 8 January 2020—The Centre Support Team again discusses the incident involving Ray, Albert and Finn

On 8 January 2020, another Interim Centre Support Team meeting was held to discuss Ray, Albert and Finn.1323

In relation to Albert and Finn, the minutes of that meeting state:

In the follow up from this incident, both boys participated well in mediation and gave assurances that this behaviour will not occur again. During [Case Plan Review] both residents accepted their part in the incident. Conferencing will take place with all three residents involved in the incident. [The psychologist] and [Alysha] in consulting with staff post incident believe that there was considerable provocation from [Finn] and [Albert] in the lead up to the incident, but these details were not recorded on incidents for [the Centre Support Team]. Following discussion, it was felt that both [Finn] and [Albert] remain red until next [week’s] [Centre Support Team meeting] as they still pose a risk with their subversive/inciting behaviour.1324

In relation to Ray, the minutes noted he was still an escape risk.1325 A decision was made at the Interim Centre Support Team meeting to remove him from ‘unit bound’ (which we understand he had been since 5 January 2020, amounting to four days’ ‘unit bound’) in the interests of his mental health.1326 Ray was instead placed on an ‘individual program with operational staff taking him outside, one-on-one, with no other residents in the yard … when [staff] can operationally schedule it’.1327 As described in the section on isolation (Case study 3), we are concerned that ‘unit bound’ and ‘individual programs’ of this kind amount, in effect, to an isolation practice. We were not provided with details of Ray’s individual program as described here and remain unconvinced the individual program was any more supportive of Ray’s mental health difficulties than being ‘unit bound’. Ray remained under Very Close Supervision.1328

1. 8 January 2020—A staff member reports concerns about the response to harmful sexual behaviours to the Director, Strategic Youth Services

On 8 January 2020, an Ashley Youth Detention Centre staff member emailed Ms Honan with concerns about the culture and practices at the Centre.1329 The email stated: ‘I would take this information to the Manager of Ashley; however I feel that my concerns will be overlooked’.1330 In particular, this staff member outlined their concerns that Albert and Finn continued to engage in sexualised acts against young people, which had been ‘minimised by Patrick Ryan to the point where staff and other residents are now at risk of these two young people’.1331

The staff member also expressed concern that Operations Team staff and Mr Ryan were ignoring case management and the Centre’s psychologist, which was placing the ‘centre in danger’.1332 Ms Honan responded on the same day, saying the information would be taken into consideration.1333

1. January 2020—The Ashley Youth Detention Centre psychologist informs the Department of Health about the poor response to the behaviours of Albert and Finn

In the months before and throughout January 2020, there were many communications and meetings between the Centre’s psychologist and her superiors in the Department of Health about the operation of Ashley Youth Detention Centre.1334

The psychologist informed her superiors of her various concerns about bullying at the Centre, her professional opinion being ignored (therefore putting children and young people in detention at risk) and the poor management of Albert and Finn’s behaviours.1335 There were also several communications among her superiors at the Department of Health and between the Director of Nursing and Mr Ryan about those issues.1336

In various correspondence, Department of Health staff expressed or were reported to have expressed the following views about the psychologist’s communications:

• The psychologist had never worked in a custodial setting and had inadvertently got people offside by ‘explain[ing] the bullying which has been occurring’.1337
• The psychologist was a ‘guest’ in the custodial setting at Ashley Youth Detention Centre.1338
• Placement of young people is an ‘operational issue’.1339

The Nurse Unit Manager told us that working at Ashley Youth Detention Centre as a health practitioner is not the same as working in the community or any other correctional facility.1340

On 13 January 2020, staff from the Department of Health met with the Centre’s psychologist to explain the differences between working in a custodial setting and working in the community.1341 The Nurse Unit Manager and Mr Nicholson, Group Director, Forensic Mental Health and Correctional Primary Health Services, told us there were no specific policies and procedures for Department of Health employees working at Ashley Youth Detention Centre.1342 We note there has been no specific custodial training provided to Department of Health staff working at the Centre.1343

The former Head of Department, Forensic Mental Health Services, Department of Health, explained to us that Department of Health staff are not employees of Ashley Youth Detention Centre and are limited in the performance of their duties while in the prison system.1344 They said the reality is that custodial staff may refuse to accept medical advice because custodial staff have overall responsibility for children and young people in detention and ensuring the good operation of the Centre.1345

Secretary Pervan confirmed that the then Department of Communities retained the ‘overall responsibility’ for the health, safety and welfare of young people at the Centre during the relevant period.1346 This is reflected in the memorandum of understanding between the Department and Correctional Primary Health Services.1347

1. Observations—Department of Health’s response to concerns of harmful sexual behaviours

We are concerned the Department of Health did not attach enough weight to the issues raised by the Centre’s psychologist about the safety of children and young people in detention.

The response to the psychologist’s concerns appeared to focus on the role of the psychologist and the Department of Health staff in the Centre, rather than recognising:

• her expertise in harmful sexual behaviours
• the fact that young people in the Centre were displaying these behaviours
• there was a need to protect other children.

We saw little evidence of advocacy from Department of Health staff for the safety of children.

While we accept that the then Department of Communities was ultimately responsible for the operations of the Centre over this period, we consider this a lost opportunity to respond to the concerning behaviours of Albert and Finn.

1. 20 January 2020—The Secretary is briefed on concerns regarding Ray

Approximately three weeks after the incident between Ray, Albert and Finn, Kathy Baker, who was the Acting Secretary of the then Department of Communities for a short period at that time, signed off on an issues briefing to the Secretary titled ‘Concern for Ashley Youth Detention Centre (AYDC) resident [Ray] due to recent incidents’.1348 Mr Ryan prepared the issues briefing, which was cleared through Ms Honan and Mandy Clarke, Deputy Secretary, Children and Youth Services, Department of Communities.1349

The issues briefing:

• noted Ray’s mental health difficulties and health history1350
• briefly noted ‘recent’ incidents involving Ray, including the incident involving Albert and Finn and the escape attempt1351
• stated work was ‘underway to identify the triggers and management of [Ray] leading up to and during these incidents, with a referral being made for a Senior Quality and Practice Advisor review’1352
• stated that Ray was moved to the Franklin Unit for operational reasons over the period when the incident involving Albert and Finn occurred1353
• stated that the Manager, Professional Services and Policy, had prepared an updated management plan for Ray, which became operational in the week after the incident involving Albert and Finn1354
• clarified that before the updated management plan, Ray was the ‘subject of standard management’ through the Centre Support Team, Multi-Disciplinary Team and Case Plan Review1355
• stated that Ray was being ‘closely monitored and well supported by the on-site Psychologist and Professional Services Team. [Ray] will be reviewed again at [a Centre Support Team meeting] on 20 January 2020 unless an earlier review is required in the interim’.1356

The issues briefing did not acknowledge that:

• Professional Services and Health Team staff had raised several concerns about Ray since his admission to the Centre
• moving Ray to the Franklin Unit, and exposing him to Albert and Finn, was contrary to the advice of both the Professional Services Team and the Multi-Disciplinary Team
• while invited to attend Centre Support Team meetings that focused on considering and responding to Ray’s behaviours, the psychologist had been actively prevented from taking part in those meetings
• the Senior Quality and Practice Advisor referral was intended to specifically identify failures by Centre staff to follow clear recommendations about Ray’s care.

