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Public hearing 27 - Conditions in detention in the criminal justice system, Perth - Day 1

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CHAIR: Good morning, everyone. I would like to welcome everyone who is participating in or following this hearing, which is the 27th Public hearing of the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability. This hearing is being the conducted at the Pan Pacific Hotel in Perth, Western Australia and is the first Public hearing we are holding in Western Australia. We had hoped to hold a Public hearing in that state in 2020, two years ago, but COVID 19 thwarted our plans. Better late than never. 

The evidence at this hearing will examine conditions in detention for people with disability in the criminal justice system, including conditions in both youth detention centres and adult prisons. The focus will be primarily but not exclusively on the criminal justice system in Western Australia. I now invite Commission Andrea Mason OAM to make the Acknowledgment of Country. 

COMMISSIONER MASON: Thank you, Chair. We acknowledge the Whadjuk Noongar people as the original inhabitants and traditional owners of the lands on which we gather today. Whadjuk is where the city of Perth is situated. We acknowledge their ongoing spiritual and cultural connection to Whadjuk Wudja. We acknowledge the Gadigal People of the Eora Nation, where the city of Sydney is now located. We acknowledge and pay our deep respect to elders past and present and we extend that respect to all First Nations people and acknowledge their enduring connection to land, sky, seas and waterways. 

Finally, we pay our deep respect to First Nations people here today and who are following this Public hearing online on the mainland, on the islands, including the Torres Strait, especially elders, parents and young people and (Indigenous language spoken) with disability. Thank you, Chair. 

CHAIR: Thank you very much, Commissioner Mason. I'm joined today by Commissioner Mason and Commissioner Alastair McEwin AM. Both Commissioner Mason and Commissioner McEwin are in the hearing room in Perth. I had hoped to attend to Perth in to attend hearing in person. Unfortunately, and much to my regret, I have been unable to do so for significant family reasons. I therefore will participate remotely from the Sydney hearing room using the technology with which we have all become so familiar over the life of this Royal Commission. 

Senior Counsel Assisting the Royal Commission is Mr Patrick Griffin SC. He is in the Perth hearing room and will shortly make an opening statement. He appears with Ms Rebecca McMahon of counsel who is also in the Perth hearing room, and with Ms Georgina Wright SC, who is participating from the Sydney hearing room. A number of parties have been granted leave to appear, including the Commonwealth, all the states and the Northern Territory. I will invite the parties with leave – granted leave to appear to announce their appearances shortly. 

If the applications for leave to appear are any guide, this is a hearing that has attracted widespread interest. As I have frequently remarked, the conduct of our public hearings requires a great deal of preparatory work, not least with people who are to give evidence, including, of course, witnesses with lived experience of disability. This hearing was originally scheduled to take place over five days this week, Monday to Friday. 

As you will be aware, Thursday of this week, 22 September, has recently been declared a public holiday as a national day of mourning for the late Queen Elizabeth II. This has required the Royal Commission to adjust the hearing schedule. We will now hold the hearing on four days this week, that is excluding Thursday, the fifth day of the hearing will be held virtually on Thursday, 6 October 2022. 

Let me say something about the Convention on the Rights of Persons with Disabilities. All hearings of the Royal Commission are conducted with the provisions of the Convention on the Rights of Persons with Disabilities in mind. The provisions of the CRPD of most significance for the subject matter of this hearing are the following: Article 12 which provides that persons – people with disabilities have the right to recognition as persons before the law and the right to legal capacity on an equal basis as others in all aspects of life. 

Article 13, which requires state parties to ensure that people with disabilities have effective access to justice on an equal basis with others. Article 15 which requires state parties to take all effective legislative, administrative, judicial or other measures to prevent persons with disability on an equal basis with others from being subjected to torture or cruel inhuman or degrading treatment or punishment. Article 25 which obliges state parties to ensure that persons with disabilities have the right to the enjoyment of the highest standard of health without discrimination on the basis of disability.

I shall now mention previous hearings on this topic. This will be the first – third Public hearing in which the Royal Commission has examined the experiences of people with disability in the criminal justice system. Public hearing 11, held in February 2021, investigated the experiences of people with cognitive disability who have complex needs and who have been detained indefinitely without necessarily having been convicted of a criminal offence. Public hearing 11 focused upon the experiences of two First Nations people given the pseudonyms of Melanie and Winmartie. 

Both had been detained for very long periods in terrible conditions, having been found unfit to plead to the charges brought against them. One important theme that clearly emerged from the evidence of Public hearing 11 is the extent to which disability is criminalised in Australia. Public hearing 15 investigated more broadly the experiences of people with cognitive disability who are incarcerated whether as a result of a conviction or otherwise. 

The evidence addressed the supports required to maximise the opportunities for rehabilitation and successful integration or reintegration into the community, including culturally appropriate supports for First Nations detainees. Public hearing 15 particularly considered two issues. First, the division of responsibility between the Australian Government and state and territory governments for providing supports and services to people with cognitive impairment or disability who are enmeshed in the criminal justice system. Secondly, the role of the National Disability Insurance Scheme, the NDIS, in assisting people with cognitive disability to transition from prison or custody into the community. Both issues will be addressed further in evidence during this hearing. 

The major issues to be considered at this hearing include the following: The reception screening of detainees on entry into custody, and whether current processes are effective in identifying people with disability, particularly those with intellectual or psychosocial disability; measures required to improve access to equipment and appropriate means of communication for people with disability in custodian settings; support for people with disability in custody, including access to treatment for psychosocial disabilities; the ways of providing culturally appropriate supports and health services to First Nations detainees; and mechanisms to reduce the risk of violence, abuse, neglect and exploitation of people with disability in custody, such as specialist units within custodial settings and more effective complaints and oversight mechanisms. 

Data was presented at both Public hearing 11 and Public hearing 15, demonstrating the massive overrepresentation of First Nations people in prisons in this country. The 2021 Prisoners in Australia survey coordinated by the Australian Bureau of Statistics is now available. It shows that between 30 June 2020 and 30 June 2021, the adult prisoner population increased in Australia by 4.6 per cent to a total of nearly 43,000, of whom just over 13,000, or 30.3 per cent of the total, were First Nations people – an increase of 7.8 per cent over the previous year. 

This percentage is 10 times the percentage of the adult Australian population who identify as First Nations people, that is, around 3.2 per cent. In Western Australia as at 30 June 2021, 2,664 of the total of 6,716 adult prisoners – 39.7 per cent – were First Nations people. The total includes 2,053 prisoners who were in custody but not yet sentenced. The comparable figure for First Nations prisoners in the Northern Territory was 85.6 per cent of the total adult prisoner population. The disproportion of First Nations people in prison is a terrible indictment of policies adopted over many years by successive Commonwealth and state and territory governments. 

Public hearing 11 and Public hearing 15 also received evidence demonstrating the disproportionate representation of people with disability in custody, particularly people with intellectual disability or cognitive impairment. I do not intend to revisit that evidence. I only wish to mention two reports that illustrate the fundamental nature of the problems to be examined at this hearing. 

A Human Rights Watch report entitled "He's Never Coming Back": People with Disabilities Dying in Western Australia, analysed the reports of coronial inquests between 2010 and 2020, a decade. It found that 60 per cent of people who died in prisons in Western Australia during that period had a disability. Half of the prisoners with disability who died were First Nations people. A study was published in 2018 of young people in a Western Australian youth detention centre. It found that of the 99 young people who completed a full assessment, 88 had at least one domain of severe neurodevelopmental impairment, while 36 were diagnosed with foetal alcohol spectrum disorder, FASD. 

We will be receiving evidence over the five days of this hearing from about 26 witnesses, of whom eight are people with lived experience of disability. Mr Griffin will shortly provide more details about the evidence we can expect to hear. I want to refer to a recent decision of the High Court of Australia, which illustrates only too clearly the difficulty of achieving transformational change in this area, despite the overwhelming evidence that reforms are necessary not only in the interests of First Nations people and people with disability, but the community as a whole. 

On 7 September this year, less than two weeks ago, the High Court by a majority of five to two upheld the Constitutional validity of the High-Risk Serious Offenders Act 2020 of Western Australia. The effect of this Act is to authorise the Supreme Court of Western Australia to order the indefinite detention in custody of a "high risk serious offender", even after the expiry of the term of imprisonment for the offences of which the high-risk serious offender has been convicted. 

The expression "high-risk serious offender" is defined as follows: 

"An offender is a high risk serious offender if the court is satisfied by acceptable and cogent evidence and to a high degree of probability that it is necessary to make a restriction order in relation to the offender to ensure adequate protection of the community against an unacceptable risk that the offender will commit a serious offence."

An offender comes within the Act if he or she has been convicted of a "serious offence." A serious offence includes robbery. The Western Australian Act specifies a number of criteria that must be satisfied before the court determines that a person is a high-risk offender. The criteria include, first, any medical, psychiatric, psychological or other assessment relating to the offender; secondly, information indicating whether or not the offender has a propensity to commit serious offences in the future; thirdly, whether or not there is any pattern of offending behaviour by the offender; fourthly, the offender's antecedents and criminal record; and, fifthly, the risk that if the offender were not subject to a restriction order, the offender would commit a serious offence. 

One of the judges in the majority in the High Court remarked of this legislation that: 

“In its generalised application to a wide range of offences, Western Australia's approach is recent but not novel.”

That reflects the fact that other Australian jurisdictions have legislation that is not dissimilar to the Western Australian Act. It is instructive to look at the facts of the case reaching the High Court. A judge of the Supreme Court of Western Australia found that Mr Garlett, a Noongar man, satisfied the criteria in the Western Australian Act for the making of an interim detention order. I have used Mr Garlett's name because it is recorded in the judgment of the High Court and so is publicly available. 

The order meant that Mr Garlett could be detained in custody pending final determination of the proceedings, notwithstanding that his custodial sentence had expired. This is how the joint judgment of three members of the High Court majority described Mr Garlett's history: 

“On 19 November 2017, Mr Garlett, in company with others, entered a dwelling without consent and with threats of violence stole a pendant necklace and $20 in cash. He pretended to be armed with a handgun. He was arrested the following day and remanded in custody. He was charged with and pleaded guilty to the offences of robbery and assault with intent to rob. For the November 2017 offending Mr Garlett was sentenced in July 2019 to a total effective sentence of three years and six months imprisonment, backdated to commence on 20 November 2017, the date he was taken into custody. On 12 January 2021, he was sentenced to a further five months imprisonment for the offence of criminal damage, committed while he was in prison. Mr Garlett's release date was 19 October 2021." 

I'm still continuing to quote from the joint judgment in the High Court:

"Mr Garlett was 23 years old at the time of the time of the November 2019 offending. He has a lengthy history of offending, which includes numerous aggravated burglaries, aggravated robberies and stealing a motor vehicle. Generally speaking, he has a record of poor behaviour while in custody. His history of offending, with his first recorded convictions in April 2007, is related to his abuse of alcohol and drugs, which was already manifest when he was 12 years old. 

Mr Garlett was released into the community in September 2017 from imprisonment for earlier offending. But shortly thereafter, he tested positively for methylamphetamine, amphetamine and cannabis. It is noteworthy that the November 2017 offending occurred only two months later. By his admission, Mr Garlett was injecting methylamphetamine daily at the time of offending."

That ends the quote from the joint judgment. The joint judgment of the High Court from which I have just quoted does not refer to Mr Garlett's upbringing and background. That is dealt with in more detail in the judgment of the Supreme Court of Western Australia. This is some of the additional information that might explain Mr Garlett's criminal history. First, he had "a sad and difficult upbringing lacking in proper nurturing". 

Secondly, in early childhood, he was exposed to domestic violence and abuse of his mother by his father, as well as abuse of alcohol in the home. Thirdly, he was placed in foster care at the age of seven when his parents were sent to prison. Fourthly, he experienced physical abuse at the hands of his parents. Fifthly, he was the subject of a protection order in 2002 when he was eight. Sixthly, his first recorded conviction was in 2007 when he was 13. Seventh, he was expelled from school at the age of 10, and at 12 was living on the streets. And finally, he has a long history of substance abuse. 

Perhaps the most remarkable feature about this case is that, as the Supreme Court judge recorded, no psychiatric or psychological reports were in evidence on the application for a detention order that was heard by the Supreme Court. A cognitive skills program completion report noted that Mr Garlett was on anti-depressants and suggested that there might be further benefit in exploration of underlying mental health issues which had led to his substance abuse. Apparently, that exploration did not take place. 

The Supreme Court judge observed in his judgment that it was:

"...perhaps surprising that there was not more evidence of Mr Garlett having been referred to at least a psychologist while in detention or custody given his apparently abusive and impoverished childhood."

It is neither my function nor my purpose to question a decision of the High Court. But perhaps we might wonder whether in 2022, 31 years after the report of the Royal Commission into Aboriginal Deaths in Custody, preventative detention is the most appropriate means of rehabilitating prisoners with disability, including First Nations prisoners with disability, and the most appropriate and whether it is the most appropriate means of allowing them to return to their communities safely and without presenting a danger to those communities. 

I shall now invite Commissioner McEwin to make some remarks acknowledging the International Week of the Deaf and Australia's National Week of Deaf People, both of these occurring in this week. I shall then take appearances. Commissioner McEwin. 

COMMISSIONER McEWIN: Thank you, Chair. This week is International Week of the Deaf. It is also Australia's National Week of Deaf People. The theme for 2022 is building inclusive communities for all. This week also coincides with International Day of Sign Languages. That falls on Friday, 23 September. Throughout this week, there are daily themes that link back to the overarching theme for 2022. Friday, 23 September, the theme being sign languages unite us. 

Here, the Royal Commission has received evidence and information from Deaf, Deaf blind, hard of hearing and hearing impaired. Those representatives, their organisations, have been providing evidence to the Royal Commission, ensuring that access to Australian sign languages, Auslan, has been a prominent theme. 

The Convention of the Rights of People with Disability recognises and promotes the use of Australian sign languages – of all sign language. It makes it clear that sign languages are equal in status to spoken languages and obligates state parties to facilitate the learning of sign language and also to promote the linguistic identity of the Deaf community. This week is a great opportunity to work together, to work in collaboration with the Deaf community, by sharing their language, their identity, their Deaf culture, and their Deaf pride. Thank you. And thank you again, Chair. 

CHAIR: Thank you, Commissioner McEwin. I shall now take appearances. Perhaps starting with Mr Griffin. 

MR GRIFFIN: Chair, my name is Patrick Griffin SC. I appear with Georgina Wright SC and Rebecca McMahon of counsel as Counsel Assisting the Royal Commission in this public hearing. 

CHAIR: Thank you very much, Mr Griffin. Can we start with the Commonwealth. 

MS ROBERTSON: Good morning. Courtney Robertson. I appear on behalf of the Commonwealth. 

CHAIR: Thank you very much. Can we then proceed to the State of New South Wales. 

MS FURNESS: If it pleases the Commission, my name is Gail Furness and I appear with Trent Glover, instructed by the Crown Solicitor for New South Wales. 

CHAIR: Thank you, Ms Furness. The State of Queensland. 

MS MCMILLAN: Yes. Good morning, Chair. My name is McMillan, initials K.A., of King's Counsel. I appear on behalf of Queensland instructed by the Crown law. 

CHAIR: Thank you. That's the first announcement of an appearance of King's Counsel. 

MS MCMILLAN: It takes it a little longer to roll it off the tongue, Chair. 

CHAIR: Yes, it does. Yes. It also involves the changes of letterhead and all the sorts of things. 

MS MCMILLAN: It does indeed. 

CHAIR: Yes. Can we move to the State of Victoria? 

MS BEDFORD: Good morning, Chair. My name is Rebecca Bedford, and I appear on behalf the State of Victoria. 

CHAIR: Thank you, Ms Bedford. The State of South Australia. Is there an appearance for South Australia? All right. I will move to the State of Western Australia. 

MR PETTIT: Good morning. If it please the Commission, I appear with Ms Naomi Eagling and Ms Jasmine Buller for the State of Western Australia, on instruction from the State Solicitor's Office. 

CHAIR: Thank you, Mr Pettit. The Northern Territory. Is there an appearance for the Northern Territory? Apparently not. Is there an appearance for the Inspector of Custodial Services? 

MR RUSSELL: Yes, there is. My name is Russell. I appear for the Inspector of Custodial Services in Western Australia. If it please pleases the Commission. 

CHAIR: Thank you. You came across quite faintly but, nonetheless, you have announced your appearance. Thank you. And is there any other appearance to be announced by any other party given leave to appear? Yes. 

MR NEWHOUSE: Yes, Newhouse. I appear for witnesses 1, 2 and 4 today. 

CHAIR: Thank you very much, Mr Newhouse. I think that concludes the appearances. If any of the parties I have mentioned have an appearance to announce later on, that can be done. Yes, Mr Griffin. 

MR GRIFFIN: Commissioners, we also acknowledge and pay our respects to the traditional custodians of the lands on which we are meeting today. We pay our respects to First Nations elders past, present and emerging, as well as all First Nations people with disabilities, following this public hearing. 

Before addressing the issues to be explored in this hearing, I must warn people watching or listening that I'm about to refer to incidents of violence against and abuse of people with disability. The Royal Commission encourages people who may be distressed to seek support. A slide will now appear on the screen with relevant contact numbers if assistance is required. 

Commissioners, Public hearing 27 will build on three previous public hearing, namely Public hearing 11, the experience of people with cognitive disability in the criminal justice system; Public hearing 15, people with cognitive disability in the criminal justice system, the NDIS interface; and Public hearing 16, First Nations children with disability in out of home care. 

In Public hearing 11, the Royal Commission heard about the factors which contribute to people with cognitive disability, first coming into contact with the criminal justice system, the overrepresentation of First Nations people with cognitive impairment within the criminal justice system, and how and why people with cognitive disability cycle in and out of the criminal justice system on a regular basis. Public hearing 15 examined the approach of the Commonwealth, state and territory governments in respect to division of responsibility for providing supports and services to people with cognitive disability involved in the criminal justice system. 

