Executive summary

Early in the afternoon of 30 January 2017, seven young people at Brisbane Youth Detention Centre (BYDC) were involved in a violent and destructive riot (the BYDC riot). The BYDC riot involved seven young people forcing their way onto the roof of one of the accommodation units causing significant damage to the centre’s infrastructure as well as injury to staff.

The riot commenced on the veranda of the unit, where the young people used cleaning equipment, such as brooms and mops, to intimidate staff and smash windows and light bulbs. A staff member was injured when they were hit by glass from a smashed window panel.

The young people gained access to a common area and continued destroying windows and other infrastructure. The young people gained access to the unit’s roof by way of a broken window. BYDC staff contacted the Queensland Police Service which sent police officers to the centre to manage the situation.

The young people remained on the roof of the unit for the remainder of the day and into the early hours of the following morning. While on the roof, the young people continued to cause significant damage to infrastructure, including throwing damaged items at staff attempting to manage the situation.

The young people progressively came down from the roof of their own accord with the last young people coming down at 2.51am on 31 January 2017. All seven young people who had been involved were placed in separation while BYDC staff attempted to restore order at the centre over the course of the next 24 hours.

Following the BYDC riot, the young people involved were spoken to by BYDC staff who tried to determine the reasons for their actions. The young people initially spoke of their dissatisfaction with a decision by unit staff to remove their possessions from their rooms the day before the riot, which they felt was unfair.

However, the young people also raised serious allegations regarding the actions of a number of BYDC staff. These allegations related to the perceived relationship between some BYDC staff and young people who had been transferred from Cleveland Youth Detention Centre (CYDC) in November 2016 (CYDC young people). The CYDC young people had been transferred following a violent riot at CYDC (the CYDC riot) which had resulted in significant injury to CYDC staff.

After their transfer to BYDC, the CYDC young people were accommodated together in the same unit. They quickly gained a reputation among the young people at BYDC as violent and willing to assault other young people. As a result, many young people at BYDC were fearful of the CYDC young people, and particularly the threat of being assaulted if they were placed in the same unit as the CYDC young people.

The young people involved in the BYDC riot alleged that some BYDC staff had used this fear to threaten young people with transfer to the unit if they misbehaved. They also alleged that some staff had told them that if they did not comply with instructions they would be assaulted by the CYDC young people.

The young people stated they took this threat seriously as they believed that some BYDC staff had purposely placed young people in situations where they would be assaulted by the CYDC young people. They also alleged that some staff had ‘paid’ the CYDC young people with soft drink to assault young people who misbehaved.

These perceptions meant that young people felt that the CYDC young people were favoured by staff and were provided with privileges that other young people at the

centre did not receive. They also felt that the CYDC young people did not receive any consequences for their actions, even though they had been involved in multiple assaults on other young people, and that staff would not act to protect them from CYDC young people.

Ombudsman investigation

Between January 2017 and August 2017 the Office of the Queensland Ombudsman (the Office) received information to suggest that there had been significant problems and disruption at BYDC in the period following the transfer of the CYDC young people and the BYDC riot.

In particular, it was evident that the arrival of the CYDC young people at BYDC had a significant impact on the safety, security and normal functioning of the centre. Issues regarding the management of the CYDC young people, and how some BYDC staff interacted with them, were identified as factors that ultimately contributed to the BYDC riot.

By way of complaints received from young people, interviews conducted with young people, information provided by BYDC staff and the Youth Detention Inspectorate and referrals from the CCC, the Office identified a number of significant decisions and incidents at BYDC between November 2016 and the BYDC riot on 30 January 2017. These formed the basis for the investigation, and included:

  • the development of risk management strategies for the CYDC young people following their transfer to BYDC
  • a rooftop incident in November 2016
  • allegations of threats and assaults on young people orchestrated by BYDC staff
  • perceived preferential treatment of CYDC young people by staff
  • concerns about safety and security at BYDC in the lead up to the BYDC riot.

The investigation also examined the aftermath of the BYDC riot, specifically the decision to separate the young people who were involved for a period of up to 10 days. A lack of available rooms following the BYDC riot meant that some of these young people were accommodated in rooms that were intended to be temporary holding areas for young people newly admitted to the centre. These ‘admission rooms’ did not have beds, running water or bathroom facilities. Some young people spent the entire length of their 10 day separation period detained in these rooms.