As described above, each of these issues was known within Ashley Youth Detention Centre and the Department at the time the issues briefing was prepared.

Ms Honan told us the purpose of the issues briefing was to outline the complexity of Ray’s needs and behaviour and the revised management approach for Ray given the escalation of incidents. She said the matters above were not expressly raised in the issues briefing as they were yet to be analysed and assessed as part of the Senior Quality and Practice Advisor referral relating to Ray.1357 This is consistent with what Ms Baker told us about her understanding of the issues briefing’s purpose.1358

While we accept the purpose of the issues briefing guided its content, we are concerned it did not, on the face of it, provide all relevant context for the concerns regarding Ray.

The ‘Secretary’s notation’ on the signed copy of the issues briefing records the following:

1. Thank you for the briefing and the ongoing care provided to [Ray], which is being managed on the advice of the Professional Services Team.
2. What is the timeframe for the [Senior Quality and Practice Advisor] review to be completed?
3. With a possible discharge date of 18 March 2020, can we please start preparing for [Ray’s] release and ongoing care for his condition outside of [Ashley Youth Detention Centre]1359

Given the issues briefing was signed off by Ms Baker, we understand this comment was not prepared or approved by Secretary Pervan.

Finding—The 20 January 2020 issues briefing on concerns regarding Ray at Ashley Youth Detention Centre was inadequate and incomplete

We are concerned the issues briefing to the Secretary about Ray, dated 20 January 2020, gave the impression that Ray’s behaviours had only begun to escalate immediately before the issues briefing and that Centre staff had acted in a timely fashion to address issues in a manner consistent with the Professional Services Team’s advice.

The briefing did not inform the Secretary that the Centre had been on notice of potential harm due to Ray’s vulnerabilities and the previous behaviours of Albert and Finn. It did not notify the Secretary that this potential harm eventuated in the 2 January 2020 incident.

Further, we are concerned the intended scope of the Senior Quality and Practice Advisor referral—being the need to identify and address breakdowns in internal processes and procedures that had caused recommendations of the Multi-Disciplinary Team and psychologist to be ignored—was not made explicit.

1. 28 January 2020—Ashley Youth Detention Centre engages a Senior Quality and Practice Advisor

Ms Honan approved the involvement of a Senior Quality and Practice Advisor, and the Quality Improvement and Workforce Development Team was advised of this, approximately four weeks after the incident involving Ray, Albert and Finn.1360

Ms Honan told us the Senior Quality and Practice Advisor’s review began in February 2020 but was not completed because of a restructure of the Quality Improvement and Workforce Development Team, staff redeployment and the outbreak of COVID-19.1361

1. 19 March 2020—The Serious Events Review Team reports its findings and recommendations about the 7 August 2019 incident involving Henry

The Serious Events Review Team’s report on the 7 August 2019 incident involving Henry, Albert and Finn was completed in March 2020.1362 There were more than 25 findings in the review team’s report, which covered decision making, incident management, supervision and support of children and young people in detention, communication, document and file management, workplace culture and staff support, training and supervision, and staffing resources.

The Serious Events Review Team’s key findings were:

• There was ‘disagreement and conflict’ among staff about the seriousness of the incident.1363
• The incident in question ‘constituted a sexual assault’ of Henry.1364
• The incident should have been urgently reported to police and Child Safety Services, consistent with best practice principles, legislation and the Department’s guidelines.1365
• Decision making in relation to the consequences for the offending child or young person in detention was ‘flawed and inconsistent with best practice principles, legislation and Departmental guidelines’.1366
• There were several issues concerning the completion of incident reports, including a lack of detail and critical information, and no evidence of review or approval as required by internal policy.1367 The Serious Events Review Team concluded that such failings had ‘the potential to expose the staff and young people to an increased risk of harm and the wider service system to internal and external criticism and a loss of credibility’.1368
• The Centre Support Team’s meeting minutes and the issues briefing provided to the Secretary did not ‘accurately portray the incident and, consequently, minimised its severity and indicated a concerning lack of understanding of sexual assault and its possible consequences’.1369
• Conferencing with Albert and Finn did not occur, which was a breach of the available guidelines and legislation.1370
• Anecdotal evidence suggested ‘the behaviour of the offenders may be impacting upon how they are managed by staff on a day to day basis which may in turn be placing residents, staff and the centre at risk’.1371
• Centre staff did not have a ‘comprehensive understanding of the issues around sexual assault’.1372
• A recommendation on Henry’s care plan that he not be placed with Albert or Finn had not been observed and, had it been, the incident would not have occurred.1373
• Albert and Finn should have been under a higher level of supervision, given their history of abusive behaviour.1374
• The use of Very Close Supervision was problematic and difficult to implement due to staff shortages and ‘differences of opinion’ among staff about when to apply it.1375
• The review experienced ‘significant difficulties’ obtaining information and interviewing staff; the ‘provision of information to the review and cooperation with the reviewers was so problematic in this case that it may have been deliberately obstructive’.1376
• Communications with executive management ‘did not accurately represent the incident and minimised the concerns which could lead to misconceptions, misunderstandings and poorly targeted and ineffective interventions’.1377
• ‘[O]pen and honest communication’ appeared to be ‘discouraged’ at Ashley Youth Detention Centre, and communications were ‘disrespectful and inappropriate’.1378
• The Centre’s filing systems were ‘inadequate, incomplete and confusing’ and did not ‘support services to young people’.1379
• There was a ‘concerning lack of training, support, debriefing and supervision of staff’ at the Centre, contributing to an ‘unacceptably high risk of psychological and actual physical harm to staff and young people’.1380
• Staffing levels were inadequate.1381
• Ashley Youth Detention Centre had a ‘toxic workplace culture … characterised by distrust, suspicion, conflict and frustration’.1382

The Serious Events Review Team made 17 recommendations to the Department, including that the Department:

• develops a strategy to ensure all Centre staff ‘are aware of the governing legislation, policies, procedures and practices’, with a particular emphasis on mandatory reporting, record keeping, the Behaviour Development System, case management and Very Close Supervision1383
• develops ‘specific strategies to address the breaches of policy, procedure and practice that have been identified as part of the review’1384
• clarifies and/or develops the policies, procedures and staff responsibilities for moving young people to a different unit1385
• ensures there is a procedure for providing support to young people following incidents, including a mechanism for reporting and monitoring that support1386
• ensures all staff are aware of grievance procedures and avenues for support when lodging or progressing grievances1387
• reviews staff training, ‘with a focus on relevance and frequency and applicability to a trauma informed approach’1388
• urgently develops a ‘mandatory, evidence based, trauma informed training schedule’ for staff, covering (at minimum): ‘trauma informed care; child development; attachment theory; the impact of trauma on children and young people; positive behaviour management; situational risk assessment; and disability, mental health and drug and alcohol issues in children and young people’1389
• provides training to all staff in relation to understanding and responding to sexual abuse, and develops associated guidelines1390
• ensures the Children and Youth Services’ ‘formal supervision model’ is implemented at the Centre as a matter of priority1391
• develops a strategy to address the ‘identified issues related to the toxic culture that currently exists at [the Centre] as a matter of urgency’1392
• conducts an inquiry into claims made about the Franklin Unit and the management of Albert and Finn.1393