It considered the barriers to people with such disability involved in the system in assessing the NDIS, including with respect to transition from custodial environments. Whilst, as I mentioned, Public hearing 16 was about out-of-home care, it looked at negative outcomes for First Nations children with disability in out-of-home care, including care criminalisation. Some of the themes emerging from the hearing are relevant here. They include the lack of culturally appropriate assessments and services, underdiagnosis of particular conditions, including FASD, and consequences of failing to identify disability. 

The hearing commencing today has a jurisdictional focus on Western Australia, including the experiences of First Nations people with disability in detention. While considerable attention will be given during the hearing to issues arising from the Banksia Hill Detention Centre, given the very significant problems currently affecting that centre, the issues we are going to examine are of relevance to prisons and detention centres more broadly. 

You will have the opportunity to hear from witnesses with lived experience of disability who have been imprisoned or placed in detention centres around Australia. Witnesses from legal bodies, prisoners' rights and advocacy organisations, together with medical experts, will give evidence in some instances as part of multi member panels appearing before you. 

On the last two days of the hearing, witnesses holding roles within the Western Australian government will give evidence and be examined. Chair, as you mentioned, the hearing was to be conducted over five days this week. The decision by the Australian Government to designate Thursday as a public holiday has necessitated a change in program. In short, witnesses originally scheduled to appear on Thursday will now give evidence on Friday, and the evidence from the Western Australian government witnesses, originally scheduled for Friday, will now be taken remotely on 6 October of this year. 

Commissioners, let me say something about the scope and purpose of the inquiry which will unfold before you this week. As I mentioned, the hearing will mainly but not exclusively focus on conditions in detention in Western Australia. We have identified six major themes emanating from the evidence which will be adduced. Firstly, the issue of reception screening on entry into custody and whether the processes of screening and assessment are effective in identifying people with disability. 

Secondly, measures to improve accessibility and access to equipment for people with disability in custodial centres. Thirdly, gaps in supports for people with disability in custody and access to treatment for psychosocial disability and how these gaps might be addressed. Fourthly, ways of providing culturally appropriate supports and health services to First Nations inmates or detainees. Fifthly, whether inmates with disabilities receive equitable access to programs in custodial settings and education in juvenile justice settings. 

And, finally, we will be looking at mechanisms to reduce the risk of violence, abuse, neglect and exploitation of people with disability in custody such as specialist units within prisons and detention centres, and the role of complaints and oversight mechanisms in relation to the treatment of those people. 

Your Counsel Assisting team anticipates that the evidence will firstly highlight the high rates of incarceration of people with disability, particularly amongst First Nations people. You will hear about violence, abuse, neglect and exploitation against people with disability detained in youth detention centres and also in adult prisons. We will address why the policies, practices and responses in these places have often failed to address the violence, abuse, neglect and exploitation which occurs in these settings. We will examine the effectiveness of oversight and complaint mechanisms in place not only in Western Australia but elsewhere in the hope of encouraging examination and reform of those processes. 

You will hear from human rights groups and advocates about their work with people with disability in detention, and most importantly, you will hear about some of their extensive proposals to change. And in this context, Commissioners, we are particularly looking at changes which can benefit not only people in custody but the people who have responsibility for taking care of them whilst they are in that setting. It's a hope of Counsel Assisting at the end of this inquiry that we might be able to put proposals in our submissions which can genuinely be described as win-win for all concerned. And we do that because we recognise these are complex issues. 

Finally, the evidence will deal with the specific Western Australian agencies' responses to particular events and to proposals for changes. Can I take a moment to comment on some of the data in relation to people with disability in custody. Chair, in Public hearing 11, you observed and I quote: 

"There is a dearth of data about people with disability, especially with cognitive disability, who are in custody."

Despite this, several past reports have raised concerns about the overrepresentation of those with disability in prisons and has been reported variously that over 25 per cent of prisoners may have an intellectual disability.

Human Rights Watch, an organisation from whom you will hear later in the week, has reported that almost 50 per cent of people entering prison have some form of disability. The estimate in the general population is, by contrast, 18 per cent. So, on that research, it suggests that those entering custodial settings are two and a half times more likely to have a disability than members of the general public. 

Chair, you have referred to recent data in relation to First Nations prisoners. I won't repeat what you've said in relation to that. Western Australia has the highest rate of overrepresentation of First Nations people in prison of all the states and territories. It's been reported that First Nations women are the fastest growing cohort of prisoners in Australia. A significant proportion of this group have cognitive impairment, as well undiagnosed psycho social disability. 

Importantly for your consideration of the issues that we will place before you is that there is no nationally consistent disaggregated data on the number of First Nations people with disability in prisons. And you will hear later in the week some evidence that's being done in the various states and territories via a national body to try and get some commonality of a collection of information and the analysis so that the extent of the issues that we are raising can be more precisely identified and the scope of the task can be better delineated. 

There is a lack of national data on a number of imprisoned people with fetal alcohol spectrum disorder. That's FASD that I referred to a moment ago. A 2017 report indicated that First Nations children with FASD are particularly prevalent in the youth justice system. One study, the first to estimate the incidents and prevalence of FASD in imprisoned children involving young people in Western Australia, found that 89 per cent of participants, 76 per cent of whom were First Nations youth, had at least one domain of severe neurodevelopmental impairment, and 36 per cent, over one third of participants in that group, were diagnosed with FASD. 

The Lililwan Project in the Fitzroy Valley of Western Australia, which was the subject of some consideration at a previous public hearing in Alice Springs, refers to the ongoing prevalence study of FASD in Aboriginal communities found that nearly 20 per cent of children assessed were affected by FASD. The significance of those figures, Commissioners, and those observing this hearing, is that a very large proportion of young people coming into detention in this state, in the Northern Territory and other parts of Australia, have very considerable disability, and we will be suggesting during the course of this hearing that that has to be the primary factor which comes into play when one assesses these young people, determines their particular difficulties and, most crucially, develops a plan for how they are going to be dealt with whilst they are in detention. 

That's an example of what I referred to a moment ago of how the evidence could end up helping everybody concerned. Particularly those working within those institutions. Chair, you have also referred in your introductory comments to the overrepresentation of people with disability in prisons, and you referred to the fact that in excess of 42,000 prisoners in Australia, including those on remand. You referred to the fact that the first decrease in prison population of the past ten years occurred only recently. 

But when one goes back 2018, the prison population in this country had increased by about 56 per cent over the previous decade, compared to a 17 per cent increase in the general population. So, not only are we dealing with the issues that I've specified, but we are dealing with a trend of an increasing proportion of people being in custodial settings and all that flows from that. There wouldn't be, I suspect, anyone in this room or listening to this hearing who wouldn't wish to reverse that trend. 

The figures in relation to First Nations people is particularly disturbing, and the recidivism rate amongst that group seems to run as high as 79 per cent, if one has been in an adult prison previously. And as you observed in Public hearing 11, Chair, it's hard to describe this phenomenon any way other than a revolving door of First Nations people in and out of incarceration. 

Let me briefly deal with some information from the Australian Institute of Health and Welfare. It dealt with people with cognitive disability and conducted a survey in 2018 which found that 29 per cent of prison entrants reported they had a long-term health condition or disability that affected their participation in education, employment, and in general everyday activities. This is a much higher proportion of people with disability in the general population, where only about 13 per cent gave the same report. 

Of those reporting such a condition or disability, one-third of non-indigenous entrants rated their disability as profound or severe. On nearly half of the First Nations entrants recording a long-term condition rated that disability as prevalent or severe. The same survey of the Australian Institute of Health and Welfare showed that almost one quarter of entrants into these settings were currently taking some form of mental health medication. 

Professor Eileen Baldry, a criminologist, gave evidence about prison population in Public hearing 11. One of her studies found that two thirds of people had been in prison between – who had been in prison between 2000 and 2008 had multiple complex needs. Nearly all of these people were known to the police as victims of crime. She concluded that many thousands of people across Australia were being managed – to use her word – by the Australian criminal justice system rather than being supported by the community. A quarter of the people in her study identified as First Nations people. 

Commissioners, as you are aware, in addition to Public hearings, the Commissioners receive many written submissions since it commenced its work. One of those submissions came from the Jesuit Social Services. In a written submissions to the Royal Commission, this group has set out some key principles for good youth justice system. These principles provide a framework of how the states and territories could improve their treatment and care of youth with disabilities in prison or in detention. 

They include – this is not an exclusive list – developing relationship-based models, listening to the voices of young people and their families, developmentally appropriate approaches to them, recognising the importance of culture and country for Aboriginal and Torres Strait Islander people, a thorough assessment and planning being particularly alert to disability and low level cognitive functioning, addressing the offending behaviour, addressing mental health, substance abuse, and other health and wellbeing needs. 

Creating strong frameworks of support and accountability, a focus on education that builds practical and social skills for the purpose of resocialisation. Crucially – and this has been said many times, but we often forget – ensuring that incarceration is a last resort. Focusing on early intervention and diversion and exploring the multitude of restorative justice approaches which are current abroad in the community amongst people that look at this issue closely. 

I stress again that your Counsel Assisting want to take what is frequently a grim situation in relation to the issues and try and take an optimistic approach to what can be achieved. And we will return to that during the hearing and during our final submissions. 

Prior to describing the particular witnesses who will give evidence this week, it is worth reiterating that this hearing will examine the conditions in custody that people with disability must navigate. This will occasionally involve consideration of the broader context of their experience of the total criminal justice system and acknowledge that there are complex issues which contribute to people with disability entering the criminal justice system and, in some cases, ending up in prison or detention. The issues examined in the previous hearings will be taken into account. 

Importantly, a targeted approach to these broader issues is critical to reducing the proportion of people with disability coming into the criminal justice system in the first place and of course then graduating on occasions into custodial settings. 

So I hope that the focus on conditions in custody will allow us to consider more deeply the extent to which corrective and health services are or are failing to support the needs of people with disability. An important aspect of this hearing is to examine some of the community based programs and organisations who are providing services and developing models to provide support for people with disability in these settings and in a number of states and territories. 

Can I now move to what the Commission describes as lived-experience witnesses. Commissioners, you will hear from people with disability who have lived experience of being in a prison and family members of adults and young people with disabilities who have been imprisoned or detained. The experience you will hear are drawn from Western Australia, New South Wales, the Northern Territory and Victoria. Their stories are confronting. 

Each of the witnesses have reflected on their experience or the experience of their loved ones and have provided recommendations with a view to improving the system and the lives of other people with disability who may be imprisoned or detained. Can I indicate at that point, Commissioners, we often lose sight of the fact that once incarcerated, people don't necessarily have family or extended family to provide support for them. It makes their life very difficult. 

The first witness today is Jasmin. She will read the statement of Nathan, who refers to her as his mother. Nathan is Noongar man from Western Australia who was diagnosed with ADHD in Primary School. You will hear about the trauma Nathan experienced growing up. He first went into youth detention when he was 11 years old and cycled in and out of detention in his teenage years. He is now 24 years old and in prison in Western Australia. 

Nathan describes a harrowing time at Banksia Hill Detention Centre. He states that he suffered physical abuse at the hands of detention staff, including while handcuffed, resulting in injuries. He experienced strip-searching, the use of mechanical restraints, isolation, and extended lockdowns. He describes the physical conditions of the multi-purpose, known as MPU cells, at Banksia he was placed, as "dirty and disgusting." 

The cells were cold and dark, with concrete floors and walls. They smelled of Urine. Some days in the MPU, he would not be let out for fresh air. Other days, he would be allowed out for 20 minutes. Nathan raises issues of inadequate mental health care, a constant theme throughout this hearing. His first self-harm attempt was at Banksia. Following that incident, he was left naked on the floor of his cell. He felt that his cries for help were not being taken seriously. 

Jasmin regards Nathan as her son. She will give evidence in the hearing room shortly about her biological son Maison, who is Nathan's best friend. They met one another at Banksia. Maison first went to Banksia when he was 15 years old. Similar to Nathan, Jasmin will also tell you that Maison experienced extended periods of isolation. Whilst in isolation Maison told his mother that he had no psychiatric visits or medical attention and rarely showered. 

He complained to his mother of being strip searched and having insufficient access to medical and mental health care. On one occasion he suffered grazes to his face following staff handcuffing his hands behind his back, cuffing his feet and then using a third set of handcuffs, joining the hands and feet. 

Both boys expressed mental health issues in the context of this trauma. Jasmin will share her recommendations of what needs to change for young people in detention centres. You will then hear from Cheryl Ellis. Ms Ellis's son Gavin died tragically between 1 and 2 April 2011, at the Metropolitan Remand Centre and Reception Centre in Silverwater in Sydney. He took his own life. New South Wales Deputy State Coroner Forbes handed down her report into the inquest into Gavin's death just over three weeks ago on 2 September 2022. 

The circumstances of his death have given rise to recommendations including that consideration given to steps that could be taken to deliver better support and care to inmates who are placed in or are recently released from so called safe cells. Ms Ellis will share with you information about her son, his strengths and his challenges. How she supported him in his life and whilst he was in custody. She wants to tell you, Commissioners, about her recommendations about how conditions in custody could be improved to better support people with disability. 

Following the evidence of Cheryl Ellis, Counsel Assisting will read the evidence of the Mother of JC, a pseudonym for a witness. JC was a Yamatji woman who was tragically shot by police and died at age 29. She left behind a 6 year old son. Let me talk about JC. She had a background of extreme disadvantage and experienced serious and long standing mental health issues. Her mother will tell the Royal Commission that she believes the Western Australian prison system neglected JC's mental health needs. 

Concerns are raised about the impacts of JC being off country and not receiving culturally appropriate care from Aboriginal health workers or other cultural support. JC received a late diagnosis of FASD, and her mother believes that earlier screening would have made a difference for her, as she would have received more support at an earlier stage. Her mother wants to share her experiences and the experiences of her daughter in prison to ensure that people with disability with complex health conditions receive the support they need both in prison and when they return to the community. 

Commissioners, that will conclude the evidence for today, the first day. Tomorrow morning, we will hear from Tina Powney, Trevor Baker, and Tyrone Justin. Tina Powney is the mother of Tyrone Justin. She is a Barapa Powley woman, who will give evidence about his experience, including her difficulties in being able to contact him and her distress about her son not being provided with the medication he needed. It was her experience of supporting her son in custody, based on her strong social work background, that led her to creating and becoming the sole director Gallawah, a First Nations run NDIS support coordination provider. 

Trevor Baker, who is Gallawah's Aboriginal Coordinator of Supports, will join Tina Powney in giving oral evidence. Gallawah is based in the Goulburn Valley in Victoria. It provides support coordination in a range of settings, including prisons in Victoria. Gallawah has 60 staff and currently provides services to 200 clients, 40 of whom are in prison, 20 on community corrections orders and four young people in juvenile detention. Approximately 90 per cent of Gallawah's clients are of First Nations background. 

The foundation to how Gallawah operates is respect for First Nations culture. Ms Powney and Mr Baker identify systemic deficiencies in prisons, where they support clients in relation to cultural safety, disability screening and assessment processes. They refer to medical and disability supports and programs and educational opportunities. Critically, the support coordination services provided by Gallawah in custody for people in their transition and then into community upon release provide a consistency of support which other witnesses highlight is sorely lacking elsewhere. 

The opportunity to examine the cultural safety offered by the service to First Nations people with disability provides an opportunity to consider the benefits of expanding the practices developed by Gallawah beyond country Victoria. Following that evidence, a pre-recording of the evidence of Tyrone Justin will be played. He is Yorta Aslan and Barapa Baraga man who lives with autism spectrum disorder, an acquired brain injury and attention deficit hyperactivity disorder. 

He was incarcerated in the maximum-security adult prison at the age of 18. He will tell you about his experience in isolation and the difficulties he had in getting his medication and not receiving mental health are he needed, and most importantly, the impact this had upon him. 

Members of your Counsel Assisting team travelled to Yarram in Victoria to pre record his evidence. He currently resides at Wulgunggo Ngalu Learning Place. He is currently thriving and, according to his family, is on the road to recovery and healing. You will see images of and hear more about the Learning Place in the course of his evidence. It is a culturally appropriate learning facility which houses and supports up to 18 First Nations men who are the subject of community correction orders. He will tell how culture and connection is central to his strength and his rehabilitation. 

I anticipate his evidence will prompt the Royal Commission to consider how programs like the Learning Place could be expanded to include a presence in prison programs designed to support First Nations people with connection to culture, and as a by product, to enhance their social and emotional wellbeing. So, you will have a considerable body of evidence from what I call the positive side of the issues we are discussing today. And, Commissioners, you will have the opportunity to give consideration whether, in your assessment, those approaches taken in relation to the two circumstances I have outlined could have much wider implementation in the states and territories. 

The next witness will be Di Lyons, who lives in community, having previously spent four years in women's prisons in Queensland. She requires as a wheelchair on account of muscular dystrophy. Whilst in prison, she suffered because of inadequate accessibility in the prison environment. She spent an extended period in a "dry cell" because, as she understands, there was a lack of accessible cells. Dry cells are usually used for safety purposes. 

There is no television or radio, personal belongings are not permitted, and fluorescent lights are left on 24 hours a day. She was required to navigate narrow doorways and passageways within the prison buildings, occasionally bruising as a result of the design of those passageways. She was assisted by staff who she presumed lacked training to help her move, having been dropped and suffered injuries on a number of occasions. A lack of staff meant that her showers were not sufficiently frequent, and at times a male officer would be present during showering. She was on one occasion dropped on the concrete whilst having a shower. 

Her evidence points to clear examples of Corrections and Health staff failing to meet her basic needs as a person who requires a wheelchair. It also raises another theme which we expect will be consistently raised in the course of this hearing, that is, a culture within Corrections which is both uncaring and rigid. This appears to be demonstrated in this case by failing to respond to the supports required. This sort of culture amongst some Correctional staff, if not seriously addressed, will no doubt be a significant barrier to effecting positive change to conditions in custody for people with disabilities as we move forward past this hearing. 

