The Inspector of Custodial Service Neil Morgan tabled his report on Wednesday, August 7.
The loss of control, he said, was not only because the young people at Banksia Hill had suddenly become worse but because the facility had become increasingly unstable over the preceding 18 months.
Escalating serious incidents, staff shortages, excessive lockdowns, poor responses and lax security practices were all warning signs, he said.
During 2012, the pending amalgamation of Rangeview and Banksia Hill into a ‘one- stop shop’ for all detainees had lost momentum and building delays added further fragility. The report contained 35 recommendations.
Opposition spokesman for corrective services Paul Papalia urged any risk analysis to be done before the merger was made public.
In a media statement, the Department of Corrective Services acknowledged that prolonged lockdowns at Banksia Hill contributed to the January 20 incident.
The department is considering the recommendations.