The Serious Events Review Team’s report noted that ‘the review experienced significant delays due to difficulties in accessing information and arranging interviews with relevant staff’.1394

As described earlier in this case study, it was the policy for a Serious Events Review Team report to be considered by the Serious Events Review Committee before being supplied to the Secretary. Ms Burton told us she could not recall her report being presented to this committee.1395 Ms Burton believes her report was provided directly to Ms Honan.1396 Ms Burton also believes that none of the other reports she prepared following reviews of incidents at Ashley Youth Detention Centre were sent to the Serious Events Review Committee.1397

In our public hearings, Mandy Clarke, former Deputy Secretary, Children, Youth and Families, Department of Communities, explained that because the Serious Events Review Team’s reviews were assessing Ashley Youth Detention Centre and were not focused on the Child Safety Services system, those reviews fell outside the terms of reference of the Serious Events Review Team.1398 As such, the reviews did not follow the usual process of going to the Serious Events Review Committee.1399

There were differences in views about the formal purpose of the Serious Events Review Team. Both Ms Honan and Ms Clarke gave evidence that the Serious Events Review Team was established for the ‘particular purpose’ of looking into infant deaths.1400

The members of the Serious Events Review Team told us that it was established not only to review child deaths but also to review serious injury and near misses across the Division of Children and Families within the Department, including Ashley Youth Detention Centre, and to make recommendations for improving service delivery.1401

The former Deputy Secretary for Children, Ginna Webster, who set up the Serious Events Review Team, also told us that its purpose, as directed by her, was to review incidents at Ashley Youth Detention Centre as well as elsewhere within Child Safety Services.1402

Secretary Pervan agreed with Ms Clarke’s distinction between official Serious Events Review Team reviews and other reviews conducted by members of the Serious Events Review Team, so it was appropriate the Serious Events Review Team report in relation to the 7 August 2019 incident was not provided to the Serious Events Review Committee.1403 However, Secretary Pervan provided a different explanation for the distinction.1404 He said that ‘[b]y the time that Ms Burton was asked to undertake the review, the [Serious Events Review Team] had been disbanded or returned to their substantive positions’.1405 He explained that the team was used to conduct the review in ‘recognition of the [Serious Events Review Team] skills’ and the reason the report took the form of a Serious Events Review Team review was ‘because that was the template structure that they used’.1406

Despite expressing this view, Secretary Pervan went on to agree with Ms Burton’s evidence that the Serious Events Review Team was formally dissolved in May or June 2020, after the review of the 7 August 2019 incident had concluded.1407 Secretary Pervan also told us that while the Serious Events Review Team is now not a standing investigative resource for the Department, it can be reconvened if required to undertake a specific investigation or review.1408

1. Observations—The Serious Events Review Team review

We found the evidence about the process for considering the Serious Events Review Team review confusing. It appears there was general agreement that the Serious Events Review Team reviews relevant to Ashley Youth Detention Centre were not considered by the Serious Events Review Committee, but the reasons given for this varied.

We are concerned the Centre reviews did not go through the usual governance process. We consider this governance process important because it provides a mechanism to ensure problems are broadly acknowledged and shared, and for further accountability when addressing recommended reforms.

We discuss the disbandment of the Serious Events Review Team, and other similar incident review mechanisms, in Chapter 9.

1. February 2020—Reviewer raises other concerns

During her Serious Events Review Team review of the 7 August 2019 incident involving Henry, Ms Burton observed various other issues at Ashley Youth Detention Centre that were outside the terms of reference for the review. In addition to preparing the Serious Events Review Team’s report, Ms Burton sent Ms Honan memorandums outlining those other issues.1409

We have received and considered two of these memorandums, one dated 21 February 2020 and another dated 27 February 2020.1410 These memorandums raise:

• concerns about a poor culture at Ashley Youth Detention Centre, including allegations of physical abuse between staff, bullying and sexual harassment1411
• allegations that the Centre’s management had refused the psychologist’s request to access the files of young people in detention1412
• alleged non-consensual sexual activity between a female young person in detention and several male young people in detention when the female in detention was housed with males1413
• an allegation of historical sexual abuse of a young person in detention by staff member Lester (a pseudonym)1414
• an allegation that Lester recently ‘strip searched’ a young person, outside the scope of his duties.1415

In addition to the above issues, Ms Burton told us she also prepared at least one memorandum for Ms Honan concerning reports that older detainees in the Franklin Unit were being used to ‘control’ younger detainees ‘by whatever means’ and that incident reports had been rewritten.1416 We have not been provided with copies of any memorandums that specifically addressed the use of older detainees to control young detainees, nor any additional memorandums, despite requesting Ms Burton’s files from the State.1417

Ms Burton told us she sent all memorandums to Ms Honan by email but that she did not receive a response.1418 We received evidence of at least one such email being sent in late February 2020.1419

We asked Ms Honan what action she took in response to the email and memorandum she received from Ms Burton in late February 2020. Ms Honan explained that the concerns about staff culture (including allegations of bullying and sexual harassment) had already been raised and were being investigated at the time.1420 She further stated that the allegation of non-consensual sexual activity between a female and male detainees had previously been investigated.1421

In relation to allegations about Lester, Ms Honan commented that Alysha had previously reported these and they had already been referred to People and Culture at the Department. Ms Honan also told us the allegation that Lester strip searched a young person was investigated and it was found that he ‘had not acted inappropriately’.1422 We discuss the Department’s response to allegations about Lester in Case study 7.

We understood Ms Honan’s response as suggesting that she considered the memorandums from Ms Burton were matters already known and that they did not require any specific follow-up (separate from processes already underway or concluded at that time).