We will then move to some expert evidence on Tuesday afternoon from Jennifer Cullen, the CEO of Synapse Australia, who will give evidence. That is a not-for-profit organisation and a peak body for brain injury. Ms Cullen's evidence will focus on the development and application of the Guddi Way Screen, which is a tool to identify cognitive impairment and psychosocial disability in the Aboriginal and/or Torres Strait Island adults over the age of 16. 

Ms Cullen will give evidence about the significance of cultural competence and safety and screening and the benefits of the Guddi Way Screen in custodial settings. These benefits include flagging possible cognitive impairment, identifying functional impacts to understand how the prison environment and programs should be modified to account for the supports required. We will also examine the possible benefits of the screening tool to assist with developing more targeted and appropriate release plans and supports. 

In your schedule, Commissioners, we then have a lived experience witness that I won't refer to at this stage because there are issues of consent which need to be resolved before that progresses. 

The next witness is Terry and his wife Kara. Terry will give oral evidence. Kara will be in the hearing room. They have provided a statement to the Royal Commission. Terry will give oral evidence about the abuse that his son Aaron experienced in youth detention in Western Australia. Aaron was diagnosed with ADHD as a child. He started having contact with the police from about the age of 12 as a result of behaviour which was directly related to his ADHD. 

When he was admitted to detention, his parents tried to tell the staff about his disability and his medication needs. He was not provided with some of the medication which his parents had indicated he needed for his conditions. Two weeks after being admitted to detention, he was sexually assaulted. According to his father Terry, the aftermath of the assault was handled poorly and this traumatic event continues to have ongoing impacts upon both Aaron and his parents. 

They believe that his disabilities and vulnerabilities should have been better understood and considered when he was admitted into detention. Terry will go into some detail of the chronology of what happened around the assault. Terry's evidence will conclude with some very thoughtful recommendations about people in detention being better supported. 

We then move on to another witness with particular expertise, and that's Megan Krakouer of the National Suicide Prevention organisation. On Wednesday, she will give evidence as the direct of the National Suicide Prevention and Trauma Project about the support she has provided prisoners at Acacia and young people at Banksia Hill – Acacia being a prison in Western Australia. Following the death of three First Nations men in Acacia, Ms Krakouer and her colleague, Gerry Georgatos, were contacted between October 2020 and June 2021 to provide services to men in that prison with the aim of reducing the rates of self-harm. 

Many of the men they supported had disabilities. They worked intensively at that facility for eight months on a full-time basis. They assisted hundreds of men, providing a range of services, including intensive supports and one on-one counselling. They helped create safety plans and post-release plans for the men. Their services were deeply embedded in culturally safe practices, and the support they provided was tailored to the individual needs of each person they were dealing with. 

In February of 2020, they were granted one-off funding to deliver an eight-week support program to girls at Banksia Hill. The majority of the girls they supported were living with FASD or cognitive impairment and had traumatic backgrounds. This work was individually tailored and included writing detailed background reports to the Children's Court, which included connecting the girls to housing options available to them and developing safety plans. 

They assisted with the preparation of successful release applications on behalf of some of these people. The work of Ms Krakouer and Mr Georgatos is an example of how community organisations – in this case, a culturally competent one – can improve the conditions for people with disability in custody and most importantly strengthen their prospects of success upon release. 

It is our expectation that the work of this community based organisations and Gallawah will provide strong evidence to the Royal Commission to consider the benefits of prisons and detention centres applying a more flexible approach to allowing community-based organisations access to their facilities to deliver a range of specialised tailored supports of both detainees and prisoners. It can create consistency of care and build the capacity of the Corrections and Health staff to better understand disability through partnerships with outside community organisations. It has the potential to fundamentally influence the culture within these custodial settings. 

The final witness on that morning will be Alen, which is a pseudonym for a witness who spent time in custody in New South Wales. Alen is Deaf and relies on Auslan to communicate. For the first four weeks of his imprisonment, he was unable to talk to anyone because he was not provided with an interpreter. Pause for a moment to imagine what that would be like. 

Understandably, his admission to custody was a difficult and worrying time. A lack of interpreters meant that period of imprisonment was lonely for many years. Alen's story gives rise to issues relating to the wellbeing of Deaf prisoners because he was unable to participate in activities and programs due to this unavailability of interpreters. Safety concerns arise from Alen's evidence because emergency alarms in the prison he was in are only audio and not visual, leaving him to rely on others to alert him when an emergency alarm sounded. Alen offers practical solutions to improving conditions for deaf prisoners including increasing the representation of Deaf people working in prisons, and the provision of things such as hearing loops. 

After Alen's evidence, we're going to move to the hear section of the hearing which deals with lawyers and advocates working in this area. On Wednesday afternoon, you will hear from a panel of three experts discussing issues and case studies of people with disabilities from a human rights perspective. The panellists are Kriti Sharma, a senior disability rights researcher from Human Rights Watch; George Newhouse, the CEO of the National Justice Project; and Deborah Kilroy, the CEO of the organisation called Sisters Inside. 

The panel will discuss a range of issues which they consider to be systemic within custodial detention environments for people with disability. Those issues will include the use and adverse impacts of solitary confinement, mechanical restraints, and strip searches. Inadequate screening and assessment of disability, considerations at reception. Gaps in accessing disability support in prisons, including mental health and mental health supports, lack of accessibility in a physical environment of prisons, particular issues faced by women with disability in prisons, and the negative cultural issues which exist amongst some correctional staff members. I anticipate the panellists will draw upon case studies from their research or their casework to demonstrate issues I've just identified. 

They will be followed by, on Wednesday afternoon, when we will play a pre-recorded evidence of Jody Ann Barney. Commissioners, as you will recall, Ms Barney gave evidence at Public hearing 25 in Alice Springs, which dealt with the effectiveness of the NDIS in remote and very remote First Nations communities Australia-wide. She is a Birri Gubba Urugan and South Sea Islander woman who is Deaf and communicates using Auslan, various forms of First Nations sign language and written English. 

She is the founder of Deaf Indigenous Community Consultancy and has over 35 years’ experience working alongside Deaf and Hard of Hearing First Nations people. My recollection from the Alice Springs hearing, Commissioners, was that she speaks or understands in excess of 20 First Nations sign languages, there being in excess of 50 such languages Australia-wide. 

Her evidence will highlight the scale of hearing loss in First Nations peoples in detention, inadequate audiological screening, the lack of access to interpreting and First Nations signing systems and the impacts of this on prisoner rehabilitation and mental health outcomes. Ms Barney explains particular vulnerabilities of Deaf of hard of hearing people in custodial settings in relation to violence, abuse, neglect and exploitation. As you would appreciate from previous hearings of this Royal Commission, such people are particularly vulnerable in those settings. 

As has been mentioned previously, the Royal Commission will not sit on Thursday due to the public holiday. On Friday morning, lawyers from the Aboriginal Legal Service in Western Australia and from the Northern Australia Aboriginal Justice Agency, known as NAAJA, will participate in a panel discussion. In particular you will hear from the following representatives: Peter Collins, the director of legal services; Alice Barter, the managing lawyer in the civil law and human rights unit of the ALS; and Sasha Greenoff a diversion officer and team lead in the bail support service of that organisation. They will be joined on the panel by Megan Donahoe, a solicitor in the crime practice group of NAAJA. 

Witnesses from the ALS in Western Australia have provided a joint statement to the Royal Commission outlining their work in acting for both young and people – young people and adults with disability, who are in custody or detention in Western Australia. They provide de identified examples of cases from recent years to illustrate their observations about the treatment of people in custody with disability. 

A significant part of the ALS's work in Western Australia, in addition to representing clients in criminal proceedings in court, is, not surprisingly, receiving complaints about alleged treatment in both police custody and prisons for First Nations people with disability across the state and making complaints to government, if appropriate, on behalf of those clients. In carrying out their work, the Aboriginal Legal Service in Western Australia has lawyers who visit prisons and the Banksia Hill Detention Centre on a frequent basis. 

They received a significant number of complaints about Banksia Hill and have done so since it commenced operation in 2012. The panel witnesses will give evidence that young people who have disabilities which impair their impulse control and decision-making abilities have less capacity to adjust to the harsh physical environment and the procedural environment of a detention centre. It is worth repeating that observation, Commissioners. That many of these young people have a disability which inherently impairs their impulse control and decision-making abilities. 

It follows that within a detention setting, which is governed by rules and regulations and strict routines, that they become much more likely to run foul of those regulations and end up in the isolation settings I have referred to earlier. The use of the intensive supervision unit of Banksia for the so-called "management" of detainees will be discussed. This issue has attracted considerable scrutiny in recent times in this state and elsewhere in Australia. 

The joint statement of the lawyers from ALS describes incidents involving young people with disability being locked in their cells for up to 23 hours a day, being handcuffed and escorted by officers from their cells, having to endure distressing noise within the detention centre, not being able to attend school or courses, having no activities to occupy themselves and experiencing isolation, witnessing self harm by others in the centre, experiencing inadequate recreation time and having limited access to medical care and showers. 

It seems, to those assisting you, that this technique, although we understand why it has been applied, has the effect of simply compounding and compounding the difficulties that these young people have arising from their disability. We ask rhetorically, where does it end? I have mentioned that many of the ALS's clients have FASD or other cognitive impairments. One case describes a client H who is diagnosed with FASD and a language disorder who received no therapeutic support throughout his period in custody, other than the support organised by the ALS itself, which was by way of providing an occupational therapist and social worker to attend on him. 

The ALS in Western Australia recently commenced legal proceedings on behalf of VYZ, a 14 year old detainee at Banksia Hill. On 25 August this year, the Supreme Court of Western Australia delivered judgment declaring that the confinement of VYZ to his sleeping quarters for over 20 hours on 26 days in the first half of this year was unlawful. VYZ turned 15 years old on 9 March this year. Our research indicates that between December 2021 and May this year, the Western Australian ALS submitted 21 complaints on behalf of young people with disabilities at Banksia Hill. 

These complaints illustrated the prevalence of neurodevelopment impairment among their clients, practices at the centre that needed a trauma-informed approach, a lack of culturally appropriate model for care at the centre. You will hear the ALS Western Australia witnesses are critical of the responses received from the Western Australian government in respect to many of those complaints. 

Those witnesses will give evidence based on personal experience in their professional lives that detainees with cognitive and psychosocial disabilities find it difficult to follow rules and self regulate in times of stress. These difficulties are compounded when the response of officers is punitive or otherwise simply not appropriate to their own disability. Similar concerns apply to conditions in adult prisons for prisoners with disability, including inadequate access to mental health support, medication and programs. As I have mentioned programs with accessibility in a physical prison environment can also be considerable. 

Ms Donahoe from NAAJA is a mental health specialist. She's a qualified social worker and solicitors and has worked with several decades with children and families living with disability in various forensic settings. In 2021, she was appointed to the Justice Advisory Group of the Queensland University's review of the Australian Foetal Alcohol Spectrum Disorder diagnostic guidelines. 

NAAJA provides specialist legal services to clients with a range of disabilities, including deafness and hearing loss, psychosocial disabilities and severe mental health issues, intellectual disability, and cognitive impairment. Ms Donahoe states her clients almost always have complex trauma histories. NAAJA has processes in place upon intake to flag that a client may have a disability and use skilled interpreters where possible to assist communication with clients in their own language or their own signing system. 

She will give evidence about the experience of people with disability in prison in the Northern Territory. A statement to the Royal Commission notes the lack of adequate screening for disability both in the community and upon reception into custody. This results in clients suffering significant hardship whilst in custody, as well as delays in their ability to access any supports. 

In the Northern Territory, a basic health screening upon entry into prisons is undertaken by a nurse. Ms Donahoe regards this process as an inadequate means of identifying disability because crucially it relies upon prisoners self-identifying that they have a disability. This is particularly problematic because a substantial proportion of prisoners that she deals with speak English as a second or third language or have other communication difficulties. 

There is a theme which runs through the evidence we have collected, Commissioners, that admitting one has a disability can render you more vulnerable to intimidation or an assault by other people in the same facility. So, for those that say, well, if they don't speak up how are we supposed to know, there are multiple advances, one of which is they might have been advised what it is best to keep their disability hidden for their own protection. 

Ms Donahoe will particularly indicate that can result in them suffering significant hardship whilst in custody including failing to get the appropriate supports. She has personally observed clients suffer significant distress as a result of their communication needs arising from their disability not being recognised. She goes on to say it can be extremely difficult to find Auslan interpreters who are able to communicate in a client's first language, and Ms Barney will also have evidence in relation to that issue. 

This curtails NAAJA's ability to begin establishing supports for a client. Such delays arising from communication difficulties are particularly problematic when clients are refused bail and remanded in custody. She will recommend to you, Commissioners, that a culturally appropriate disability services unit should be established within correctional centres to case manage and support people with disability, including assisting them to facilitate access to the NDIS and provide support for pre-release planning, including flexible visitor access for care teams to begin working with the clients to assist their transition back into the community. 

She will speak of the lack of a court-based assessment and referral service in the Northern Territory to identify and diagnose disability. This is despite the fact that the Youth Justice Act of 2005 in the Northern Territory and the Sentencing Act in the same year both empower the court to order pre-sentencing reports addressing medical and psychiatric history. She expects that a court-based service staffed by professionals would have a significant impact on the extent to which cognitive and mental health impairments are identified within the criminal justice systems in the Territory. 

She will go on to say that intensive case management support to assist with access to the NDIS accommodation and health services, particularly for highly complex clients is required. Having direct experience of regularly visiting prisons and detention centres and advising – and supporting their clients who are detained, the panel from the ALS and from NAAJA bring a wealth of on the ground experience to assist you Commissioners in understanding the conditions and treatment of people with disability in the settings we are examining. 

You will then hear evidence from an independent regulator in this state; Mr Eamon Ryan, the Inspector of Custodial Services in Western Australia. His function under the Inspector of Custodial Services Act of 2003 in this state is to provide independent oversight of places where prisoners, detainees and other persons in custody are held and to administer an independent visitor service for prisons and places of detention. 

Crucially, he's not subject to the direction of the Minister for Corrective Services in this state or any other person in the performance of his functions. The current inspector has a term of five years, which commenced in May 2019. He is required to inspector each prison and detention centre amongst, other places, at least once every three years. And if one thinks that's a fairly relaxed inspection program, he has the right to inspect at any other time on any number of occasions. 

The inspector is required to prepare a report which must be tabled in Parliament. Most recently, in March 2022, Mr Ryan produced report number 141 in relation to an inspection of the intensive support unit at Banksia Hill Detention Centre. That report concludes decisively that Banksia Hill is and I quote: 

"...not fit for purpose as a youth detention centre."

It is noted that reports since 2013, when Mr Ryan's predecessor was in the role, have repeatedly highlighted and made recommendations regarding the absence of an operational philosophy at Banksia Hill. In a report dated 26 February 2018, the then Inspector of Custodial Services in state, Neil Morgan, recommended that the Department of Justice: 

"Develop and implement and operational philosophy for Banksia Hill." 

He said the centre had been unstable for more than – most of its previous seven years and that he was required to report on Banksia Hill every three years but the centre's problems were such that this was his sixth report in six years. He said: 

"The young people at Banksia Hill invariably face major social and developmental challenges, and the majority have experienced abuse or trauma. Despite this complexity, Western Australia holds all young people in one place, and has no separation or dispersal options. For good reason, no other state or territory believes it is appropriate to hold such a large number of a diverse group of young people in the one place."

He went on to refer to there being "promises dating back at least five years" to develop an operational philosophy articulating the centre's aims and core principles and tying them to operational practices. And that the department had: 

" response to this report stated that an operational model has now been developed based on the Model of Care, which is a trauma informed approach to delivering services." 

It had been provided a three-year target for full implementation of the new philosophy which the inspector noted was – and I quote 

"... a realistic timeframe that will not be met unless the centre maintains a far more sustained focus than in recent years."

I don't want to put words in the mouth of Mr Morgan, but it does suggest a degree of scepticism. On 20 April 2021, the new inspector and current inspector, Mr Ryan, made an identical recommendation in report 135, namely, that the centre "develop and implement an operational philosophy for Banksia Hill." He outlined the history of failed attempts to implement a trauma-informed model of care at that centre. In his most recent report – report 141 that I referred to – inspector stated that: 

"The management and care of these children must be trauma-informed and evidence-based with at the very least an equal focus on welfare needs alongside custodial needs". 

He said that there was an urgent need for additional welfare support within the ISU and the Cue – that's C U E – unit at Banksia. The Director General of the Department of justice in Western Australia has informed the Royal Commission in a statement dated 16 September 2022 that Banksia Hill is undergoing a general transformation practical process with development of the new operating philosophy and service model, and that there has been systemic reform process in recent years to adopt best practice. 

He states that:

"The implementation is planned to commence later in year."

An issue which will be explored by your Counsel Assisting during the public hearing concerns the delay in implementation of an operating philosophy involving a trauma-informed model of care, despite the numerous past reports urging this to occur. In particular, how will any philosophy accommodate the needs of a high proportion of children and young people with cognitive disability. We look forward to the responses from the Western Australian government witnesses following the hearing.

Mr Ryan will give evidence about the processes for identification of disability in prisons and in Banksia Hill. With regard to young people, these processes for identification of cognitive impairment are, in his view, inadequate. It is expected he will give evidence that while awareness of disability has increased, screening remains poor and lacks consistency. His observations are borne out by the material provided to the Royal Commission by the Department of Justice in the lead-up to this public hearing. 

It is arguable in Western Australia no disability screening or assessments are undertaken on a systemic level. We understand that young people at Banksia can be assessed for neurological impairments if concerns are raised. In adult prison, while a screening form is applied to all prisoners who enter custody which includes some questions about disability issues, the screening relies especially on self reporting of disability by prisoners.