The following sections provide a summary of the issues examined by the investigation and the outcomes.

Development of risk management strategies for the CYDC young people

Upon arrival at BYDC, the CYDC young people were identified as an ‘extreme risk’ and a potential threat to the safety of both staff and other young people at BYDC.

BYDC staff developed a plan for the CYDC young people’s transition to BYDC and a strategy to ensure they could be safely accommodated in the centre’s general population. However, vital information regarding the risks posed by the CYDC young people, as well as the management strategies that were developed to ensure the safety of staff and other young people, were not adequately communicated to staff actually responsible for the daily supervision of the CYDC young people.

Pool rooftop incident

CCTV records showed that BYDC staff had used one of the CYDC young people to speak to two young people who had climbed onto a rooftop next to the pool on 24 November 2016 (the pool rooftop incident).

Given the fear of the CYDC young people within the broader BYDC population, the use of one of the CYDC young people in BYDC’s response to the pool rooftop incident failed to consider the significant risk he posed to the safety and security of the centre. Records made by BYDC staff about the pool rooftop incident also did not record the CYDC young person’s involvement, undermining confidence in the management of the event and compromising the review of the incident by both inspectors from the Youth Detention Inspectorate and this Office.

Allegations of threats and assaults on young people orchestrated by BYDC staff

A number of young people made complaints that some BYDC staff threatened young people with being transferred to the unit where CYDC young people were accommodated, and that young people were ‘set up’ by some staff to be assaulted by the CYDC young people.

The evidence indicated that during December 2016 and January 2017 there were a series of incidents involving the CYDC young people that appeared to cause considerable concern and anxiety among young people at BYDC. These included:

  • assaults between the CYDC young people and other young people
  • perceptions by young people that some BYDC staff were threatening to move
  • young people to an accommodation unit so they would be assaulted by the CYDC young people
  • the perceived use of the CYDC young people as ‘enforcers’ by some BYDC staff
  • young people being ‘set up’ by BYDC staff to be assaulted by the CYDC young people.

BYDC staff interviewed during the investigation denied making any type of threats to transfer young people to any particular unit. However, some staff did acknowledge that they had heard rumours that these types of threats had been made, or that a young person had told them that they had been threatened by a staff member in this way.

While the investigation did not substantiate any specific allegation of a staff member threatening a young person with transfer to any particular unit, the weight of evidence indicates that threats of this nature were likely made by some BYDC staff. The reason for staff making such threats was not determined.

Perceived preferential treatment of CYDC young people by staff

Young people alleged that:

  • the CYDC young people had items in their rooms that were not available to other young people, particularly soft drink
  • these items were a form of payment from BYDC staff to the CYDC young people for assaulting other young people
  • there were differences in the consequences for misbehaviour experienced by the CYDC young people compared with other young people.

These specific allegations were not substantiated. It was not possible to conclude with certainty that the CYDC young people had access to soft drink in their room during the relevant period between November 2016 and January 2017.

Despite this, the fact that other young people had observed these items in the CYDC young people’s rooms added to the perception of favouritism and special treatment that was present in the centre between December 2016 and February 2017.

There was evidence that the CYDC young people were not always subject to the same consequences as other young people, particularly regarding being placed in separation. This fuelled the perception among other young people that CYDC young people were in a privileged position at BYDC.

Concerns about safety and security at BYDC in January 2017

Throughout January 2017, intelligence reports generated by BYDC staff suggested that some young people were gathering makeshift weapons in anticipation of having to fight the CYDC young people. The intelligence also suggested that some young people were planning a significant event, such as an attempted escape, and were attempting to inform other young people of their plan.

Weapons and other contraband concealed by young people were increasingly being found by BYDC staff throughout January 2017.

Despite these concerns, there were no apparent strategies developed by BYDC management to address the young people’s concerns about the CYDC young people which were a significant factor that was contributing to their behaviour.

By the morning of 30 January 2017, BYDC staff were aware that there was a risk of a significant incident occurring. Staff discussed the intelligence at the daily management meeting at 8.30am that morning. The volume of weapons and contraband that had been found over the previous few days was laid out for participants to view.