1. 20 May 2020—The Commissioner for Children and Young People receives the Serious Events Review Team’s report about the 7 August 2019 incident involving Henry

Despite Commissioner McLean’s request to be kept up to date with the Serious Events Review Team’s review of the 7 August 2019 incident involving Henry, it appears she did not receive any update until 18 February 2020, when Secretary Pervan notified her that there had been delays in the Serious Events Review Team’s review due to staff absences over the Christmas and New Year period.1423 Commissioner McLean received a copy of the final review report on 20 May 2020.1424

Evidence suggests that between May 2020 and January 2021, Commissioner McLean maintained regular contact with Ms Honan, Ms Clarke and Secretary Pervan, and received quarterly updates on the progress of implementing the Serious Events Review Team’s recommendations.1425 After that period, there does not appear to be any further correspondence in relation to monitoring implementation until May or June 2021. In May or June 2021, Commissioner McLean was provided the ‘Response to the Findings of a Serious Event Review Team (SERT) Review in Relation to Former AYDC Resident [Henry]’ written by Stuart Watson, Centre Manager, setting out the steps the Department had taken in response to the recommendations.1426

1. June 2021—The Department responds to the Serious Events Review Team’s report about the 7 August 2019 incident involving Henry

Fiona Atkins, Assistant Manager at the Centre, told us she was part of the working group within Ashley Youth Detention Centre responsible for implementing the recommendations that resulted from the Serious Events Review Team’s review of the 7 August 2019 incident.1427 In June 2021, more than a year after the Serious Events Review Team’s report was finalised, Mr Watson emailed Ms Honan with his final ‘response’ to the Serious Events Review Team’s findings.1428

Mr Watson explained that the delay in his response to the Serious Events Review Team review was due to him just taking over the role of Manager at Ashley Youth Detention Centre in March 2020 (which we note was more than a year before), the COVID-19 pandemic, staff shortages and more immediate priorities.1429 Ms Honan attributed the delay in implementing the recommendations to the ‘interdependent’ and ‘large in scale’ nature of the recommendations, which required time to resource and sequence.1430 She stated that implementation had been progressing for 13 to 16 months, but it was not until the recommendations had ‘momentum towards completion’ that Mr Watson could complete the response.1431

That response summarised how a similar incident would be managed differently and identified the following improvements made to Ashley Youth Detention Centre’s processes since the 7 August 2019 incident:

• Reports and CCTV are reviewed by the Operations Manager and then the Centre Support Team (now the Weekly Review Meeting).1432
• Case/shift notes are reviewed by Ashley Team Support (formerly Professional Services) staff and feedback provided as part of a continual improvement process.1433
• All stakeholders are now included at the conference held following an incident, and the process is facilitated by ‘experienced, qualified people that are legislatively aware’.1434
• Victim-survivors are given immediate support and post-incident follow-up to ensure safety, health and wellbeing needs are met, and they are informed of their rights to make a formal complaint.1435
• Staff are regularly rotated through all units, provided with professional supervision and enter Professional Development Agreements so they are consulted about their work preferences and the reasons behind them.1436

We are unaware if the response was provided to anyone in the Department other than Ms Honan and her Executive Officer.

Ms Honan’s evidence was that the recommendations of the review have been actioned and that she monitors their progress.1437

Ms Clarke said that ‘to the best of [her] knowledge the [Serious Events Review Team] recommendations were accepted’.1438 She told us the Centre’s management team was responsible for implementing the recommendations.1439 She later provided us with a Minute to the Strengthening Safeguards working group dated August 2021 that stated the last of the review’s recommendations had been implemented.1440

Secretary Pervan told us he had not received a ‘briefing on the progress of these issues’ and therefore, he did not answer some of our questions about the Serious Events Review Team, including how the Department has ensured the successful implementation of the team’s recommendations.1441 Secretary Pervan told us he understood that the recommendations had been accepted and ‘integrated into wider ongoing reforms’ at Ashley Youth Detention Centre but that Ms Clarke and Ms Honan were responsible for implementing those recommendations.1442

The Serious Event Review Team Information Sheet, dated August 2019, stated that the Children and Youth Services Executive was responsible for implementing any recommendations of a review, and the Minister for Human Services and the Secretary were to receive monthly updates.1443

The former manager of the Serious Events Review Team told us the Department’s executive was not required or expected to report to the Serious Events Review Team on implementing recommendations.1444 An undated version of the terms of reference for the Serious Events Review Committee, which the former manager of the Serious Events Review Team provided to us, stated that that committee played a role in monitoring ‘progress reporting against recommendation implementation’.1445 We note however, that as discussed above, Secretary Pervan and Ms Clarke explained that reviews of Ashley Youth Detention Centre were not provided to this committee.

Finding—The response to the Serious Events Review Team review of the 7 August 2019 incident did not follow a clear process for implementation and oversight

It appears there was no clear accountability or governance process for reporting against the recommendations of Serious Events Review Team recommendations concerning Ashley Youth Detention Centre. As we observe in relation to the reviews themselves, strong governance structures ensure problems are shared and acted on.

Had a clear formal oversight and accountability process been adopted, there would have been mechanisms for the Secretary and the Minister to be regularly briefed and potentially for a body like the Serious Events Review Committee to provide additional oversight.

We find that acting outside the review structures resulted in a collective lack of ownership in the Department for responding to the Serious Events Review Team’s report on the 7 August 2019 incident involving Henry.

1. Post June 2021—Reforms are implemented in response to the Serious Events Review Team’s report

Ms Honan and Mr Watson identified the following improvements made to Ashley Youth Detention Centre practice and procedure following the Serious Events Review Team report:

• A policy review working group was established, led by a senior policy officer, to revise all policies and procedures at the Centre. Finalised procedures are reflected in the electronic practice manual.1446
• Training in mandatory reporting, case note and record keeping, the Behaviour Development Plan and Very Close Supervision was updated, delivered to staff and incorporated into the induction for new staff.1447
• Case management procedures were under review and were a work in progress. In August 2022, Ms Honan told us she expected this review would be completed by the end of 2022.1448
• Moving detainees to a different unit is now determined by the ‘Weekly Review Meeting’ (previously the Centre Support Team), and an additional risk assessment process is followed if safety concerns arise. Ms Honan told us that the on-call manager must approve any after-hours movement of young people.1449
• Case note and incident recording is now electronic and centralised.1450
• A new therapeutic practice framework and learning and development framework have been implemented, which are designed to help staff work with young people in a trauma-informed way.1451
• Key positions that support operational roles have been reviewed and reclassified to ensure policy development, training and supervision is up to date and delivered by suitably skilled and qualified staff.1452
• Recruitment has been centralised through the People and Culture Team.1453
• There has been a change in leadership and a ‘significant focus’ on workplace behaviours.1454
• A Senior Business Partner has helped staff to proactively manage complaints and to address conflict and concerns.1455
• Security improvements have been made, including securing the courtyards for all units.1456
• Workshops have addressed low morale and the Centre’s poor workplace culture.1457

1. Mid-2021—Ray displays harmful sexual behaviours

It is notable that in later periods of detention at Ashley Youth Detention Centre, Ray displayed an ‘emerging pattern of sexual disinhibition’, including making ‘sexually inappropriate comments’ and engaging in ‘increased sexualised talk’.1458 Eventually, staff raised concerns that he may sexually assault other young people at the Centre. We are not aware of any evidence that he did so. We are concerned, however, by evidence that Ray began displaying similar harmful behaviours in the months following his exposure to violent behaviours at the Centre. A failure to respond appropriately to harmful sexual behaviours may perpetuate the behaviour.