I will speak briefly about the data about people with disability in custody. In preparation for this public hearing the Royal Commission issued notices to government departments in every state and territory with authority for adult prisoners in juvenile detention seeking information about the data kept in relation to prisoners and detainees in custody that have a disability. Questions were asked about how people are screened for disability on reception into custody, what supports are provided and the skills and training of the custodial staff. And also, about the availability of culturally appropriate supports and health services for First Nations people. 

The information provided to the Royal Commission raises questions about the sufficiency of the data collected by correctional services agencies around Australia with regard to prisoners and detainees with disabilities. It appears that generally there is insufficient high-quality data collected about the nature of the disabilities and impairments experienced by prisoners and detainees and the disability supports needs of the prison detention centre population. 

I do take the opportunity, though, to thank the various states and territories for their prompt response to our notices and look forward to collating that information and raising the possibility, Chair, that at the conclusion of the hearing in Perth, if any of those states wish to be heard orally, they should indicate to us what. What we are particularly interested in assisting your work, Commissioner s to try to give you a balanced view across the nation as to what's happening, what's working and what appears not to be effective. 

This week's hearing will conclude with the West Australian government witnesses. I won't comment about the substance of their evidence at this stage but you will hear from Dr Joy Rowland, the director of medical services in Corrective Services; Wayne Reid, the superintendent of Banksia Hill Detention Centre. Dr Angela Cooney the Deputy Superintendent, Rehabilitation and Reintegration at Banksia Hill Detention Centre. Mike Reynolds, the Commissioner of Corrective Services of the Western Australian Department of Justice. And Dr Adam Tomison, the Director General of the Western Australian Department of Justice. I also thank them for the time and effort they've put into their statements, which have enabled your Counsel Assisting to do considerable preparatory work prior to this week.

Can I deal with some procedural issues involving this public hearing. I speak first about witness protections. I would like to take the opportunity to remind everybody at this point that the protection afforded to Royal Commission witnesses are set out first in section 6D of the Royal Commissions Act 1902 of the Commonwealth, which makes an offence for any person to publish information that might enable the identification of a witness who is subject to a Royal Commission direction for suppression of their name. This includes all witnesses granted pseudonyms at this hearing. 

Secondly, section 6M of the Royal Commission's Act of the Commonwealth makes it an offence for any person to use, cause or inflict any violence, punishment, damage, loss or disadvantage to a witness who has been provided evidence to the Royal Commission for or on account of the evidence they give. In non-legal terms, no witness that comes forward before this Royal Commission should suffer any detriment as a result of doing so. 

There is also the question of procedural fairness and the tendering of documents. Commissioners, you are committed to ensuring this hearing is conducted fairly. Consequently, any employee or former employee of any entity referred to in the evidence will have the opportunity to be heard and to respond to the issues we examine. Chair, you will make directions at the conclusion of this hearing as to how you wish Counsel Assisting to prepare any written or oral submissions on the evidence, and how parties with leave to appear and others may respond to any findings or recommendations proposed in the Counsel Assisting's submissions. 

In addition, as has been the case in previous hearings, the Royal Commission has received extensive documentary records in the course of preparing for this hearing. Some of these records will be discussed during the hearing. However, the formal tendering of documents into evidence will be done following the conclusion of the oral presentation of the evidence. This will allow for any redactions to be made in order to protect the identity of any person requiring such protection. It also will enable us to address any concern raised by any of the parties represented in this hearing. All this will occur prior to the public release of those documents. 

Thank you, Commissioners. It may be appropriate to adjourn briefly at this stage. Upon resumption, we will play an extract from the ABC 7.30 Report in relation Banksia Detention Centre before I examine the first witness, Jasmin. 

CHAIR: Yes, thank you very much Mr Griffin. Is now 10.47 or 48 Western Australian time. If we resume at 11.05, will that be satisfactory?

MR GRIFFIN: It will. Thank you, Chair. 

CHAIR: Thank you. We will adjourn briefly. 



CHAIR: Yes, thank you. Mr Griffin. 

MR GRIFFIN: Chair, we now propose to play the extract from the 7.30 Report, after which Jasmin will be sworn. She will read extracts from the statement of Nathan and then take questions in relation to her own statement. 

CHAIR: Yes. Thank you. Let us play the tape. Thank you. 

(Video plays)

DANA LEVITT: Youth justice in Western Australia is completely broken. 

DENIS REYNOLDS: Treatment which is overly harsh, inhumane and, on occasions, unlawful. 

RHIANNON SHINE: Banksia Hill is the only dedicated youth detention centre in the entire state of Western Australia. But over recent years, it's gained a notorious reputation. 

GRAN: My grandson was locked away for 79 days. That's in isolation. 79 days. I mean, can you imagine being locked in your bedroom for 79 days? 

TELEPHONE RECORDING: The Banksia Hill Detention Centre. Your conversation will be recorded. 

GRAN: It's Gran. 

RHIANNON SHINE: We can't identify this woman for legal reasons. Her 15 year old grandson has been in and out of Banksia Hill for the past five years for offences including robbery and home burglary, as well as assaulting youth custodial officers inside Banksia Hill. 

GRAN: He was in custody from when he was 10, but he was in care, Department of Child Protection, from when he was about six. But when he got incarcerated with Banksia, I believe it was 10 and from then his life went downhill and his anger issues escalated. You know, this kid just didn't wake up one day and say, "I'm going to do this" or, "I'm going to be a real mean person."  This kid had a childhood but it's been ripped from him. Like, it's just been taken away. 

RHIANNON SHINE: In February, a judge labelled the boy's behaviour while in custody as vile, but also slammed the dehumanising conditions he was being kept in. Justice Hylton Quail described the cell where he was kept as a fishbowl and his exercise yard as a cage, warning that when you treat a damaged child like an animal, they will behave like an animal.

GRAN: I was thinking this poor kid. Even this judge knows what's going on. 

DENIS REYNOLDS: If you have to decide whether or not a child is sentenced to a period of detention and you know that that person is going to go to a facility where he or she is going to be treated harshly, inhumanely and possibly unlawfully, it weighs heavily on your mind. 

RHIANNON SHINE: Retired Judge Denis Reynolds was the longest serving President of the Children's Court of Western Australia from 2004 until 2018. 

DENIS REYNOLDS: Where Banksia Hill is now, has deteriorated to the point where it is simply not fit for purpose. The idea of a single detention centre for a state the size of us, the size of Western Australia, is flawed. 

RHIANNON SHINE: Western Australia's prisons watchdog, Eamon Ryan, released a damning report on the situation at Banksia Hill following inspections last year. 

EAMON RYAN: They are spending less than one hour out of a cell. So when you turn that on its head, that's 23 hours locked in a cell with no other human interaction. I was really concerned that we would finish up with a youth suicide. And those concerns haven't gone away. 

RHIANNON SHINE: In July, the situation at Banksia reached a crisis point. After trashing their cells, a group of 17 boys, a dozen of them Indigenous, were moved to a stand-alone unit inside WA's Max security adult prison. 

ADAM TOMISON: The last four weeks, we finally got to the point where the young people were getting out of cells and assaulting staff. Now, at that point, I've got no choice but to make some decisions around how I will keep that facility safe. 

DENIS REYNOLDS: I think it's an appalling decision and one that should be condemned. This is not a situation where children have been treated properly at Banksia and then completely out of the blue unforeseeably commit or engage in behaviour where they cause so much damage. 

ADAM TOMISON: I didn't make this decision lightly, but I think it's the right decision. 

MOTHER: Down here, this is the room where my son stays when he's not in Banksia. He's scared. I can tell he's scared. He's only 14. Any kid would be scared to be in an adult prison. 

RHIANNON SHINE: This woman's 14 year old son is among those who have been moved to the juvenile unit at Casuarina for bad behaviour. 

MOTHER: I went to Banksia for a visit, and when I got to the visit, they told me that my son was no longer at Banksia Hill, that he's been moved to Casuarina Prison without telling me, without a phone call. 

RHIANNON SHINE: Over the weekend, a number of the juvenile inmates at Casuarina Prison damaged their new cells before climbing into the roof space. They were later brought under control by the prison system's riot squad. 

DANA LEVITT: Moving children to a more secure adult prison is not going to stop them from destroying their cells. What will stop kids from engaging in destructive behaviour and acting out in desperation, as these children have, is being treated in a humane, trauma informed, youth centric and age appropriate manner. 

RHIANNON SHINE: Last year, lawyer Dana Levitt starting building a class action against Banksia Hill. 

DANA LEVITT: The key allegation made in the class action is that Banksia Hill is fundamentally not fit for purpose and, as such, has a detrimental impact on every single child that enters it. 

RHIANNON SHINE: 21 year old Nikkea Graham is one of the former Banksia Hill detainees who has given statements to the class action. He spent time at the centre's ISU as a teenager. 

NIKKEA GRAHAM: There's kind of procedure. They, like, bring you out to that birdcage thing, but, like – it's got, like, a tennis ball, a flat basketball, and the phone. 

RHIANNON SHINE: Nikkea's parents died when he was a teenager. 

NIKKEA GRAHAM: Every time, it comes to my call time, I just walked out and smash the phone. I just go to my cell, cry all the time. Every single time. No one answered it. I just go and cry in my cell. Nothing else to do. When you put a dog in a cage and go out – like, the day you let it out, that thing is vicious. The same with a person. You leave them in the cell or leave them, like, locked up for, like, a certain amount of time, it's going to click. 

RHIANNON SHINE: The WA Government says the teenagers are only being kept at Casuarina temporarily while plans for a $25 million upgrade of Banksia Hill are being developed. 

DENIS REYNOLDS: My view is that what we should have is a regionalised system where we have children – and particularly Aboriginal children, that we leave them on Country, get them to know themselves, get a sense of their own identity, get a knowledge of their own culture, and then have a good sense of self worth and, in turn, be good members of the community and render the community safer. 

RHIANNON SHINE: In May, the WA government announced new funding for an on-Country facility in the state's far north Kimberley region. 

MARK McGOWAN: We are currently working with local traditional owners on a site so that it is an opportunity for rehabilitation on Country rather than being sent to Banksia Hill. 

RHIANNON SHINE: For now, the families young people locked up hope their kids will one day stay out of a system that they feel hopeless to fix. 

GRAN: The damage that they do to these places is what they are showing, what they are feeling inside. They are damaged, they are broken. And so is the system. 

MOTHER: I'm scared that he might, you know, keep self harming himself and then I get the phone call that's every mother's worst nightmare. Yes. That's my biggest fear, is getting that phone call. 

(Video ends)

CHAIR: Yes, Mr Griffin. 

MR GRIFFIN: I understand that Jasmin will take an affirmation. And after that I will identify the relevant documents for you, Commissioners. 

CHAIR: Thank you. Jasmin, thank you very much for coming to the Royal Commission to give evidence today. Thank you also for making a statement, which we have and have read. So, would you be good enough to follow the instructions of Commissioner Mason's associate, and she will administer the affirmation to you. 

JASMIN: Perfect. 


CHAIR: Jasmin, I should explain where everybody is, although you probably know. In the same room as you are Commissioner Mason, of course, and Commissioner McEwin. Mr Griffin, whom I have asked to ask you some questions shortly, is also in the room. I am joining the hearing from Sydney. Unfortunately, I'm unable to travel to Perth this week. So that is where we are. I will now ask Mr Griffin to ask you some questions. Thank you.


MR GRIFFIN: Jasmin, have you made a statement to this Royal Commission dated 14 September 2022? 

JASMIN: Yes, I have. 

MR GRIFFIN: Does that statement comprise some 19 pages and 124 paragraphs. 

JASMIN: Yes, it does.

MR GRIFFIN: To the best of your ability, is that statement true and correct? 

JASMIN: Yes, it is.

MR GRIFFIN: Commissioners, can I indicate for the record the statement appears with reference STAT.0620.0001.0001 and appears in Tender Bundle A at tab 3. 

CHAIR: Thank you. 

MR GRIFFIN: Jasmin, it is also my understanding that you have agreed to read out parts of a statement made by Nathan. 


MR GRIFFIN: Commissioners, could I indicate that that's a statement made by Nathan on 14 September 2022. It comprises some 131 paragraphs. It appears with a reference number of STAT.0619.0001.0001 and can be found at Tender Bundle A under tab 2. 

CHAIR: Yes. Thank you. 

MR GRIFFIN: Jasmin, can I invite you to read extracts from Nathan's statement, and if you could from time to time identify the paragraph number just so people can follow. 

JASMIN: Yes, okay. Paragraph 3. My name is Nathan. I am a Noongar man from Western Australia. I am 23 years old. When I was a kid and out in the community doing things with my family and listening to my nan's stories meant everything to me. Mostly I was connected to my culture through dancing, painting, and going hunting. My uncle used to take us all out, my cousins and uncles and me, and we would go fishing and hunting, and he would teach us about the land or he would teach us to paint and to dance. When I was grade 3 or 4 at school, I was diagnosed with Attention Deficit Hyperactivity Disorder, ADHD, and I was put on medication for it. 

Paragraph 6. I had a good life up to grade 4. My family had a car, house, food and shoes. Dad provided for us and made me and my siblings feel safe. But then my dad started going to prison, and my life began to get interrupted. When I was around 13, dad lost his job and things were happening with his mental health. He has bipolar disorder, and it made living at home scary at times, so I would stay away and sleep at friends' houses. Some days he would just change and be evil in a way and it was like it wasn't him. I remember we didn't have enough money for rent, and around that time dad received a long prison sentence. Mum then started using drugs. Sometimes she wouldn't come home for six or seven days. 

Paragraph 10. I tried drugs for the first time when I was 12. It started with a bit of dope here and there, but when I was 13 or 14, I started using meth. I became dependent on it and it made me very violent and angry. It was affecting me mentally and I wasn't the same person I used to be. 

While my dad was in prison and my mum was doing a lot of drugs, we often didn't have food to eat. I didn't know anything about working, so this is when I started to steal so my brothers didn't go to school hungry and so that they had shoes to wear. I don't have a good relationship with my mum because of what happened during that time when my dad was in prison. 

I first went into youth detention in 2010 when I was 11 years old. I was put in Rangeview Juvenile Remand Centre. I was then transferred to Banksia Hill Detention Centre when I was around 12 or 13 years old. I was in and out of detention at Banksia. I don't remember the exact dates, but my solicitor has prepared a chronology which sets out my stays at Banksia Hill as follows: 4 October 2012 to 17 January 2013; 16 April to 12 June 2013; 28 November 2013 to 11 October 2014; 17 to 26 February 2015; 1 April to 31 October 2015; 8 February to 20 April 2016; 25 April to 5 May 2016; 23 to 25 June 2016; 30 July to 21 September 2016; and then 23 October 2016 to 17 November 2017. 

In November 2017, I was transferred from Banksia to Hakea Prison. After that, I went to Acacia Prison to Bunbury Regional Prison and now I am in Casuarina prison. I have been in the system since I was a little kid. I as am looking for a way out, but whenever I get out of prison, I can't break the cycle of thinking I'm just going to go back, so I get in a rush thinking I have to do everything before I get sent back to prison. 

Paragraph 16. When I first went into Banksia, I was put into Karakin Unit. That was a normal general population unit. It was all right. There were two people in each cell, and you could walk around whenever you wanted to. You didn't have officers escorting you everywhere, there were Xboxes, privileges, and you got a lot of education. 

MR GRIFFIN: Jasmin, could I just interrupt you for a moment.


MR GRIFFIN: I had a request from the interpreters if you could just slow down a little for their benefit. Thank you. 

JASMIN: Paragraph 17. After Rangeview was shut down, Banksia changed and lockdowns started. Lockdown is when you are locked in your cell. When I was about 12 or 13 years old and I was in Banksia, I broke my finger playing football. The guards took me to the hospital. On the way back, I was in the paddy wagon and feeling sick and needed water. And then I started vomiting. When we got to Banksia, the guards opened the paddy wagon doors and as soon as I stepped out, the officer hit me and winded me. He pushed me into the sand and called me "a little black dog." He punched me in the back, 15 or 16 times. I'm sorry. 

CHAIR: It's okay. Take your time and if you need to have a break, just let us know and that can be done. 

JASMIN: I was calling for help, so they put a bag on my head. They dragged me to the multi purpose cells, the MPU, and cut my clothes off and left me there naked for about 40 minutes. I stayed in there for about a week. 

Paragraph 19. Banksia Hill has about eight units. About six units are normal boys units; one is a girl's unit, Yeeda; and there is Harding, which we call down the back or Harding. Inside Harding, there are four separate wings which are used for different purposes. They are named A, B, C and D wing. A and C wing are similar. They are better than other cells because they are normal living units. There is some sunlight and they have showers inside the cells. In D wing, there are no showers inside the cells and it is lockdown all the time. There was a TV when I was in there, but the guards chose the channel. 

There is some natural light, but it's not great. One side is better than the other. B wing has two sections: The multi-purpose cells, MPU; and observation cells, OBS. There is no fresh air in these cells. OBS cells had a whole glass window so you could be seen all the time. I could see through another window which looked on to the outside but I couldn't see directly outside. But I could see light through this window. In OBS, I also had access to a TV but not the remote control. 

Paragraph 22. MPU is dark and cold. The floor and walls are all concrete. It was very dirty and disgusting. The cells smelled like a urinal. It made me feel sick. There was slimy stuff on the floor, which I thought was vomit. MPU was never clean from the first time I went in until the end. I was only ever given a broom to clean my cell, but felt like I needed disinfectant at least, but they would never give that to you. The grilles where the air came through into the cells never got cleaned. There was mould on the walls and on the roof because there was no sunlight in the cell. 

MPU cells have windows with roller shutters on the outside. The officers kept the roller shutters down on these windows all of the time. I believe they did this deliberately so that I couldn't talk to anyone if they walked past the window. The lights were generally kept on all the time, even during the night. Because of this, I didn't even know what time of the day it was and I couldn't sleep. There was no mattress when I got in there. If I was good I would get it at 3 pm. If I wasn't I wouldn't get it until lock up at 6.30 pm. They said it was because you're not allowed to sleep during the day. So, I had to sit on the concrete floor. There were no showers or TVs inside the cells in MPU. 