At this meeting, staff discussed how to manage the risks, including the intelligence that had been received. Unfortunately, evidence from staff who attended this meeting about what was discussed and agreed cannot be reconciled as no records of the meeting were made, including any agreed outcomes or strategies to address the risk of an incident occurring. As a result, it is not clear that BYDC established or implemented adequate strategies to manage the identified risks. Consequently, this may have been a missed opportunity to prevent a serious incident from occurring.

The BYDC riot occurred later on the day of 30 January 2017.

Use of separation at BYDC

Following the BYDC riot, the seven young people who had been involved were placed in separation for a period of up to 10 days. Separation of a young person in youth detention is effectively a form a solitary confinement. It generally involves the involuntary placement of a young person in a locked room.

In relation to the separation of the seven young people, the investigation examined:

  • whether BYDC considered relevant factors for each young person in deciding whether their continued separation was necessary
  • whether relevant approvals under the Youth Justice Regulation 2016 (YJ Regulation) were sought for the separations
  • the management of each young person’s separation.

The investigation found that the separation of the young people had been approved by the relevant decision-maker. However, there were significant failures in the recording of approvals obtained for separations and in the proper application of agency policy relevant to the separations.

The investigation found that there was insufficient evidence recorded to justify the continued separation of all seven young people for the full 10 day period. Due to inadequacies in the available records, it is not possible to determine whether a young person was separated in accordance with agency policy and whether they were appropriately managed.

Use of the admission rooms to accommodate young people

During their separation, a number of the young people were accommodated in the BYDC admission rooms. The admission rooms contain a small bench seat, but no other furniture. There are no bathroom facilities or running water. Young people accommodated in the admission rooms overnight slept on a mattress placed on the floor.

The investigation found that:

  • young people were required to ask a staff member to be let out of their room to be taken to the toilet. During the night, there may have been delays in escorting young people to the toilet because of staffing requirements
  • young people received drinking water in plastic cups or water bottles and had to request additional water from staff
  • there was a lack of appropriate temperature control and ventilation in the admission rooms which caused young people to complain about excessive temperatures.

Because of the lack of essential facilities, the admission rooms are clearly unsuitable for accommodating young people for any significant period of time, and particularly overnight.

Recommendations

Recommendation 1

The Director-General of the department:

  1. identify and implement necessary improvements to the process for developing and documenting risk management strategies for managing high risk young people
  2. review methods of communicating risk management strategies to staff working with high risk young people to ensure they have a sufficient knowledge of documented plans to manage particular high risk young people.
Recommendation 2

The Director-General of the department ensure that a directive prohibiting the use of young people in response to incidents is published in all Queensland youth detention centres.

Recommendation 3

The Director-General of the department provide further guidance and training to all staff in Queensland youth detention centres regarding:

  1. when to seek approval to move a young person/young people throughout the centre
  2. assessing risk prior to and during movement of a young person/young people throughout the centre
  3. accurately recording movements and the associated approvals.
Recommendation 4

The Director-General of the department provide further guidance and training to youth detention centre staff about incident reporting, including:

  1. when an occurrence report is to be submitted, regardless of having been requested to provide one
  2. what information is to be documented in an incident report and an occurrence report.
Recommendation 5

The Director-General of the department amend current policy and procedure regarding the review of incidents at a detention centre to ensure that where CCTV footage of an incident is available, that footage is reviewed.

Recommendation 6

The Director-General of the department amend the Youth Detention Centre Operations Manual to provide more detailed guidance about the items permitted to be in the possession of young people and the reasons for any restrictions. The Manual should also outline any specific exemptions or special circumstances regarding items permitted to be in the possession of young people.