1. December 2021—Max asks to be transferred from Ashley Youth Detention Centre to adult prison

Beyond the incidents noted above, Max was also involved in other incidents at the Centre that were unrelated to harmful sexual behaviours.1459 Max’s time at the Centre ended in late 2021 with him displaying continuing and increasingly challenging behaviours: ‘I just kept going and I would have code blacks called on me every day. I kept hitting staff and stuff like that’.1460 Max told us he behaved this way in an effort to get transferred from the Centre to an adult prison, despite being under 18:

Well, I had— as there’d be paperwork of me trying to request to move out of there, I put in request forms, and that’s what the [Centre Support Team is] there for, and they just kept coming back saying, ‘No, you’re not going to be able to move no matter what you do’. So then that made it even worse for me, because like, I felt I had the— I should be allowed to go to an adult prison, not sit in Ashley after everything that’s happened to me.

I don’t get treated like a kid up there, so why should I be there when just, like, I’ve had so much trauma and that there I just didn’t feel like, like, it wasn’t good for me, it wasn’t good for my headspace, so I just kept releasing all my anger on all—everyone.1461

In a Department Minute to Secretary Pervan dated 22 December 2021 about the proposed transfer of Max to the adult prison system, Max’s behaviour was summarised as follows:

[Max]’s current presentation includes frequent aggressive behavioural outbursts, extensive property damage, threatening/intimidating/assaulting staff, fighting with other residents, and high levels of emotional distress.

[Max] has had 17 incident / detention offences in November and 12 as at 20 December 2021. This includes attempted staff assaults, resident assaults including an assault on a 14-year-old resident, standoffs/riotous behaviour including inciting other young people to join him on three occasions, he has attempted to access staff security equipment on several occasions.

[Max] has increased threats to include threats of sexual assault against staff and other young people including exposing himself to other young people and staff.

[Max] poses a significant risk to staff and other resident safety and cannot be adequately managed to ensure safety of staff and other residents.1462

In an email from Ms Honan to Secretary Pervan on 8 February 2022, Ms Honan wrote that Max was transferred to the adult prison system because ‘his behaviour was too complex and high risk to manage at [Ashley Youth Detention Centre]’.1463 Based on Max’s evidence, the transfer appears to have been consistent with Max’s wishes and stated requests at the time. However, we were also told that Max had been experiencing high levels of emotional distress during this period and frequently changed his mind regarding the transfer.1464

Max told us that when he was transferred to adult prison, Ashley Youth Detention Centre staff told him it was his Christmas present.1465

A memorandum of understanding between the former Department of Health and Human Services (Children and Youth Services) and Department of Justice (Tasmanian Prison Service) executed in December 2014 governs and facilitates the transfer of young people between the Centre and the Tasmania Prison Service. This memorandum of understanding, which remains in effect, enabled Max’s transfer.1466

1. Early 2022—Max asks to be transferred from adult prison back to Ashley Youth Detention Centre

It appears that in early 2022, when he was still under the age of 18, Max asked to return to Ashley Youth Detention Centre.1467 As part of that process, Max contacted the Commissioner for Children and Young People, Leanne McLean, to advocate for his request.

Commissioner McLean wrote to Secretary Pervan on 17 March 2022, outlining Max’s experiences in the adult prison system.1468 Max had reported to Commissioner McLean that he was being exposed to long periods of isolation, was self-harming (which resulted in further restrictions on his movement) and was being housed with a large number of adults.1469 Commissioner McLean also noted Max’s desire to attend Ashley School.1470

Commissioner McLean asked Secretary Pervan that Max be allowed to return to the Centre.1471 Commissioner McLean noted that she was ‘not supportive’ of Max’s transfer to the adult prison system when the original decision was made.1472 Secretary Pervan responded to Commissioner McLean’s email on 20 March 2022, writing that ‘it is my determination that the information provided does not mitigate the significant risk that [Max] continues to present to the safety of other young people and staff at [Ashley Youth Detention Centre]’.1473

On 22 March 2022, in response to Secretary Pervan’s determination, Commissioner McLean made the following comment about the apparent inability of Ashley Youth Detention Centre to manage or address the challenging behaviours of a young person like Max:

Thank you for informing me of your decision that [Max] will remain at the [Tasmanian Prison Service], and the information influencing your decision. It is unfortunately an indication of the limitations of our current model, that these types of behaviours cannot be responded to in an appropriate therapeutic fashion within a youth-specific environment.1474

Commissioner McLean also asked Secretary Pervan for more information about Max’s circumstances, including:

• how he would communicate the determination to Max, and inform Max whether he could seek a review of the decision through the Ombudsman
• what measures were being taken to ensure Max’s wellbeing in the adult prison system, raising her concerns as to ‘who is responsible for the wellbeing of a child remanded to an adult facility’
• how the decision to remand Max in the adult prison system was made following his earlier arrests, subsequent to his initial transfer from Ashley Youth Detention Centre.1475

We asked Secretary Pervan about his decision not to allow Max to return to Ashley Youth Detention Centre once Max was detained in an adult prison, and his response to Commissioner McLean’s other queries of 22 March 2022 about how Max would be provided with the appropriate therapeutic supports if he remained in adult prison. Secretary Pervan presented us with his email response to Commissioner McLean, dated 26 April 2022, more than a month after she sent him her queries. Secretary Pervan’s email made the following points:

• He had assumed that Commissioner McLean, as Max’s advocate, would inform Max of the determination not to transfer Max back to Ashley Youth Detention Centre and any rights he had to review that decision.
• Max’s wellbeing in the adult prison system was being supported by visits from his Community Youth Justice Worker and Child Safety Officer, the therapeutic services offered by the Tasmania Prison Service, as well as information provided by Ashley Youth Detention Centre authorities to the Tasmania Prison Service about Max, such as his ‘trigger points and associated behaviour management strategies’.
• Upon Max’s previous arrest and him being remanded in custody, Secretary Pervan had formed the opinion that it was not practicable to detain Max at Ashley Youth Detention Centre based on the factors considered when Max was first transferred to the adult prison system.1476

Secretary Pervan acknowledged the limitations of Ashley Youth Detention Centre to be able to address the needs of children with complex needs and stated that the issue was ‘being taken into account in the design of the new facilities that will replace [Ashley Youth Detention Centre]’.1477

Finding—Ashley Youth Detention Centre was not equipped to meet the complex needs of children and young people, resulting in at least one young person being transferred to adult prison

Ashley Youth Detention Centre should be able to meet the needs of children displaying complex behaviours. It was not able to in early 2022, resulting in at least one young person being detained in adult prisons.

We remain concerned about how the needs of young people in detention are being met now, given Secretary Pervan’s indication that the complex needs of children and young people are being considered in the design for the new facility, which has not yet been built. It is unacceptable that the solution to a young person displaying challenging behaviours in youth detention is to transfer that young person to an adult prison, where they face further risk of sexual abuse.