Paragraph 34. When I was in MPU, I was sometimes let out for 20 minutes a day. But sometimes I wasn't let out at all. I was always the last person to get recreation time, so by the time I got to the small caged yard where the phone was, the cage, the sun would be down. The officers would then say, they had had to lock up early so I would miss out on my phone call. The cage where we did rec didn't have any grass. It was a concrete area with just a phone in it and nothing else. During my time in Harding in 2016 before the incidents, I was initially on a four-man unlock, which meant that they needed four officers to let me out of my cell and escort me to the shower or the cage for recreation time. 

Paragraph 42. I went back into Banksia Hill in October 2016. Paragraph 46. In November 2016 I was in Harding but I was smashing things up and they said I was inciting other boys so they put me in Cue. Cue is inside Yeeda, the girls' unit. It used to be down the back for the girls. I was there for just over a month. When I got to Cue, they took everything from my room. I had blood all over my clothes and they didn't give me clean clothes. There were only girls clothes there. I showered with my clothes on to wash them. 

There was no other person at Cue then. It's a building with four cells and a yard which is the only place they would let me out to. There was no one to talk to except the guards and my psychologist. I had more food and a telly, and I could see outside to some trees. They let me have my phone call. I was on a three-man unlock then because my behaviour was better. 

Paragraph 52. The officers would come to my cell and say things like, "You're a bad kid. You're nothing but a piece of shit. We are going to try and send you to Hakea." I smashed a light in my room then. I was on my own in Cue and I didn't want to be there by myself. I went crazy after a while and threw some bricks. Then they moved me back to Harding. 

Paragraph 55. On 4 May 2017, I was involved in the incidents which caused damage to D wing in Urquhart Unit at Banksia. Leading up to the incidents, there were lockdowns all day over and over. They called this rolling lockdowns. I was told it was because there weren't enough staff. There was no education during the rolling lockdowns. During this time, I was let out for one hour per day. On the night of the incidents, I could feel the tension and I knew there was something going on. 

It was just like everyone had had enough and a lot of the boys were saying they wanted to kick off. I had a lot going on at the time. I had just been kicked out of A wing of Urquhart and lost my privileges. I was also stressed about my dad because he got an extra year on top of his sentence. I wasn't in a good head space, and I had tried to self-harm a few days before the incidents. I was trying to stay out of it, and I asked one of the officers to lock me in my cell, but she refused. 

Paragraph 64. Immediately after the incidents, I recall for the first two days following the incidents, I was not given a mattress to sleep on. I had no bedding, and I had to sleep on the concrete. I was naked because they had taken my clothes so I didn't try to self-harm with them. The day after the incidents, I was given lunch or dinner and I didn't eat breakfast until around 12 pm the following day on 6 May 2017. So, I hadn't been fed for over 24 hours. 

I wasn't able to have a shower for over a week. The electricity was off for a few days after the incidents and it was pitch black. The water was also turned off, and it wasn't turned back on for 36 hours. On 5 May 2017, the morning after the incidents, I was moved to Obs. I was the last one to be taken to the showers. When I tried to get out of the shower, the officer stood in front of me so I hit him. He hit me. I fell over. I was lying on my back, and he kicked me in the face. 

Then some other officers came in and folded me up. While I was folded up on the floor, one of the officers held his foot on my face for about five minutes. I was dragged back to my cell in the MPU by my handcuffs. If you have been restrained in handcuffs, a medic is supposed to assess you and take photos. I asked the officers for the medic and they refused. I asked them again 10 minutes later, and that's when it began to kick off. 

There were about 10 officers in my cell. It was packed. One of the officers stood up on top of the toilet and held his hand up to the camera in the corner. I believe he deliberately did this to block the camera. Another officer had his knee in my face so I couldn't really see. I felt like I was getting hit from everywhere. And that more than one officer was hitting me and kicking me. 

It went on for a couple of minutes. I was trying to fight back but they were kicking and stomping on my back, and I was handcuffed. I was left bruised with two black eyes and lumps on my back, ribs and head. My head was split and my nose was bleeding. I asked to see a nurse, but they refused. After this incident, I asked to see an AWO and asked to have photographs taken of my injuries. My request was refused. 

Paragraph 70. I was kept in Harding for the entire time after the incidents until I was transferred to Hakea prison on 17 November 2017. I had spent a lot of time in Harding and MPU before the incidents, but everything stepped up after the incidents. Showers were cold. They took my mattresses. The officers started playing games with me. They didn't want me to come out of my cell. They would come to my cell and talk smart until I talked back to them. Then they would say, like, "That's all we needed you to do. No shower today". 

During my time in MPU right after the incidents, I was confined to my cell all day and night, and I recall only being allowed to leave my cell for 10 or 15 minutes a day only to have a shower. I didn't get a shower for over a week and I remember eight or nine times when I didn't get a shower or a phone call at all. There was no hot water so we could only have cold showers. I was not allowed to go into the cage for recreation time for the entire four weeks. There was no electricity at first, so the MPU cells were pitch black all the time. I was not allowed to see my psychologist or the AWO. 

Paragraph 73. I attempted suicide not long after the incidents. But they got to me before anything happened. After the incidents, I was put on a five or six or seven-man unlock for a month or two. This meant that I couldn't go anywhere outside my cell without that number of officers escorting me. Sometimes they would also put 12 or 13 officers in the hallways before they let me out. They would lock down the whole unit just to give me a shower. 

When I was first given recreation time at the end of about four weeks in the MPU I would be taken out of my cell by about six officers. I was only allowed to be in the cage by myself with the officers and none of the boys would be there. My wrists were handcuffed the entire time. And sometimes I was handcuffed to the fence even when I was there by myself. 

Paragraph 77. When I first went to Harding after the incidents, officers were telling me for the first three weeks, "If you progress through the milestones, you will have a chance to move up to the units." The officers would promise that we would get back to the general population units if we were good or if we reached milestones. They told us the date we would be getting out of Harding, but it would never happen. It made things so much worse for me, and I would kick off sometimes because of it. 

The officers just kept saying, "A couple of months you'll be out" or sometimes when we asked when we were getting out, they would say they didn't know and walk away. In the end, I never left Harding again until I was transferred to adult prison on 17 November 2017. 

Paragraph 82. After the incidents, I was strip-searched nearly every day. Every time I would go have a shower, they would make me shower with the door open and would search my cell and then strip search me when I got back. If I tried to resist a strip search they would just slam me to the floor and cut my clothes off. 

Paragraph 87. For the first three months after the incidents, I was always cuffed when I was out of my cell. Even though I was on a six-man unlock and when I was in the cage by myself. For the first three weeks, I was even cuffed with my hands in front of me when I had a shower and they watched me. 

Paragraph 90. Folding up. Folding up is when guards slam you to the floor face down. Then they put your hands behind your back, they cross your legs over and put them up against your back and it hurts your calf. Your arms are crossed all the way up your back. It's hard to breathe. I was 11 when I was first folded up. It would happen often when I was in Banksia. If security thought that they were in danger, they would do it. 

But we were just kids, and we didn't have the strength they did. They didn't need to do it. After they folded you up they would leave you there until they felt like you had calmed down. I just learned not to say anything. You just have to do what they want you to do. 

Paragraph 93. I had access to my psychologist while I was at Banksia. It was the psychologist I saw when I was in Rangeview and she knew me well. She was aware of my history of self-harming, depression, and ADHD. I didn't like talking to her because she made me cry all the time. And she would want to bring up old stuff like it was affecting – like it was affecting me still, and it wasn't. It wasn't related to what I was for, so I didn't know why she was bringing it up 

Paragraph 96. I felt like the psychologist didn't understand and that they never gave me strategies to deal with things. They did not give me any coping strategies. When I was at Banksia, I don't remember that they ever did any tests on me or that I was ever assessed for ADHD. Paragraph 99. They started giving me pills when I was about 14. I think it was Seroquel. After that, they moved the dosage up and down depending on the doctor. 

When I was 16 or 17, they started me on Alonzepine. But then they changed it again. I'm not sure because they didn't really tell me what they were giving me. They just gave it to me and said, "Here, take this." A mental health lady in Banksia told me I had been diagnosed with depression and anxiety, and I already knew I had ADHD. Even though my psychologist knew about my problems, I was only given medication here and there. It wasn't consistent. 

My psychiatrist changed all the time, and every time they changed they changed my medication. Sometimes the medication would make me tired. Sometimes it would make me hungry and I would put on weight. At other times, it would make me less hungry and I would lose weight. Some pills gave me weird dreams and bad sleep. And when I woke up I, felt like I had a hangover. I asked to be put on medication for my ADHD while I was in Banksia Hill, but they told me that they couldn't prescribe it in there because I was taken off it before I got locked up. 

Paragraph 103. I had never self-harmed before I came to Banksia. The first time I self-harmed was in 2016. I was in Harding in A wing at the time, and I tried to hang myself using a shirt tied around my neck. The officers took me to Fiona Stanley Hospital. They didn't call my family to tell them what had happened. 

Paragraph 109. When I self-harmed after the incidents, no one took me seriously and no one cared. Sometimes, when I asked for my psychologist to come to me, they just said that they were short-staffed, and she couldn't come. I didn't self-harm as much after the incidents as I did before, because I had all that time down the back before and I had gotten used to it. My mind was stronger. 

When I was in primary school, I had a teacher or social worker who followed me around. I had special dispensation at recess and lunchtime and didn't have to go to the playground. My social worker would help me with school. She would sit and explain things to me. When I first got to Banksia they didn't give me a test to do to figure out my level of education, they would just give you work and if you could do it then they would move you up. 

When I was in the normal units at Banksia, we would have class in the morning for one or two hours and then another hour in the afternoon. I mostly didn't understand what the teachers were saying so I got distracted and then I would get kicked out of class. I was never given anything different to help with my ADHD like I was in primary school. During my long stints down the back in 2016, I really didn't have much access to education. 

When I was in the MPU, there was no education. In MPU, I wasn't given any books or schoolwork at all. I was given word sleuths but I wasn't allowed to have a pen or a pencil, so I had nothing to do the sleuths with. The teachers never came to see us when we were in the MPU. 

Paragraph 122. We had access to some programs at Banksia, but it was not really anything you could use in life. The programs did not help people like me change. They didn't give us something to do when we got out or help us to be someone different. The courses were optional, and you just had to tell your case planner if you wanted to do a course. Some courses went for a few days and some went for a few weeks, but they weren't consistent. 

When we were in Harding, it was more inconsistent. We never knew what we would be doing for the day and there was never a routine. I only remember one program from Harding, and it was about budgeting and hygiene. It wasn't about how not to re offend. Paragraph 127. I am a strong person, but I don't think anything could have prepared me for what I went through at Banksia. It was so bad. It broke me and it made me a different person. 

I am just happy to be sitting here today. My time in isolation changed me and turned me into a person I didn't want to be. Banksia took me to a dark place and ruined my life. I no longer feel like I can have relationships with anyone. I feel stuck and like I can't trust anyone anymore. I had never tried to self harm before I went to Banksia. What happened at Banksia made me feel so bad that I wanted to kill myself. 

There was no acknowledgment of my culture at Banksia. Even though there were Aboriginal officers there, they were always just – we were always just seen as problem children. The Aboriginal officers would watch things happen to me and just let it go and this hurt me the most. I wouldn't wish my experience at Banksia on anybody. I was only a kid. I didn't have any support. I was locked in a cell on my own and stuck with my own thoughts. 

It seemed like the answer they had to every problem at Banksia was to just lock us in a cell, but that just made me worse, and it made me change. It made me grow up a lot quicker than I had to. 

MR GRIFFIN: Thank you, Jasmin. I want to now ask you some questions about the statement you have provided –


MR GRIFFIN: – to the Royal Commission. You were born in New Zealand. And you and your partner came to Australia and you have four children. 

JASMIN: We do. 

MR GRIFFIN: And in your statement, you deal at great length about one of your children, Maison. 


MR GRIFFIN: What was the relationship between Maison and Nathan you have been speaking about? 

JASMIN: So on 4 and 5 May, there were some serious incidents in Banksia Hill. My biological son Maison was also detained in the same unit that the incidents happened, although he wasn't involved in the first one. The – all the boys from that unit were taken down to the isolation unit that the boys refer to as Harding or down the back. And there was another incident the next day on 5 May that Maison was involved in, and the punishment of those incidents was to be kept in the isolation unit. 

After a few hundred days – consecutive days in the isolation unit both Nathan and Maison were all each other had. So, they became very, very close and they consider themselves brothers. 

MR GRIFFIN: And Nathan refers to you as Mum. 

JASMIN: Mum, if he's greasing, Aunty if he's not. 

MR GRIFFIN: Just very briefly, can you tell the Commissioners a little bit about Maison and his particular disabilities. 

JASMIN: Can you repeat that? 

MR GRIFFIN: Yes. Maison. Can you tell the Commissioners a little bit about Maison and his particular disabilities and what led to him being in detention? 

JASMIN: Okay. So, Maison struggled at school a lot. He had quite prominent learning disabilities, and he was always a big boy so he was teased a lot. Maison also struggled a lot with the separation of myself and his biological father. When he came to live with my husband and I in Perth, he did not do so well at the high school that we enrolled him in. And he was often – to put it better, he was seldom allowed at school. He was always suspended. 

So we – it was suggested to my husband and I by the principal of that high school that Maison be enrolled in what they called an alternative school, which was for children with behavioural issues. So, we did that and, unfortunately for Maison, he was now in a school with every other child that had behavioural issues so his absconding and wagging became more frequent, and that led to very poor choices in peers and ultimately a very poor choice one night that landed Maison in custody. 

MR GRIFFIN: And he was then in Banksia Hill from November 2014 to February 2016. 

JASMIN: That's correct. 

MR GRIFFIN: And he was released from that institution, then he went back there on a second time from May 2016 to May 2017. 

JASMIN: Yes. He was released on a children's order, so very similar to parole, and he did not adhere to his parole conditions and returned to Banksia. 

MR GRIFFIN: And during his time in Banksia, he was placed in the observation cells on occasions because of a threat of self harm. 

JASMIN: That's correct. 

MR GRIFFIN: How often were you able to see him whilst he was in the detention centre? 

JASMIN: Look, my husband and I to – to begin with, for Maison's first 15-month sentence, we were able to visit three or four times a week. Four times is – used to be the maximum amount of visits per week you could have in Banksia Hill. So my husband and I took every opportunity to take those visits when we could. 

MR GRIFFIN: What about on the second occasion he was in the centre? 

JASMIN: After the incidents, my husband and I were residing in Kalgoorlie. We would do our very best to visit and make the journey every two to three weeks. That was made a lot more difficult by Banksia Hill staff pushing our visits back or informing us that we were unable to be in a visit room with another family, we would have to rebook. So, those visits became less and less and as Maison – as Maison's mental health deteriorated, when we got to around 250 days in the isolation unit, he would then refuse visits. 

MR GRIFFIN: Initially, was it difficult to visit because of security concerns expressed by the staff? 

JASMIN: Yes. So, often our visits were pushed back because we were told Maison had numerous security alerts. That was explained to me very simply as staff members at Banksia Hill had intel that Maison would not get along with another inmate or that Maison had – would not be suitable to be in a visit room with another – with another child or simply because Maison had allegedly threatened to kick off if he was allowed out of his cell. 

MR GRIFFIN: What did you understand him to mean by the expression "kick off"? 

JASMIN: I suppose – get angry. 

MR GRIFFIN: And if a staff member recorded an alert in relation to Maison, what effect did that have on your ability to visit? 

JASMIN: If there was a recorded alert for Maison and for example he was alleged to have mentioned something about another boy, if that boy's family had booked their visit in the same timeframe that we had, we were not allowed that visit. We would have to rebook that visit because that was an alert on Maison. 

MR GRIFFIN: Did you make any observations about Maison's mental health during that time he was in isolation? 

JASMIN: I think when – when Maison was first put into the isolation unit after the incidents, it was quite chaotic in Banksia Hill. When we got to November of 2017 and Maison had been in there for almost six months, the changes in him were – they were very, very noticeable. He was very withdrawn, and he had become very skinny. Maison was a very, very large boy, and that was very noticeable that – that he was no longer as big as he was. 

MR GRIFFIN: Is it your understanding that two to three months after the May incidents, most of the detainees were moved back into the general population. 


MR GRIFFIN: But Maison wasn't one of those? 

JASMIN: Maison was not one of those children. 

MR GRIFFIN: Do you know why he was one of the couple that were not returned to the general population? 

JASMIN: I believe the staff at Banksia Hill labelled him the ringleader of the 5 May incident. Nathan was labelled the ringleader of the 4 May incident. And I wholeheartedly believe that that was why they were left down there. 

MR GRIFFIN: Was there then a visit from Amnesty International to the detention centre in about November 2017? 


MR GRIFFIN: And what happened as a result of that visit? 

JASMIN: I think Banksia were surprised. I think they were afraid. They had an Indigenous Rights Manager from Amnesty International asking to come into their facility, asking to see their intensive support unit. So, they did two things. They shut down a lot of the communication with me. I emailed a lot and didn't get a lot of replies. If I did get a reply, it was never answering my question specifically. And they decided the Superintendent at the time that he would take Maison, into his office, and offer him a contract to – between himself and Maison that if Maison behaved and reached milestones that he would be allowed back into general population units. 

MR GRIFFIN: Did Maison enter into that agreement with the Superintendent? 

JASMIN: He did not. He sat at the desk with the Superintendent who had the alleged contract face down on the table. He did pat to it when he explained it to Maison, but I mean, Maison was very excited at that prospect, but that never eventuated. 

MR GRIFFIN: You describe Maison in your statement as being someone that sees the world in very black and white terms. How does that manifest itself? 

JASMIN: Maison, as you say, he sees things very black and white. He sees things very literally. What he says is exactly what he means, and he expects the same. He is a man of his word and he expects everybody else to be. When he has done wrong, he admits it, and he expects everybody to do the same. And he can become very upset if he feels he has been lied to or duped. 