Recommendation 7

The Director-General of the department review the process for gathering and analysing intelligence at detention centres to ensure that intelligence can effectively inform operational outcomes. As part of this review, the Director-General should ensure the following issues are addressed:

  1. clarifying which officer at a youth detention centre is responsible for collating and assessing intelligence and assessing risk to the safety of the centre, staff and young people based on that intelligence
  2. clarifying which officer at a youth detention centre is responsible for deciding the appropriate operational action in response to the assessed risk to the safety of the centre, staff and young people based on that intelligence
  3. how operational responses to intelligence are communicated to detention centre staff
  4. how the operational action in response to intelligence is recorded.
Recommendation 8

The Director-General of the department review the current internal review capacity at youth detention centres and ensure the following:

  1. detention centres have a review group that is responsible for conducting internal reviews of significant incidents that occur at the centre
  2. membership of the review group is multidisciplinary and includes, at minimum, representatives from management, operational, casework and behaviour support teams as well as staff responsible for oversight and compliance
  3. appropriate records are kept of meetings held by the review group
  4. reviews include a consideration of the root cause of each incident as well as the centre’s response
  5. appropriate outcomes from reviews are disseminated to staff to encourage a culture of continuous improvement.
Recommendation 9

The Director-General of the department ensure that the responsibility for managing complaints at detention centres is appropriately prioritised to ensure high priority or high risk complaints are dealt with in a timely way.

Recommendation 10

The Director-General of the department immediately prioritise enhancing the CCTV coverage at BYDC to maximise coverage of the centre, particularly in the accommodation unit common areas, in the interests of protecting both staff and young people.

Recommendation 11

The Director-General of the department implement body worn cameras that provide both a visual and audio record for all operational staff working in youth detention centres.

Recommendation 12

The Director-General of the department ensure all directives at a youth detention centre are:

  1. communicated in a way that ensures all staff are made aware of them
  2. available in a single location which is easily accessible to all staff.
Recommendation 13

The Director-General of the department amend the separation policy to require approval from the chief executive’s delegate where a young person is separated for a continuous period of 24 hours, regardless of the reason for this separation.

Recommendation 14

The Director-General of the department provide comprehensive training to all youth detention staff with the delegation to place a young person in separation for any period of time about:

  1. the circumstances when a young person may be placed in separation for any period of time
  2. when approvals for separation must be sought, including how the approval must
  3. be sought
  4. the specific requirements for a separation that continues past 24 hours
  5. the potential consequences for non-compliance with the requirements under s.21 of the Youth Justice Regulation
  6. the staff member’s responsibility to make adequate records about the separation.
Recommendation 15

The Director-General of the department develop and implement a procedure regarding the administration of separation, which has a particular focus on strategies to ensure the safety and wellbeing of young people while separated. Once implemented, all detention centre staff should be trained in the requirements of the procedure.

The procedure should, at minimum, address the following issues:

  1. mandate a minimum period that a young person placed in continuous separation must be outside their room each 24 hour period
  2. require staff to accurately and clearly record the time a young person spends out of their room for any reason during periods of separation, including for the purposes of using the bathroom, making phone calls, attending visits or exercising
  3. ensure there is an adequate system to allow staff to make records of a young person’s out-of-room time and that staff are trained and demonstrate competency in its use
  4. require young people placed in separation for longer than 24 hours to be visited and assessed by a registered health practitioner and a case worker, and for further visits to occur on each subsequent day the separation continues.
Recommendation 16

The Director-General of the department review the legislative and regulatory framework regarding the use of separation in youth detention centres and determine whether they are effective and sufficient to protect the safety and rights of young people. At minimum, this should include:

  1. a review of the provisions of the Youth Justice Regulation and relevant departmental policies and procedures
  2. a comparison with the regulatory and policy requirements and safeguards for separate confinement under the Corrective Services Act and Corrective Services Regulation
  3. a comparison regarding how separation is regulated in other Australian jurisdictions
  4. a review of the adequacy of recordkeeping systems, recordkeeping requirements and the capacity of staff to efficiently and effectively use these systems
  5. a review of current training provided to youth detention centre staff.
Recommendation 17

The Director-General of the department ensure that:

  1. young people are not accommodated in rooms at a detention centre that do not have access to a bathroom, clean drinking water and adequate temperature control and ventilation unless in exceptional and limited circumstances
  2. a policy and procedure is developed and implemented to regulate the specific use of the admission rooms, including the adequacy of staffing while these rooms are in use
  3. staff are provided with adequate training about the requirements developed regarding the use of the admission rooms.
Last updated: Thursday, 19 September 2024 8:16:54 PM