Max’s specific circumstances are complicated somewhat by his admitted desire for such a transfer in late 2021 and his stated intention to escalate his behaviour to compel that outcome. However, once he requested a transfer back to Ashley Youth Detention Centre after experiencing the adult prison system—while still a minor—the Centre should have been in a position to manage and meet Max’s needs. In addition, any opportunity for Max to improve his behaviour and receive therapeutic care at Ashley Youth Detention Centre should have been properly assessed.

1. Observations—Harmful sexual behaviours displayed by Albert and Finn

Ashley Youth Detention Centre was aware that Albert had displayed harmful sexual behaviours as early as January 2018, 17 months before the 7 August 2019 incident with Henry.1478 Records of multiple other incidents involving Albert and Finn, while not investigated in detail, suggest their behaviours were frequent and persistent and indicated a need for specialist treatment.1479

In addition, the Centre was notified, on multiple occasions by different staff, that not enough was being done to manage Albert’s and Finn’s harmful sexual behaviours and the risks these behaviours posed to other detainees, including Henry:

• On 13 August 2019, Ms Gardiner and the union delegate raised concerns that the Centre’s response to the 7 August 2019 incident involving Henry was inappropriate.
• On 22 August 2019, Ms Gardiner advised that she was reporting the incident to Child Safety Services.
• On 18 September 2019, the Ashley Youth Detention Centre psychologist raised concerns about Henry being placed in a program with Finn, given Finn’s harmful sexual behaviours towards Henry on 7 August.
• On 13 November 2019, the psychologist again raised her concerns about Albert and Finn’s behaviours in an email.
• On 15 November 2019, the psychologist once more raised her concerns in a letter.
• On 6 December 2019, the psychologist advised that she had made mandatory reports to Child Safety Services and the Commissioner for Children and Young People.

Even when attempts were made to address the behaviours of Albert and Finn, these were not progressed. We are concerned that Alysha and the psychologist’s review into the behaviours of Albert and Finn was quashed, seemingly by Centre management.

When asked about the management of Albert and Finn, a Case Management Coordinator at the Centre told us:

They weren’t managed appropriately because the senior decision makers were completely dysfunctional. One simple thing that would have helped was to separate [Albert and Finn] as they were a poor influence on each other.1480

Ms Gardiner stated that not addressing the needs of Albert and Finn ‘placed them at risk for being perpetrators of future sexual assault. [Ashley Youth Detention Centre] had a responsibility for rehabilitation for the detainees, and this was not addressed’.1481

In her evidence, Ms Honan expressed concern with the failure of Centre management to act on the advice of Ms Gardiner and the psychologist, saying ‘these were highly skilled practitioners, why their advice was disregarded is not okay’.1482

Some staff at Ashley Youth Detention Centre raised serious concerns about harmful sexual behaviours, as well as other harmful behaviours, at the Centre. We were concerned that other staff at the Centre did not appear to appreciate the seriousness of Albert and Finn’s behaviour and the risk they posed to other children (and staff) and to members of the community after their release if they were not rehabilitated. We also query why Centre staff did not consider moving Albert and/or Finn out of the Franklin Unit.

1. Observations—The Department of Communities’ response to allegations about placement decisions

As described in this case study, we received evidence that the Centre and the Department were made aware of allegations that older detainees were being used to threaten younger detainees. Specifically:

• The psychologist emailed Mr Ryan on 13 November 2019 advising that a young person had reported to her they had been threatened with placement in the Franklin Unit and that detainees get ‘stood-over, abused and raped’ in that unit.1483
• Ms Burton told us she reported the matter to Ms Honan by a memorandum prepared during her review of the 7 August 2019 incident.1484
• Ms Honan acknowledged that Alysha reported the matter to her.1485

We asked Ashley Youth Detention Centre management and Department officials about the evidence from former Centre staff that misbehaving detainees had been threatened with transfers to the Franklin Unit so their behaviour could be ‘sorted out’.1486

In his statement to us, Mr Ryan did not answer our question about whether there was, at any time, a practice of using placement decisions to threaten or punish children or young people detained at the Centre.1487 He did state that he was not aware of any perception among children or young people in detention that they would not be protected against the risk of sexual abuse in the Franklin Unit until the Centre’s psychologist told him.1488

Mr Watson could not comment on practices before starting work at the Centre in 2020.1489 He said that a policy or practice of using older detainees to control or influence younger detainees was not presently in use, and he agreed any such practice or policy would be ‘totally inappropriate’.1490

In response to our question about whether there was a policy or practice of using some young people in detention as a threat to influence or punish the conduct of other detainees (particularly in relation to the Franklin Unit), Mr Brown told us that ‘[f]rom memory the [Behaviour Development System] and induction processes were the only policies used to assess where residents were placed’.1491

Ms Clarke also told us she had no knowledge of any practice of using placement decisions to punish children or young people in detention.1492 She confirmed that such conduct ‘would warrant a formal investigation’.1493

Secretary Pervan denied knowledge of any policy of Centre staff threatening young people with a placement in the Franklin Unit.1494 He stated that he had not been made aware of concerns with placement decisions until receiving a request for statement from us on 2 August 2022.1495

Ms Honan told us she became aware of the possibility of such a practice after Alysha raised the matter with her in late 2019. As described here, Ms Burton told us that during her investigation of the 7 August 2019 incident, she raised with Ms Honan reports that older detainees in the Franklin Unit were being used to ‘control’ younger detainees.1496

Ms Honan said that this issue formed part of the terms of reference of the Serious Events Review Team and Senior Quality and Practice Advisor reviews.1497 We note that the Senior Quality and Practice Advisor review was never completed and the referral does not raise the issue of using children and young people in detention in the Franklin Unit as a control mechanism.1498 We are unsure which Serious Events Review Team review Ms Honan was referring to, but note that the terms of reference of the review in relation to the Henry incident in August 2019 did not refer to the allegations that older detainees were used to control or threaten younger detainees.

Finding—The Department should have fully investigated allegations that staff at Ashley Youth Detention Centre used older detainees to threaten or control younger detainees

We are concerned that the allegation that some staff at Ashley Youth Detention Centre used older detainees to threaten or control younger detainees has not been fully investigated, despite this concern first being raised with Centre management in late 2019 and being subsequently raised with Department staff. We would have expected such an investigation to speak to children and young people in detention and staff about their views, particularly children and young people’s sense of safety. We remain concerned that some staff who are the subject of those allegations may still be working at Ashley Youth Detention Centre.

1. 6 May 2022—A new unit placement procedure is put in place

In a statement provided to us, dated 27 July 2022, Secretary Pervan attached a copy of the Unit Commissioning, De-Commissioning and Allocation to a Young Person Procedure (‘Unit Placement Procedure’).1499 The new Unit Placement Procedure acknowledges that decisions about unit placement are ‘critical, as placement decisions can affect a young person’s health and wellbeing by either increasing or decreasing the risk of immediate or future harm’.1500 The following ‘critical requirements’ are identified in the policy to ‘ensure the safety of young people’:

All new arrivals will be housed in the admission induction unit.