MR GRIFFIN: When you say "very upset", how does that manifest itself? 

JASMIN: He will yell. He can swear. And depending on his environment, that can manifest itself in violence. 

MR GRIFFIN: Are the things that Maison told you about being in the isolation unit and the way in which he was treated similar to what you read from Nathan's statement? 

JASMIN: Yes. Yes. 

MR GRIFFIN: When did he eventually get out of the detention centre? 

JASMIN: Maison was put into the Harding unit on the night of 4 May 2017. He spent 406 consecutive days in the isolation unit and was released only when he was transferred to Hakea prison in – I think it was June of 2017. July. 

MR GRIFFIN: During those 406 days, did he receive any education? 

JASMIN: It's not what I would call education. 

MR GRIFFIN: What did you understand he was receiving? 

JASMIN: Maison did not receive any education for the first few months of being in Harding. That was not allowed. He did receive a – I suppose an attempt where he was allowed to spend half an hour to an hour with a teacher in the Harding unit in around October of 2017, but as far as I'm aware, this did not happen very often. 

MR GRIFFIN: And at some stage, did he decline to see you? 


MR GRIFFIN: What were the circumstances surrounding that decision he took? 

JASMIN: When asked, Maison simply said he just did not feel like coming to visits. A lot of that had to do with fact that he would be strip searched before and after visits, so for him, it was just easier to refuse visits, and Maison was – when we were eventually allowed into the normal visit rooms with other families, Maison was handcuffed to each visit and often put up against the glass pane to be patted down in front of the other families. 

He was always made to leave the visits five minutes early so he did not mix with other boys, and often he was taken the long way back to the isolation unit in his handcuffs and what I believe paraded around the facility as an example. So, all these factors for Maison – visiting became degrading to him. 

MR GRIFFIN: Chair, I note the time. I will be a little while more with Jasmin. I can either continue or I can – we do have time to continue after lunch. 

CHAIR: Well it's now 12.10 Western Australian time. Is it convenient to adjourn now and resume at 1.15?

MR GRIFFIN: Yes, it is, Chair. 

CHAIR: Or would you prefer to continue, subject to Jasmin being able to continue?

MR GRIFFIN: I would like to give Jasmin the opportunity to – voice her opinion about that. 


MR GRIFFIN: Would you prefer to continue or have a break? 

JASMIN: I'm happy to do either. 

CHAIR: I'm happy to do what you and Jasmin agreed between you. So, Jasmin, you might have to negotiate with Mr Griffin. Get the result you want. 

MR GRIFFIN: I previously observed, Chair, that sometimes you give the illusion I have some control in this room, but we will discuss that later. 

CHAIR: I'm content for the illusion to continue, Mr Griffin.

MR GRIFFIN: How have you – let me go back a step. Your other children haven't been involved with the criminal justice system? 


MR GRIFFIN: What about Maison and his particular disability, do you think contributed to him going down the path he went? 

JASMIN: I – I don't know if I could pinpoint that, but I do believe that – I do believe there was some trauma. I believe that he was just very misguided, immature, child-like and, look, he was very – he had very inconsistent friends. He did not have a core group of friends and peers. Those would often change for Maison. He never really fit in with a group of friends, so often to feel like he fit in, he would be the muscle. 

MR GRIFFIN: Was he easily led by others, to your observation? 


MR GRIFFIN: To those of us listening to your evidence, it seems unusual that a young man would elect not to have a visit with his de facto family in the way you have described. Have you ever had a chance to discuss with him in any detail why he took that choice that it would be better in all the circumstances not to see you? 

JASMIN: Yes. Maison's reply is as we – he has sort of layers to that, but I think the most prominent one for me was that we were getting into hot weather and Maison had been self-harming, which I was unaware of, and, unfortunately, the hot weather meant he would have to sit in this a visit room in 40 degrees with his jersey on so we couldn't see his self harming. 

MR GRIFFIN: During any of those visits did you have the opportunity to talk to any of the staff of the centre about his self harming and what if any support they were providing to him? 

JASMIN: No. I was never aware that Maison was a self harmer, and by that time, the staff at the centre were very cagey about Maison and anything that went on with him, and staff were noticeably steering clear of my husband and I. 

MR GRIFFIN: In around November of 2017, he was transferred to an adult prison. Did Maison say to you words to the effects of this was the only way he thought he would ever get out of Harding? 

JASMIN: Yes. So, when Maison was charged with the incident on 5 May, he made it very clear to his lawyer that he was going to ask the magistrate or the judge that he or she allow him to carry out that sentence in an adult prison because he knew the only way he would get out of the isolation unit was to be transferred to an adult prison or in a body bag. 

MR GRIFFIN: And was he subsequently transferred on 14 June 2018 to Acacia Prison. 

JASMIN: He was first transferred to Hakea and then to Acacia. 

MR GRIFFIN: And what was his experience to your observation in Acacia? 

JASMIN: Acacia found Maison down the back again shortly – 

MR GRIFFIN: By that you mean? 

JASMIN: In isolation. 

MR GRIFFIN: In isolation. Thank you. 

JASMIN: In isolation. Shortly after he was sent there, there was a brawl in the unit he was in, and Maison was sent to the isolation unit along with other inmates. After approximately four or five weeks of being down there, Maison rang frantic. He was very distressed, very depressed and his words were, "I can't do this again. I can't do isolation again" 

MR GRIFFIN: What did he do to try to get out of isolation? 

JASMIN: Maison spoke with the staff at Acacia who offered him what they call being maxxed out, and Maison signed a form to acknowledge that he was not suitable for medium security and he opted to choose to be transferred to Casuarina maximum security so he could be in the general population. 

MR GRIFFIN: So, your son was in a juvenile detention centre as a result of the reasons you have outlined, was transferred to a medium-security prison. 


MR GRIFFIN: And then actively elected to be put in a maximum-security prison. 


MR GRIFFIN: How did you feel about that? 

JASMIN: It seems – it seems like insanity to some people, but you must understand that Maison was so very ruined by then, by isolation, that the prospect of four walls again for another 400 days was not an option for him. 

MR GRIFFIN: How does Maison currently view the world? 

JASMIN: He sees it as a very cruel, cold place. Maison has lost a lot of empathy. He does not see the world as – as a place where children are safe. Maison is now 23 years old and often says he will never have children because he does not want them – he does not want to raise them in a world that treats children the way he was treated. He does not trust anybody, and he – he finds it very, very hard to be independent. 

MR GRIFFIN: What's he doing now? 

JASMIN: He is living at home with my husband and I. Like I said, Maison is still very child like. Although he is 23, he's a child in a man's body in a lot of ways. Maison does not have the ability just yet to live independently. 

MR GRIFFIN: Is he in a place currently where he can speak to psychologists or others to seek assistance? 

JASMIN: Currently?



MR GRIFFIN: Have you observed that as far as you're aware he's not self harming? 

JASMIN: As far as I'm aware he's no longer self harming. 

MR GRIFFIN: Would he tell you if he was? 

JASMIN: I don't know. 

MR GRIFFIN: I was wondering if you might take a few moments to reflect upon what you would like to tell the Commissioners of how things might change to stop someone else having the experience that Maison had. 

JASMIN: Look, I think there would be a lot of things that I would change. First and foremost, I would like to see the age of criminal responsibility raised so that we are not traumatising and criminalising disabled 10-year-olds. Secondly, I would like to see some – something put into place in Banksia Hill where CCTV cannot be taped over and it's not allowed to be taped over as it has been. I believe having that will ensure transparency and accountability on the facility's part. 

We care for our most vulnerable children in that facility and I think accountability and transparency when it comes to CCTV footage is vital, but I think what would have made the most difference for Maison and for Nathan is that if the staff  – the guards in particular who spend day and day out with these boys, if they had more understanding of FASD, ADHD, trauma, including intergenerational trauma, if they – let's just scrap the way they are trained. 

They are trained in how to restrain a child, they are trained in how to pepper spray a child, but they have no idea why these children are the way they are. If they were properly trained and educated in cognitive impairment, in brain injuries, the things that are so very prevalent in Banksia Hill, I believe it would manifest more empathy for these children and I believe that the staff would be better equipped to be able to walk into a unit or into a cell and say, "I know Nathan has ADHD. I know that he will probably react negatively if I go in and say this because of his disability." 

This may light something in the staff to approach situations differently, then be able to build rapport with these children. Because at this point, Banksia Hill punishes by way of lockdown and they don't understand or they do understand and they don't care that the isolation, the solitary confinement and the degradation is making these kids so much worse. They are literally shooting themselves in the foot every day when they treat these children like this. 

If they had more education and more training – proper training, not some glorified little course at an academy – some proper training sitting with an Indigenous led organisation that can explain cultural differences that will help these guards maybe be mentors, because once those children understand that the staff that have day to day contact with them have empathy, understand and actually care, you will find that staff will be a lot safer with these children. 

MR GRIFFIN: Chair, I wonder if I might invite you or the Commissioners to ask any questions you wish to ask. 

CHAIR: Yes. Jasmin, if it's okay with you, I will ask my colleagues first if they have any questions for you. And I will start with Commissioner Mason and ask whether Commissioner Mason has any questions she would like to put to you.

COMMISOSIONER MASON: Thank you, Chair. I have a couple of questions. Today we have been talking about Banksia Hill Youth Detention, but the whole way through your evidence today you have referred to Nathan and to Maison as children. And so it strikes me as a conflict to call a facility a "youth detention" when we are talking about children. Do you have a view about that? 

JASMIN: I call it a youth detention centre because that's the PC term. It's a children's prison. It's a prison for children. 

COMMISSIONER MASON: Young children. 

JASMIN: Well, and this – you know, we've got 10 year olds in there with 18 year olds before they are transferred. So, we go from children to teenagers all in the very same facility. So, I think – I mean, I – I don't even know why we put 10 year olds in children's prison. 

COMMISSIONER MASON: My last question is about where children should go if they have a custodial sentence and they are 10 years to 18 in Western Australia. If you were able to influence that or make a suggestion? Where should children go? 

JASMIN: For starters, I know that children's prisons are never going to be abolished. We live in a country that loves to punish. It is what it was built on. But what I would like to see first is that 10 to 13 year olds are not put in a prison setting at all, that – that they are given – you can provide community orders. You can provide the support that families need and let's identify these 10 to 13 year olds as fast as we can. 

We – we live in a day and age where technology reigns supreme. We can't assess them in school at five years old when they are being enrolled. Can that not be a part of it so as that we can identify children - identify children with FASD and we know they are probably more likely to come into contact with the justice system. Can we not give their families the wrap-around support that they may need to maybe stop this little one from entering Banksia Hill, and from those 14 to 18, I understand that some of these children are going to be imposed a custodial sentence. 

I get that. Maison and myself have never shied away from that. We have never denied that. Maison took his punishment and his custodial sentence without a shred of self pity. But I think if we can – for starters I don't think we should have girls in with boys. Secondly, I don't think we should have remand in with sentenced. I think that although these – some of these children may have to be given a sentence where they are deprived of their liberty, I think they should only be deprived of their liberty. 

I don't think they should be deprived of showers, food, education, self-worth, dignity. So, I don't think 10 to 13-year-olds should be in prison at all, and I think that we can change the way our youth detention settings are immensely and provide those that must be imposed a custodial sentence some actual rehabilitation as opposed to a punitive sentence. 

COMMISSIONER MASON: I just want to say thank you for the evidence you have given and the experiences of these two young men with disability in the justice system here in WA. And giving Commissioners a real insight into what they have experienced and also the trauma that has continued as a result of their time in custody. Thank you very much. 

JASMIN: My pleasure. 

CHAIR: I will ask Commissioner McEwin if he has any questions for you. 

COMMISSIONER McEWIN: Thank you, Chair. Jasmin, following on from Commissioner Mason, I too say thank you, in particular for sharing with us some very disturbing incidents. I have one or two questions. One is about Maison first. When he was at high school, you described that he was getting a lot of suspensions before he went to the alternative school. What attempt if any did that first school try to address what the causes of his behaviour was? Did they engage with you in a way to try to say, look, let's try to address this before we think of other alternatives. 

JASMIN: To be honest, no. They basically put up with it for as long as they could and then it was the principal of that school that suggested the alternative school, and I think they really were just, "Let's get rid of him." 

COMMISSIONER McEWIN: So it's fair to say that the school didn't try and actively proactively engage with you, Maison, to try and address that 

JASMIN: We met with the principal a lot but those conversations that we had with him were never around Maison's care or support. It was always a very punitive meeting. 

COMMISSIONER McEWIN: Thank you. And my final question is about Nathan also when he was getting education. At paragraph 111 in Nathan's statement, you mentioned he had a social worker. 


COMMISSIONER McEWIN: Do you think if he had, say, ongoing support with a social worker that would have helped more? 

JASMIN: While he was incarcerated? 

COMMISSIONER McEWIN: No, when he was in school. You said he had – at paragraph 111, when I was in primary school. So, I might just take you back to 111 of Nathan's statement: 

"I had a teacher or social worker who followed me around". 

So I'm interested to know what's your observation of – do you think that social worker that had been ongoing support, do you think that might have made a difference? 

JASMIN: I think so. I think when Nathan admits something is good, it's usually – was usually a pretty good thing for him. So, I think had that continued, Nathan would have felt a lot more supported and probably it would have helped with his cultural identity which Banksia took away. 

COMMISSIONER McEWIN: Thank you. And thank you again, Jasmin. No further questions. Thank you, Chair. 

CHAIR: Thank you. Jasmin, did Maison receive any support by way of transition from prison to when he was released? How did that process work, from your perspective? 

JASMIN: No, there wasn't. Unfortunately, Maison was served his deportation papers while he was in Banksia Hill. So, Maison opted to do his full sentence in adult prison while we waited for a decision from Immigration, and once we got the decision that he had had his visa reinstated, he was actually due for full time release five days later, and I left work, I picked him up, and my husband and I have looked after him since. 

CHAIR: The deportation proceedings were because he was a New Zealand citizen, presumably, and not an Australian citizen? 

JASMIN: That's correct. 

CHAIR: After Maison's release, have you thought about or perhaps applied for the NDIS for Maison? 

JASMIN: As far as I'm aware, we are not entitled to it as non citizens. 

CHAIR: Because of the non citizenship? 


CHAIR: May I ask whether you're an Australian citizen? 

JASMIN: No, I'm not. 

CHAIR: It's a good idea to become one. 

JASMIN: Our pathways are very limited. 

CHAIR: That's right. I will just inquire whether there is any other party that may want to ask you questions. I doubt that but I will just ask just in case. 


CHAIR: If there is silence, I will assume nobody wishes to ask you any questions. There being silence, I will take it that nobody does. Jasmin, I would like to thank you very much for your evidence, for such a thoughtful – such thoughtful evidence that you have given today in circumstances that are obviously not easy for you or for your family, and we very much appreciate the – 

JASMIN: No, thank you for your time. 

CHAIR: The information you have provided and the way in which you have done that. It's been of enormous assistance to the Royal Commission. So, we thank you very much. 

JASMIN: Thank you. 


CHAIR: Mr Griffin, have we now earned ourselves some sort of break?

MR GRIFFIN: You have, Chair. 

CHAIR: Well, it's now – as I do my swift calculations, 12:40, nearly, in Western Australia. Shall we resume at 1.40?

MR GRIFFIN: That would be suitable, Chair. 

CHAIR: Thank you. We will adjourn until 1.40 West Australian time which translates into 3.40 on the east coast. 



CHAIR: Yes, Ms McMahon. 

MS McMAHON: Thank you, Chair. Commissioners, you will now hear from Cheryl Ellis. Tragically Cheryl's son died in custody on 2 April 2017 when he was only 31 years old. The inquest report can be found at Tender Bundle A, tab 7. Gavin Ellis had diagnoses of ADHD, Tourette's syndrome and obsessive-compulsive disorder. Gavin was later diagnosed with schizophrenia. The coroner found that the treatment he received prior to his death was inadequate. Thank you for being here today, Cheryl. 

MS ELLIS: Thank you. 

MS McMAHON: Cheryl will take an oath, Chair. 

CHAIR: Thank you very much. Would you prefer to be referred to as Ms Ellis or Cheryl? 

MS ELLIS: I think Cheryl will be fine 

CHAIR: Thank you very much. We want to thank you, Cheryl, very much for coming to the Royal Commission and sharing your story and that of Gavin. We very much appreciate the statement that you have provided, and we are very grateful also for the evidence that you will give this afternoon. If you would be good enough to follow the instructions of Commissioner Mason's associate, she will administer the oath to you. 


CHAIR: Cheryl, just to explain where we all are   I'm sure you are aware of it but I will just make sure. In the same room as you in Perth, we have Commissioner Mason and Commissioner McEwin. Ms McMahon is also in the room, and she will ask you some questions in a moment. I am in Sydney, unable to come to Perth this week, so I am joining the hearing remotely and you will   I assume, can see me on the video. 


CHAIR: I will now ask Ms McMahon to ask you some questions. 


MS McMAHON: Cheryl, you have provided a statement to the Royal Commission dated 13 September 2022. Is that statement true and correct? 

MS ELLIS: That's correct 

MS McMAHON: And, Commissioners, you can find that statement at volume A, tab 6 of the Tender Bundle. Cheryl, you raised Gavin and his three older siblings on the coast in regional WA. 

MS ELLIS: Yes. Yes, that's correct. 

MS McMAHON: And when Gavin was a younger child, you said that he was a very active little boy. What did he like to do? 

MS ELLIS: He liked to go fishing, go camping. Anything to do with bush or nature, he loved to do that. Anything to do with animals. Yes. He was really extremely happy when he was in the outside. In the bush. 

MS McMAHON: And you have indicated that he had a real affinity with nature. What sort of things would he do? He would go camping? 

MS ELLIS: He would go camping. And as I said, he would go fishing. He would bring things home to the house. Anything that he had caught, anything that he had found in the bush, anything   we were right on the beach so he would find things down in the sand and he would bring them all home. He would look for coins if he went out to sporting things that were outside like football or soccer with his older siblings, he would find coins and all sorts of things and he would bring them all home. He was an avid collector.