Male and female detainees will be housed separately. Detainees that identify as transgender will guide their unit placement.

If deemed safe, young people from Aboriginal and Torres Strait Islander backgrounds should room share.

Placement decisions about young people must be made in the best interests of all young people at the Centre.1501

We note that the new policy does not refer to harmful sexual behaviours or more broadly that safety should be a paramount consideration in placement decisions. We also consider that the policy lacks clarity on what ‘operational considerations’ may warrant decisions about unit placement and is generally unclear as to who has what power to make a placement decision in any given context (and who is required to review or may override such a decision). In Chapter 12, we discuss this policy, the importance of clear responsibility for decision making in placing children and young people in detention and the importance of clinically-led responses to safety concerns.

Finding—There is a lack of consistent policy and practice at Ashley Youth Detention Centre on unit placements

There continues to be a lack of clear policy and practice around placement decisions and unit moves at Ashley Youth Detention Centre, including who is responsible for the final decision and reviewing any decision.

This lack of clear process is concerning when children are displaying harmful behaviours and may cause a threat to the safety and wellbeing of other children and young people in the Centre.

There should be clear ultimate decision-making responsibility for placement decisions, which should consider the risks posed by young people who display harmful sexual behaviours.

1. System observations—Max, Henry and Ray

It was apparent to us that systemic problems at Ashley Youth Detention Centre contributed to the risk of harmful sexual behaviours among detainees, as well as the failure to appropriately respond when these risks are realised. Combined, the treatment of Max, Henry and Ray—particularly their unit placements—highlighted several systemic problems. We discuss some of these earlier in the case study. Here we focus on others.

1. Lack of thorough assessment, including risk assessment

It is our view that many staff at Ashley Youth Detention Centre failed to appreciate the risks to Max, Henry and Ray. Consequently, Max, Henry and Ray were subjected to what we consider to be predictable and therefore, avoidable incidents of significant harm.

Henry’s placement in the Franklin Unit with Albert and Finn should not have happened given that staff knew Albert and Finn had ongoing and prolonged histories of harmful sexual behaviours. Max’s placement in the Franklin Unit should not have happened given that staff were aware that Henry had recently been subjected to harmful sexual behaviours by Albert and Finn. Given Ray’s clearly recorded mental health condition on his admission to the Centre, his mental health difficulties over his first months in detention and the escalation in his behaviours in the lead-up to his transfer to the Franklin Unit, Ray should not have been placed with Albert and Finn, who were known to engage in aggressive and violent behaviours.

No risk assessments were undertaken by operational staff with decision-making authority for placements about the suitability of the Franklin Unit for Max, Henry and Ray before these young people were placed in that unit. Rather, where risks had been identified by professional services staff, these were not given appropriate weight. Other operational considerations seem to have influenced the decisions about Max, Henry and Ray’s placements.

1. Staff tensions

It was also apparent to us that tensions between staff and/or teams hindered collaborative decision making about the safety of detainees, which, if addressed, could have significantly mitigated the risks to Max, Henry and Ray.

We observed, on the evidence before us, a dysfunctional relationship or a culture of professional disregard between some operational staff on the one hand and some professional staff on the other hand, particularly during 2019 and early 2020. One staff member described the relationship between some teams as ‘caustic’.1502 We heard of allegations of professional staff being invited to attend meetings but not being allowed to speak. We observed a range of instances where some expert staff recommendations were ignored or their involvement in managing vulnerable detainees was explicitly denied by both operational staff and management. This meant decisions were being made without consultation and in contradiction to professional advice. In our view, this placed children and young people in detention at risk of sexual harm and ultimately contributed to the harm caused to Max, Henry and Ray. We are concerned that some of these staff tensions reflected a broader divide among staff about the philosophical approach to youth detention and whether a corrections or therapeutic focus was preferable.

The influence of Department employees, including the psychologist, was limited by and subject to the operational decisions of Ashley Youth Detention Centre staff, which prevented concerns about harmful sexual behaviours from being escalated further and prevented clinically-led decision making necessary for a therapeutic response.

We consider the psychologist’s repeated reports as indicative of her professional concern. We are concerned that her attempts to raise concerns appear to have been met with a lack of care.

We are also troubled by the alleged conduct of some staff towards other staff who raised concerns about harmful sexual behaviours, including unprofessional conduct, silencing, finger pointing and dismissiveness.

1. Capacity to identify and respond to harmful sexual behaviours

It was apparent to us that some Ashley Youth Detention Centre staff lacked capacity to recognise and respond to harmful sexual behaviours between detainees. We consider that all staff should receive training on harmful sexual behaviours, particularly senior decision-makers.

If the response of Centre staff to incidents of harmful sexual behaviour is not therapeutic or trauma-informed, problems for young people, staff and the Centre as a whole, now and into the future, will continue with devastating consequences.

Max’s experiences at Ashley Youth Detention Centre highlight the ongoing cost of the Centre’s failure to meaningfully identify and address harmful sexual behaviours. When Max’s long history at the Centre is viewed holistically, we can see that he has become caught in a cycle of trauma and abuse. The 2018 Serious Events Review Team’s report into the harmful sexual behaviours Max experienced, while seemingly prepared by the investigator with diligence and in good faith, somewhat and perhaps unintentionally downplayed incidents that caused significant distress to Max. The broad outcome appears to have been a lack of appreciation for the harm caused to Max and an affirmation of the limited response by Centre staff to those incidents. Shortcomings in the response to Max’s experiences of harmful sexual behaviours appear to have contributed to Max using violence and harmful sexual behaviours against others.

It is disappointing and concerning that there were seemingly no therapeutic responses available to address the behaviours of Max within the youth custodial context. This is apparently the case despite the best efforts of individuals to have such therapeutic capacity built within the institutional context of the Centre.

1. Serious Events Review Team

It appears that the Serious Events Review Team’s investigation into the incident involving Henry, although delayed, eventually led to several improvements to the Centre’s information systems, security systems and responses. These included:

• centralising and digitising incident reporting
• improvements to risk assessments for after-hours unit moves
• improvements to staff training for incident reporting and mandatory reporting obligations.

We note that without that investigation, the actions and decisions of Centre staff regarding harmful sexual behaviours would not have been scrutinised and challenged. The Serious Events Review Team’s investigation highlights the importance of having a permanent, experienced and skilled investigative team available to the Department for when serious incidents occur. We note the importance of young people participating in decisions that affect them, including in investigations, is consistent with international obligations and child safe standards.

1. Recent reforms

Ms Honan told us that harmful sexual behaviours would be managed differently if they were to occur at Ashley Youth Detention Centre today. She told us that:

• Placement decisions are now subject to a risk assessment and are more thoroughly scrutinised at Weekly Review Meetings.1503
• The Advice and Referral Line would be notified (Ms Honan did not clarify who would make the notification).1504
• Clinical staff would better protect and support victim-survivors.1505
• There would be a referral to police (Ms Honan did not clarify who would make the notification, but Fiona Atkins, Assistant Manager, Ashley Youth Detention Centre, told us that referrals are made to police ‘upon the assessment of the [Centre Support Team] with the [Centre] Manager’s support’).1506
• Incidents involving harmful sexual behaviours would be referred to the Sexual Assault Support Service.1507
• Post-management of an incident would be more comprehensive and centralised with the Ashley Incident Management System. All electronic notes and witness statements would be quality assured by the Operations Coordinator and reviewed by the Assistant Manager before being forwarded to the Manager and Director.1508
• Staff are now better able to address the behaviours of the kind presented by Albert and Finn due to the current Behaviour Development Program.1509
• There is greater support for Operations Team staff from managers and practitioners in relation to enforcing boundaries and reinforcing pro-social behaviours.1510
• A Risk Assessment Process Team would be convened to provide recommendations, practical support and advice in managing risk.1511
• The Director would be informed about all incidents involving harmful sexual behaviours.1512
• All incidents would be reviewed by the Commissioner for Children and Young People and the Custodial Inspector.1513
• Young people engaging in harmful sexual behaviours would be referred to services and safety precautions would be placed around them.1514

Ms Honan also stated that staff at Ashley Youth Detention Centre would be supported to:

… call out and address not placate intimidating behaviours. Focus on rewarding positive behaviours when they do occur using the changes within the [Behaviour Development Program] system would have been used to incentivise change. Improvements to incident management reporting and the quality and detail of information now contained in [Weekly Review Meeting] minutes further safeguard the minimisation of incidents and under reporting of them.1515

Secretary Pervan told us that where a young person is subjected to harmful sexual behaviours by another young person, they are ‘supported therapeutically’ by the onsite nurse, medical officer and psychologist, and the young person’s care plan is updated and overseen by the Multi-Disciplinary Team.1516 That said, we received information that the position of onsite psychologist at the Centre has not been filled since November 2021.1517 Secretary Pervan did not confirm whether mental health support is offered to a young person engaging in harmful sexual behaviours. He did state that Ashley School provides programs on healthy relationships, consent and sexual decision making.1518

The Nurse Unit Manager told us that in the event of an incident of harmful sexual behaviour, she would ensure Ashley Youth Detention Centre staff were ‘aware’ and that ‘conferencing is scheduled to address the behaviours of concern’.1519 She also stated that longer term supports through services such as family planning would be enlisted to ‘tailor the delivery of a safe sex education session, which cover aspects of healthy sexual relationships and behaviour, as well as legal boundaries (such as consent)’.1520

Ms Honan acknowledged that Ashley Youth Detention Centre is only in the early stages of adopting trauma-informed practice.1521 Her evidence was that the concept is understood by staff but ‘the breakdown is probably in having the skillset and the clinical oversight and guidance about working with that’.1522 We received evidence from Ms Atkins that Operations Team staff still lack the training, skill and resources to respond to and manage young people displaying harmful sexual behaviours.1523

Despite that information regarding the current practice for responding to incidents of harmful sexual behaviour at the Centre, we also received information that the functions and powers of the Commissioner for Children and Young People to review such incidents is limited, and entirely dependent on being notified of such incidents.1524 Commissioner McLean informed us she has not been formally contacted by the Department to review any harmful sexual behaviour incidents at the Centre, despite making requests to be notified of such incidents.1525 Further, Commissioner McLean told us that, in situations where she has provided feedback to the Centre and the Department about the way an incident of harmful sexual behaviour has been or should be handled, she is generally not provided with a response to such feedback by the Centre or the Department.1526 Notably, in a recent instance where Commissioner McLean was contacted by a young person regarding an incident of harmful sexual behaviour at the Centre, she requested advice from the Department in late April 2023 regarding measures taken in response to this incident, however, as at 11 July 2023, had not received a response from the Department.1527

1. Harmful sexual behaviours—2022–23

In early 2023, the Tasmanian Legislative Council was conducting its Inquiry into Tasmanian Adult Imprisonment and Youth Detention Matters. Some submissions to that inquiry raised concerns about, among other things, the behaviours of detainees, staff safety and the lack of a clear understanding of therapeutic and trauma-informed care, and questioned if it was appropriate for a detention setting.1528 In particular, two submissions we read were by retired police officers who had answered a call in late 2022 to work at Ashley Youth Detention Centre to address immediate staffing shortages. They described similar concerns. One described the challenging behaviours of young people in the Centre this way:

Indecent assaults are common practice with resident on resident fondling and touching and resident on youth worker touching. There were many times where I asked a resident if they wished to make a complaint—the answer was always similar, ‘just playing, joking around (normally an expletive), just having fun’. Of the many sexual contacts I witnessed, resident on resident, not one complaint was made.

In my case I was touched on the breasts on occasions and being asked ‘if I liked it’, being touched on the backside and in other sexual ways. I was frequently being asked about my sexual activity the night before and on one occasion and in front of other residents and a youth worker (female) a resident asked ‘if I liked it up the bum’.

The resident was severely chastised by the other youth worker and me and, as was a common practice, said ‘can’t you take a joke’. This was the similar response in all inappropriate touching—‘only joking’.

I witnessed many vicious assaults—resident on resident and resident on youth worker.1529

While not described as such in the submission, this is a description of harmful sexual behaviours. It echoes, for us, comments made in the 2018 Serious Events Review Team report, which said inappropriate sexual behaviour by children and young people in detention ‘must be managed on a daily basis’ in the Centre and noted that ‘it may be useful to consider expert review, advice and [ongoing] consultation concerning this issue to support [the Centre] to assist residents to develop socially appropriate behaviours for transition to the community’.1530

We are concerned these sexualised behaviours may have become normalised within the Centre.

Finding—Ashley Youth Detention Centre has been aware of harmful sexual behaviours at the Centre and has not taken steps to protect children and young people from these

While this case study has focused heavily on events from 2018 to 2022, and identified specific failings in relation to those events, we are concerned that these events and the response of the Centre and the Department echo a pattern across many years at Ashley Youth Detention Centre.

We heard too many accounts, from as early as the 2000s, of children and young people being harmed by the sexualised behaviours of other detainees, sometimes facilitated by, or with the knowledge or implicit approval of, staff.

At times staff have failed to respond to known risks of harm, allowing vulnerable children and young people to be placed with or exposed to young people who pose a risk to their safety.

When harmful sexual behaviours did occur, staff or Centre management often failed to respond appropriately—whether by not removing the risks, not supporting the victim-survivor, or punishing them for making a complaint. When some staff raised concerns about the risk of harm to certain children or young people in detention, those concerns were sometimes not given appropriate weight within the culture and operations of the Centre.

We hold serious concerns about allegations that, at times, staff have used unit placement or threats of unit placement with other detainees known to display violence and harmful behaviours to threaten, intimidate or control more vulnerable children and young people.