MS McMAHON: And, Cheryl, in those early years, you worked as a nurse. Whereabouts did you work? 

MS ELLIS: I was actually working initially at a private hospital there, and then eventually I moved   because it suited the family more to actually work in the regional prison. I did shift work there. I became quite familiar with, yes, prisons and the workings of   both, like, clinically and with prisons, yes. The children were surrounded with that quite early. 

MS McMAHON: And so that assisted you, didn't it, to understand some of the health systems and other systems within custodial environments? 

MS ELLIS: Absolutely. Yes, absolutely. 

MS McMAHON: Now, you have indicated in your statement that Gavin struggled at school. 

MS ELLIS: He did struggle academically. Prior to going to school, he had his own way of learning. He was a very loved child because he was the youngest of three. So, he had a lot of attention and he could speak to people, and once he was in the school, he was in the confines of a classroom, and because he had very   he would just have, like, reactive, spontaneous behaviour because of his diagnosis, he would find it very difficult to have the attention at school. 

So, in the first year we   he actually had a teacher who was known to us, and she would accommodate his needs, but in the second year of schooling and some of the years from beyond there, the teachers would   and the parents would class him as a naughty child because he wasn't able to learn like that. And he couldn't see the relevance in learning there when he was getting ahead and he was learning. So, it was very disruptive behaviour. 

MS McMAHON: I want to   before I ask my next question I might just ask if you can just slow down a little bit. 

MS ELLIS: Sorry. 

MS McMAHON: Because we have our interpreters interpreting everything you say. 

MS ELLIS: Yes, sorry. 

CHAIR: Don't worry, Cheryl. It's a very common trait among our witnesses. Certainly not the first. 

MS ELLIS: Yes, okay. Thank you. Yes. 

MS McMAHON: Thank you, Cheryl. Now you were talking about some of his behaviour that made it difficult for him at school. Is it your opinion that those behaviours were related to his disabilities? 

MS ELLIS: Absolutely. Do you want me to give you an example of what sort of thing he was doing? 

MS McMAHON: Yes, that would be helpful. 

MS ELLIS: Yes. I know one stage there he was actually   the sport – phys-ed teacher actually kept him after school, because they were out in the sports ground and what was happening was they were doing a whole lot of exercises. It was very late and they had to rush back into the classroom. What had happened was Gavin was right at the end of that group and he was going very slowly, and the teacher kept telling him to speed up. He couldn't do that. 

So, the teacher got very angry and said, "You can stay in later." He came home from school late, and I had asked what had happened. And he said, "Like, I was walking behind" and I said, "Why were you doing that?"  And what had actually happened he said, "I had to walk this way."  So, I asked him and I said, "Show me what's happening."  And what he was doing, he had to step on certain bricks, and he actually had to put one foot in front of the other and that was part of his OCD. So, I then realised at that stage that, you know, there was some sort of OCD coming into that but the teachers who didn't know him didn't understand that. 

MS McMAHON: And were some of his   you have indicated that some of his impulsive sort of behaviours got him into some difficulties too. 

MS ELLIS: Yes. That was another thing. I   just recall that one time there was a van that came up from Perth and it was a display caravan. It had all the parts of the body where the children would go in and look at all the different parts of the body, which was an educational thing. It was sort of really good, but the very last thing they said to all of the children before they got on to that, they actually weren't allowed to touch anything. But by the time Gavin had gone in, he had just forgotten all about that. 

He just wanted to touch things. He was very, very tactile and that's how he learnt. So, he walked straight into the caravan and started to touch all the exhibitions. That made the other children laugh because that's their response with any sort of that impulsive behaviour. Then the other children started to touch all the display and the whole thing was like Vesuvius   can I say that. And so, therefore, it sort of came back to the headmaster, the school got a bad report, and it was all his doing, but he never got the opportunity, nor did I, to explain that that was just his impulses that he would touch things. So   yes. 

MS McMAHON: And, Cheryl, you have also indicated that some of these sorts of behaviours would also affect him socially, including with other parents? 

MS ELLIS: Absolutely. There were so many examples of that happening. At school and also, I would say, in the community, because it was a small community, so wherever we were, he was inclined to have these impulsive behaviours. So, that soon got back to the parents. The children would laugh, and they then thought he was a naughty child and he would have a bad influence on the children. When that happened, I noticed that he was just not invited to school   sorry, to birthday parties or anything at all like that. 

MS McMAHON: I see. 

MS ELLIS: He didn't actually seem to mind because he had his family there and he was just so busy all the time. But it was actually   you know, as a family we noticed that that was happening. Yes. 

MS McMAHON: But something that did happen positively for him at school was that he flourished in a particular school that had a small student to teacher ratio. 

MS ELLIS: Yes, that was actually in his second year of high school. In the first year of high school, he wasn't able to go to the school camp. They actually would hold a school camp before they started high school so that all the children would get to know each other. Unfortunately, there was a parent in the primary school who went to the high school and said that Gavin had all these behaviours, so they wouldn't allow him to go to the school camp which I thought was, you know, quite sad because the children were supposed to know each other and see the skills. 

And I think if he had have gone to the school camp in the bush they would have seen that he had quite a lot of natural abilities and that was his style of learning. So, with that, what happened was I had a disability officer and we had a meeting with the Education Department, the disability officer and the principal, and what they did was find a place for him in the north parts of Perth to go to a school. And at that school, it was run by the Health Department and the Education Department. 

They had a really small ratio at the school so that they would look at what type of education they would best achieve with but also too that they had an input into their health issues which would go back to the psychologist and the adolescent clinic. So, at that school he really flourished and it was excellent. And that was for 12 months but he could only stay there for 12 months. 

MS McMAHON: I see. But that certainly showed you, didn't it, that with the right support, he could learn. 

MS ELLIS: Absolutely, yes, yes. 

MS McMAHON: Now, you indicate at paragraph 18 of your statement that Gavin had a really positive nature, and he was never uncomfortable asking police or clinicians or correctives when he needed help. 

MS ELLIS: No. I think it was probably a few things that   that was responsible for that. I think, number 1, me being in a nursing role and being in a small community. Being in a nursing role   so he very easily spoke to clinicians. At an early stage we sent him to a paediatrician who asked him all these personal questions. So, he was able to answer that, and he knew it was for a good purpose.
And, as I said, being in a small community a lot of the people that we mixed with were   once I went into the prison, they were actually the prison officers who were the fathers or mothers of the children that he was playing with or against or perhaps my older children knew them. So he was around   he didn't see them with a uniform on. They were just people that he knew. If he asked for something, they would respond. So, it was effective for him to be able to work his way through, yes. And he didn't see people as being intimidating. They were just helpful. 

MS McMAHON: And, Cheryl, you said in your statement when   talking about his early contact with jails that when he was in jail, you felt like he was safe. Was part of that because you thought he knew to ask for help when he needed it? 

MS ELLIS: Absolutely. When he went into jail, he was able to get   by that stage, he had medication, but he was also well versed about his medication. So I knew that he would be able to give his own history. Although I also knew, being in prisons, that, as a family member, I could have no input into that. So, I was   we were very lucky that he was able to know his medications really well and what were the effect of the medications. 

So, I knew that medically he would be okay. I knew that he would understand to go to a clinician, tell his story and obtain help. He was safe because he knew the officers and he wasn't going to be intimidated by anybody if there was any type of   intimidation or abuse that was sort of happening, that he would then go to probably the clinicians there and tell them that it was happening. So   and he always found someone   he liked people and he had a likeable personality.

So, he would actually find a group or more so an older person and that would be his mentor. He would always find the right person that he could talk about what he was interested in. So, with that happening, I knew that he wasn't out in the bush somewhere when he was younger   or when he was older and started to go to refuges or to be homeless, I wasn't going to not get the phone call. That phone call that you don't get and you wonder where they are is terrible. 

MS McMAHON: So is part of the reason you felt like he was safe in custody because you knew where he was? 


MS McMAHON: And he was likely to be taking his medication at certain points    


MS McMAHON: Whereas when he was in the community, it was more stressful for you. Is that right? 

MS ELLIS: Absolutely, yes. 

MS McMAHON: Okay. Now, you   he did spend some time in prison in WA and also later in New South Wales. 


MS McMAHON: You always supported him in prison, didn't you? 

MS ELLIS: Absolutely. We visited him. When he was in WA, we were able to go there. And at some stage, his father and myself split up so we   which, in a way, as far as visiting, it was helpful because we would take turns in going to visit him. And I also had   my parents were over here   came over from Sydney at that stage and they would go and visit him, and he also had a very good friend from school who would go and visit him. So, that was sort of quite frequent. 

But when the marriage split up, I actually went over east. Gavin stayed here because he was in prison here, and so we   he actually went into prison. It was in Sydney, and we were living on northern New South Wales. So, we couldn't visit him as often. 


MS ELLIS: But, once again, he was also going into living in refuges, because he would go between Sydney and Melbourne and then coming back to us, so that was when I was really happy that he was actually in prison because then, as I said, I knew he was safe. 

MS McMAHON: Now, you   in your statement, you have talked about the sorts of supports that you would have liked to have been available for Gavin when he was in custody. And you have indicated both social workers and some employment opportunities. 


MS McMAHON: Are they the sort of supports you think were missing for him throughout his periods of custody? 

MS ELLIS: I think so. I actually worked for a while in a prison farm, and I think because of who he was and what he did, I think it would have been excellent if he had been able to   and he did for a little while. He actually did go out to the prison farm. I just remembered. So, that would have been excellent if he could have been in that sort of environment, I think. I think at   once he went to Sydney and he was in the prisons that are over there, I think that would have been horrible for him. 

I mean, it's horrible for anyone, really, but to sort of   to have known him, for the family to have some input into his likes and his needs and his background, it would have made a big difference. 

MS McMAHON: And is that the role that you think a social worker could have played in terms of ensuring that the history that you knew as his mother was translated to the authorities in the prison setting? 

MS ELLIS: Absolutely, yes. I see that in prisons, what you have is actually health and you have security, and it's very hard to get something in between. They haven't got the time. And it's   I think health is actually medicine, treatments, injections, and I think security, at the moment, is just that. So, you need somewhere in between to get the familiarity with the prisoner, get the background, get someone that's able to contact the family. 

I think that is just so important because security and health, neither of those have the opportunity to contact the families and get the back   families or friends or somebody, or spend time actually with the inmates themselves. 

MS McMAHON: And on that, were you ever asked by either Justice Health, say, in New South Wales or Correctives, whether it be in WA or New South Wales   


MS McMAHON:   about Gavin's needs? 

MS ELLIS: No. And when I was working in that, as much as I would have wanted that, I recognise that even all those years ago there was no time to do that. I was very lucky in that I actually was in a regional community, so I knew the family. But once you go into a setting where the families aren't there, there's just nothing. 

MS McMAHON: Would you recommend that prisons, whether it be the Health or Corrective Services, be made to talk to family members about disability needs? 

MS ELLIS: Absolutely. Yes. Absolutely. There has to be some sort of flow there where all of that is   somehow incorporated so that they can get back to the services. I have got some recommendations. So, later on I will    

MS McMAHON: Perhaps I will turn to that now. Would you like to tell the Commissioners the recommendations that you do have, Cheryl? 

MS ELLIS: Yes. Yes. I wrote them down. So, one of the first things that I think is absolutely on top is education for the inmates. I really think the inmates need to have different types of education, and you have to look at what's suitable. I know Gavin, with his learning disabilities, for him to have an in classroom thing is   is maybe not possible but I do remember one time he was living in a refuge and he   they   he did a course in, like, window cleaning or mopping or something like that, which when you think about it, if he was not in prison, he would be able to get employment with that. And you have never seen anyone so proud as when he got that Certificate I. It was incredible. 

So, I think when I'm talking about education, let's sort of broaden the scope of what's available and suitable for people. Whereas   I know I'm going sideways at the moment, but I did   when I was in, I did have a lady that I looked after who was in prison and she actually did her Masters while she was in prison. She was in long term, and that was her need, and it would have been inappropriate for her to be mopping floors because she was spending her time. So, that's really, really important that education. 

With the education, I think the staff need to be educated. I think that the officers need to have more education around mental health, and I'm sort of saying that because I don't know what's available with disability, other disabilities at the moment so I can't answer for that. But definitely with mental health so that they can sort of understand where the point is that if somebody   if an inmate is doing something, it is actually a call for help. It is a mental health issue, and it's not just attention seeking. 


MS ELLIS: And it is only with education and working with people that you can   you can see that. So   and I particularly noticed when Gavin   in his last days, when he   when I was at the inquest, I thought about that a lot and I was listening to things that were happening in the inquest. And I met a few of the officers who   they just kept coming up and apologising, and I could feel that they were really happy that I was bringing this out so that that gave them an opportunity to perhaps get that learning that they are not getting. The education around mental health. Yes, I think that's extremely important. 

MS McMAHON: Was there another recommendation that you would like to share, Cheryl? 

MS ELLIS: Yes, I have got a few. 


MS ELLIS: What came up   and the past witness was the same thing   was activities. You know, for anybody, could you imagine yourself being in a cell for 23 hours and not having some sort of activity to do in the cell or to look forward to. I mean, I don't know. I'm not the one that's going to say what that is, but they need to have a look at that. You know, it's just not good for your mind, for your body, for your soul not to have something. It's   it's inhumane, I think not to have that. That's all I will say about that. That's for someone. That's a recommendation that someone has to look into that. 

The other thing that I have written down is industry, because as I said, I worked at the prison farm. And I think when   when anybody is on a prison farm but anybody with a disability, it's an opportunity for them to look at some sort of industry that when they get out, they can take with them, and they can be gainfully employed. Once again, what that is, it would be different for different people, but also it's an income. It gives people a sense of self worth which, you know, if you are a cell how can you prove anything if you are not challenged? So, I think industry   

MS McMAHON: Skill building yes. 

MS ELLIS:   could be something eventually that could be looked at. The fourth one that I know is happening in the prisons now is technology. I think they really have to look at technology. And what I've got is appropriate technology and obviously that would be monitored. But I think IT screens need to be given to prisoners so that they can access security staff in times of crisis. That wasn't accorded to my son, and when I was working, it wasn't accorded to some people, so I think that's very important. 

Sometimes when they are in a crisis, it may well be that they are ringing a bell, and because they haven't got enough staff to come and see them, security staff, then what actually happens is that there is that period   there is that period where the prisoner is   or inmate is there, and they are getting very agitated. And so, by that time they come anybody like with mental health and is sort of extremely reactive or active, they might burst out. Whereas that's not really how they feel. They are just agitated. 

So, if they could have a screen that could come up to them straightaway, but it will all have to be worked out. The other thing they can have clinical services on that screen because what actually happens is, the inmate calls for security, security comes. This is when they are locked up. Security comes and then they say, "We will get the nurse for you." They have to go and get the nurse, and then they have to have enough staff to bring the nurse down. If it's after hours, they may not have the staff to come down. So, if you actually had a screen there, they would be able to organise that so they can monitor them straightaway and that would stop the crisis   that might stop that from happening. 

MS McMAHON:    yes. 

MS ELLIS: Also   and I have got assessment but that goes with assessment as well. If they need to be assessed   and I think my son was actually in the prison and he was to be assessed by the at risk team every 24 hours, and what happened because of lack of staff, lack of time, he was   he was assessed every 48 hours. They have since gone back to 24 hours. So if they needed a rapid assessment, then what they could do is go on to a screen and talk to them directly, and they wouldn't have to go through the officers, perhaps. Talk to them directly and, once again, that would assist in things getting out of hand. 

Also, too, there is therapy. You know, if has got a disability, and if it's a physical disability, there is no reason why they couldn't have a program on there to do exercises or even anybody in there. They may be able to put on an exercise regime appropriate at that time and they can follow an exercise regime rather than just sitting there and pacing and pacing and pacing around the room, which is agitating them. 

And there's one more thing that I think will be really good is TV programs. You know, obviously, that would have to be under some sort of control but, you know, 23 hours, you have to have some mental stimulus. So, my next one is support services. There are some of them, like the psychiatrist. Yes, they have psychiatrists. Do they have a lot? No, they don't. And if they had technology, a psychiatrist would actually be able to do   assess them in   more people and they also would be able to assess them in need out of hours. 

Psychiatrists and psychologists. Those two would be there. That would be excellent. I think also occupational therapists, anybody who has a physical disability, they would need, you know, a certain   like the bed situation, perhaps, you know, somewhere where they have got to hold to get up to the toilet. The toilet might be too low. Like, just everything like that. So, definitely an OT. And, once again, that can be done on screen. It may not need a visit. 

A physio as well to give them, as I said, exercises and to give them appropriate exercises. And the other thing which I have sort of thought about   and I have only thought about that now, is because of the last lady that was talking   is life skill courses. Because there is different skills that we all need, and maybe somebody needs to work within the prison. If it's somebody that's just come in and they have got a mental health problem or a disability, it may well be they need to work through the prison system or it may well be that they need to say, "Look, this is what I need when I get out."  Just to get through   because Gavin had that because we had taught him all the way through, and it must be so hard for somebody coming in new. And   so that's the support services. 

The last thing is mentoring programs. They do have   when you go into prison, they have like a case manager, but I think there is never enough people to do that. 

MS McMAHON: Do you think that perhaps a more formal mentoring program would be helpful within prisons? 

MS ELLIS: I think it would be really good if that mentoring program and to have   I don't know what they do, but I think if the mentoring program was by officers and inmates because I know the value when Gavin found an older mentor. So, if they had mentors in there, and certain rewards and recognitions for the   the inmates who were mentors, and also too for the officers. It would give them   and then also too the prisoners would be able to go on to think, "One day I can be a mentor."  You know. "And that's my reward." So, that's the end of the list. That's it. 

MS McMAHON: Thank you, Cheryl. And thank you for sharing all of those thoughtful recommendations. 

MS ELLIS: Yes, yes, yes. 

MS McMAHON: Now, you have read New South Wales Deputy State Coroner Forbes' report following the inquest, and I understand that you agree with all of her recommendations?

MS ELLIS: Absolutely. 

MS McMAHON: And, Commissioners, Cheryl has asked if I could read just a portion of that inquest so that the wider public is aware of the circumstances of Gavin's death. 


MS McMAHON: So that positive changes can be made. 

MS ELLIS: Absolutely. 

CHAIR: Can you tell me, please, which paragraphs you are intending to read? 

MS McMAHON: Certainly, Chair. From paragraphs 96 down to 100 and then the recommendation on to page 25, if I may. 

CHAIR: Can I suggest that you start with paragraph 40. If   unless this is too distressing for Cheryl. And include, then, paragraph 61 and then move on to paragraphs 96 and so on. That seems to me to give some context to the report. 

MS McMAHON: If I just could clarify, Chair. Just paragraph 40 and 61 and then 96. Is that what you suggest? 

CHAIR: Yes. I'm suggesting that we start on 20 March. Paragraph 61 tells us the situation concerning the availability of psychiatric care. 


CHAIR: In the light of what happened on 20 March and then that leads into paragraphs 96 to 100. 

MS McMAHON: Thank you, Chair. 

CHAIR: As long as that's not upsetting to Cheryl. 

MS ELLIS: No. That's   that's fine. I just thought   I think this is really good. I don't mind what's read out because I think people   this is all about change, and I think a lot of people see prisons as if I go in or if my child goes in then they have expectations and I have even heard people say it will be good for him or her to go into prison. It will teach them a lesson. There is no lessons to be learnt, and I think people need to know, so we have change, that it is not a good place and the sort of things that can happen. So, yes, I'm fine with anything that people   that's fine. 

MS McMAHON: Thank you, Cheryl. Now, before I do that, Chair, I might just ask if the Commissioners have questions before I start to read that material. 

CHAIR: I think it might be better if you read the material and then we will see if there are questions. 

MS McMAHON: Thank you, Chair: 

"On 20 March 2017, Mr Ellis was heard screaming from his cell that other inmates were going to get him and were calling him a paedophile. When approached by Corrective Service officers, he threatened to slash his own throat if he were not moved from the area. Mr Ellis was subsequently placed in restraints and escorted to the holding cage while a safe cell was organised for him."

Paragraph 61: 

"Dr Sarah Jane Spencer, forensic psychiatrist, who is the Coordinator (Clinical) Services and Programs, and Clinical Director, Custodial Mental Health at Justice Health Forensic Mental Health Network, gave evidence that resources constraints led to Mr Ellis not being seen by a psychiatrist for a follow up appointment as was recommended by Dr Wade on 20 February 2017. She said that at the time there were two days of staff specialist time per week to cover 138 patients in the Hamden unit, and priority for Mr Ellis' psychiatric review was determined by a case review discussion after the mental health's nurses review on 1 March." 

The conclusions are as follows. Paragraph 96: 

"After being assessed by Dr Wade on 20 February 2017, Mr Ellis was never reviewed by a psychiatrist in the six weeks that he spent in custody until his death. During that time, he exhibited signs of psychosis and expressed concerns about his new medication not working. He was taken to a safe cell, which is a 24 hour camera cell, where he was stripped to his underpants. He remained in that cell for four days without any psychiatric or any other therapeutic support. 

He was then transferred to a single cell at Darcy Unit, where no further mental health follow up occurred prior to his death. Darcy Unit houses new intakes, often coming down from drugs and alcohol. This court heard evidence that it is noisy and chaotic. Dr Wade in her initial assessment had referred Mr Ellis to the Hamden unit. This is a mental health dedicated unit which has two psychiatrists and a full time mental health nurse. Mr Ellis' mental health was complex, and he had long term high level risk of harm to himself. It would have been far more appropriate for him to have been housed there. The care and treatment that Mr Ellis received prior to his death was inadequate, and I propose to make the recommendations as set out below."

I will read paragraph 100, the expression of condolences: 

"I express my condolences to Mr Ellis' family, and confirm my opinion that the care pathways model should be implemented as soon as feasible. I will arrange for a copy of these findings to be forwarded to the Ministry of Health to include in their consideration of the model."

I shall now read the recommendations: 

"To the Commissioner of Corrective Services of New South Wales. (1) I recommend allocating funding as a priority to the removal of ligature points in all Darcy unit cells at the MRRC. And (2) I recommend consideration be given to adding a requirement for additional random patrols of Darcy cells in the roles and responsibilities of officers on the B watch at the MRRC. 

To the Commissioner of Corrective Services New South Wales and the Chief Executive Officer, Justice Health and Forensic Mental Health Network. (1) I recommend that consideration be given to what steps could be made to deliver better support and care to inmates who are placed in safe cells and to inmates who have recently been released from safe cells, including the provision of multi disciplinary services such as occupational therapists, social workers and psychologists in order to minimise the likelihood of deterioration of their mental health. 

To the Chief Executive Officer, Justice Health and Forensic Mental Health Network. (1) I recommend that further training and education be given to Justice Health staff in completing the health problem notification form in relation to inmates who have been subject to an RIT..."

And I will just indicate that that stands for risk intervention team:

"...for the purpose of assisting Corrective Services New South Wales officers identify relevant signs that may indicate risk of self harm."

And they are the recommendations, Chair. 

CHAIR: Thank you. Cheryl, do you mind if I ask my colleagues if they have questions for you? 

MS ELLIS: No, that's fine. 

CHAIR: Thank you. I will ask first Commissioner Mason. 

COMMISSIONER MASON: Thank you, Chair. Were you able to hear the Chair's opening statement this morning? 


COMMISSIONER MASON: One of the pieces of information the Chair talked about was a Human Rights Watch report entitled "He's Never Coming Back": People with Disabilities Dying in Western Australia. 


COMMISSIONER MASON: And it talks about between 2010 and 2020, 60 per cent of people who died in prisons in Western Australia had a disability. Half the prisoners with disability who died were First Nations people. 


COMMISSIONER MASON: The coroner here, the deputy coroner, is talking about a need to look at the workforce of prisons, particularly in the circumstances of your son's death. 


COMMISSIONER MASON: And it said in those safe cell’s environment, release from them, that there should be attention given to including the provision of multi disciplinary services such as occupational therapists, social workers and psychologists in order to minimise the likelihood of deterioration of their mental health. You also talked about the type of workforce  


COMMISSIONER MASON:   that should be looked at in prisons and you also talked about social workers and mentors and different types of approach with education. I'm listening to what everyone has said leading up to your evidence. Are you   you're really talking about there needs to be a review or a re looking at the workforce because the workforce is not fit for purpose in terms of the profile of prisoners with disability in prisons. And it's causing mental harm and increasing the harm that is being experienced by prisoners with disability. That's what you are saying, Cheryl? 

MS ELLIS: Absolutely. And that's people with known disabilities. But is it not a disability when it's not a good environment and you get depression and anxiety? Therefore, you have got a disability as well. So, do you know what I mean? It's not just the long term. The way that the prisons are built and structured is not helpful for anybody. I would say you could almost call people   a bit like, you know, 100 per cent of people that go in, especially in the first time they go in, you would almost say they are given a disability because they have gone in there. They suffer all that anxiety and that acute depression. But, yes, it's just not structured for them. 

COMMISSIONER MASON: Thank you very much. 

MS ELLIS: Does that answer your question? 

COMMISSIONER MASON: Yes, thank you. 

CHAIR: Thank you, Commissioner Mason. Commissioner McEwin, do you have any questions for Cheryl? 

COMMISSIONER McEWIN: No, no questions from me other than to say thank you very much, Cheryl, for your very valuable evidence. 

MS ELLIS: Thank you. 

CHAIR: Cheryl, I appreciate very much your suggestions, and obviously have you thought very carefully about them. But I wonder whether there isn't something more fundamental here. That Gavin should never have been in a place like this, that if Gavin was going to be helped, then it needed to be in an environment where he wasn't subject to being placed in a cell by himself or watched or suffer degradation by the practices in prison. I just wonder whether the suggestions maybe don't quite   I understand what you have put, and I understand your thinking about it within the context of a prison environment. 


CHAIR: I just wonder if we are trying to put a bandaid solution for something that is much, much more fundamental. 

MS ELLIS: Yes. In   when I have got industry, I've got regional and in the cities. And if people are taken away from their families or their environment, they may be somewhere where families can visit and they may choose to be there, but if you did have technology there, because everybody sort of has FaceTime now, so perhaps if some of those prisons that they are building for the future would go into more regional areas and they had industry and they had all structures put in there, then people with disabilities may choose to go there. 

Because, as I said, we are used to sort of seeing people on FaceTime anywhere. So, let's rethink about, you know, what's happening. And the ligature points that are in   where Gavin was, in Sydney, it's going to take them a long time to get rid of all those ligature points. So, let's sort of say   you know, let's look at some other way to do it because all of the things that I have suggested would easily be able to be accommodated if they weren't in the city centre. 

CHAIR: I see. Thank you very much. Can I express on behalf of us all our sympathy for your loss and our condolences. 

MS ELLIS: Thank you. 

CHAIR: And thank you very much for your statement and giving evidence and for allowing us to hear your story and evidence as well. Thank you so much. 

MS ELLIS: Thank you. Thank you. 


CHAIR: Yes, what   should we adjourn or do we move on to something else right now?

MS McMAHON: We can move on to the reading of the Mother of JC's evidence but if we could just have perhaps a couple of minutes to   

CHAIR: Yes, certainly. We will adjourn for a few minutes. It's now 2.25 Perth time. We will return in another five minutes, 2.30. 



CHAIR: Yes, Ms McMahon. 

MS McMAHON: Thank you, Chair. Commissioners, the statement of the Mother of JC dated 7 September 2022 will now be read and you can find that at Tender Bundle A, tab 5. The Mother of JC is unable to attend today for health reasons, and we extend our best wishes to her and gratitude for providing her evidence to the Royal Commission. There are two non-publication orders applied to the name of the Mother of JC. 

This evidence may bring about different responses, including feelings, for people. It will include accounts of violence and neglect of a First Nations person with disability. The evidence includes references to a First Nations person who has passed away. If the evidence raises concerns for you, please contact the numbers that will now be provided on the screen. 

JC was a proud Yamatji woman. The Mother of JC lost her daughter when she was tragically shot by police. The Mother of JC statement will be read by Chelsea Johnson. Ms Johnson is the Director of First Nations Engagement at the Disability Royal Commission. Ms Johnson is a proud Yaggera woman from Minjerribah. Thank you, Ms Johnson. 

CHAIR: Yes, thank you, Ms Johnson. 

MS JOHNSON: Thank you, Chair. I am the Mother of JC. A mother who has watched her daughter be neglected by all government institutions. The prisons, the hospitals, Department of Communities, NDIS, Housing and the police. I have seen failures from all sides of the government departments when it comes to JC. While I haven't had access to all of the information about JC's time in prison and rely on what she has been able to tell me, I can speak to these failures from our direct experiences. 

JC was a proud Yamatji woman, a daughter, sister, dear friend and a mother herself. She was only 29 years old at the time of her tragic and completely avoidable death. Her son was only 6 years old when he lost his mother. JC was deeply loved by her family, who she would always look out for. Her friends in Bandyup and Greenough Prison looked up to her as a monitor. If anyone was down she would make sure they were okay. The prison set up a seat under a tree in the yard with a plaque for her after she passed because of her reputation for helping inmates. She is also dearly missed in Geraldton by those she would visit, have a yarn with and help in any way she could. 

She always went around and visited family and friends, and she would help a lot of old people. She was well loved and respected. She was kind at heart. Yet she was repeatedly failed by the government, including through its prisons. And I will show from the experiences she shared with me. I hope that the Disability Royal Commission can ensure that people who live inside those prison walls, especially those with disabilities and complex health conditions, receive the support they need in prison and when they return to community. 

A lot of people like JC come out of prison with no support and nowhere to go. I saw this happen to JC, and I can see it happening to so many others still. Without support, JC would relapse on her drug use, and she told me that she would sometimes end up in jail just to get help. Even though the support in prison was inconsistent and not enough, it was better than nothing. She would put herself back in prison just to have her basic needs met. 

JC's return to prisons and to hospitals need to be understood as a result of the failures of the prison system to provide appropriate support. If the support JC received in prison was at an appropriate standard and she was linked with appropriate services when released, I strongly believe that her experience out of prison would have been different. 

JC's background. JC's birth mother was an alcoholic who drank heavily throughout her pregnancy. She surrendered JC to the hospital when she was one month old because she didn't have the support needed to care for her. Instead of helping her, the government took JC away from her mother and siblings. I got custody of her, and she lived under my care from when she was around five months old to around 15 years old. JC struggled with her mental health and addiction from young age. When she had her son, he was also taken from her straightaway and put into foster care. Like her own mother, she wasn't supported to care for him. 

JC's mental health. For years before JC was shot, she had been calling out, "Help, help, help" to the mental health system. She wanted the mental health mob to help her get a home, but they never helped her. She needed support when she was in and out of prison, but the quality in prison was inconsistent. Greenough Prison gave no support to JC. The Superintendent would target her because she thought JC had an attitude problem. That's what JC said. 

Bandyup was the only place where she was given any help, but this care stopped as soon as JC was released. She left prison with no mental health follow up arranged for her. The hospitals gave her no support either. They just left her. So, without consistent contact with the mental health services over the years, JC's mental health was not stable, and I would watch her relapse, return to hospital and return to prison. 

JC's experience with mental health was something she struggled with from a very young age. By the age of 20, JC had attempted suicide five times, with her first attempt at age 12. She would leave prison. She had a family to go to. She had a place to stay if she needed. But she didn't have somewhere that was hers. She kept crying out for the mental health mob get her a place in Geraldton, but it never happened. 

A home would have given her a safe, stable place to get well and get on with her life. It would have given her some dignity. I have learned through the records that when she was in the hospital in 2019, her distress over not having her own home and lack of progress with her application for Home West Housing was noted as pushing her towards another suicide. Still, no one listened and no one helped her. 

When JC was released from prison, she told me she had no mental health appointments lined up by the prison. Within a couple of days, she was threatening suicide and had attempted to take her life so she was admitted to hospital. JC and our family were very concerned about her mental health and about her self harming. When she was provided treatment in prison, the treatment did help, but she went straight back to her addiction problems and mental health struggles when she was out because there was no follow up support lined up by the prison. 

JC was quick at walking away from people when she relapsed and would isolate herself when she wasn't well, but when she knew she was going to harm herself she would call the police. A week before the shooting on the Monday afternoon, JC rang 000 as she was having suicidal thoughts. I got a call from the nurse at the hospital who told me that JC had tried to harm herself. The ambulance took her to hospital again, but they sent her down to another hospital in Perth rather than keeping her close to family.

My niece went to check on JC, who was very sick with drug withdrawal. I called her and could tell that she wasn't okay, and my niece agreed. So, I called the nurse on Friday and told her that JC wasn't okay. I asked if they could wait until Monday to discharge her so I could arrange to come and get her and make sure she was safe. I knew JC. I knew she wasn't okay. But the nurse didn't listen to me. The nurse said, "She's right. She can go back on the bus." 

All they do is keep them for a couple of weeks or so and then discharge them without support on the outside. The hospital didn't listen to me even though I am her mother. They didn't care. Instead, they put her on the 3.45 pm bus on Friday back to Geraldton, and she went straight back to drugs. Four days later on the next Tuesday, JC was shot by police after she called 000 again due to concerns about her mental health. 

I understand that the Disability Royal Commission is focusing on the conditions in prisons: however, I believe that JC's health both in and out of prison is important to this discussion. There is a clear link between the failures of the prison in providing any ongoing care and JC's mental health worsens which ultimately led to her death. Recovery was not possible for JC because those systems failed her time and time again. 

Detention conditions and neglect of JC's mental health. The prison system is failing. Failing a lot of people. JC had a long history with mental health crisis and disability, and the criminal justice system failed over and over to give her appropriate care. Despite her well known history of hospital admissions, psychiatric reports and formal diagnoses, the suggestion of FASD, JC did not receive the level of care she needed when she needed it. 

In 2016, for example, I was told by JC and the prison that she was in at that time that she had attempted suicide. In prison, JC told me she had help, but not frequently enough and not necessarily at every prison. I know of her experiences in prison because she would call me in the morning and the afternoon every day. In around 2015 or 2016 at Greenough Prison, JC told me she was seeing an Aboriginal mental health worker but not often. Only every couple of weeks. 

She should have seen an Aboriginal health worker more frequently to ensure that she received ongoing appropriate and culturally safe care. Instead, the Aboriginal healthcare worker was not accessible, and prisoners could only see them during their very limited availability. She wasn't offered any other support. The lack of support was so bad that JC ended up burning her mattress in protest. Something she told me afterwards. 

Instead of improving and taking care of her, she was transferred off country to Bandyup. She told me how this really affected her, and I think Greenough should have kept her close to family and provided more support. It is well known how bad the support is at the prison, as inmates have rioted against the terrible conditions. There are a lot of problems in that prison, and they didn't want JC there because they thought she had an attitude. They treated her so badly. 

The Superintendent was especially terrible, moving prisoners off country and not providing enough support. Greenough didn't even have access to programs such as reading and writing classes on site. The prisoners had to travel to access these. I know that these problems continue today through other family members. From around 2016 or 2017, at Bandyup Prison, JC said she was seeing a psychiatrist who was helpful but who wanted her to take medication. I'm not sure how often JC spoke with the psychiatrist, however JC told me that she didn't want to take medication and the psychiatrist didn't offer her much else in terms of support. 

I'm not sure whether she received any education about her medication. JC did take her medication sometimes but she didn't like taking it because it would slow her down. Sometimes it would help her sleep, but sometimes she would experience delusions. She would tell me that other prisoners on the medication were also struggling with it, and she didn't want to take her medication as she felt sorry for them. Alternative treatments such as cultural supports were not provided. She was never offered the Elder Visit Program or a similar initiative, to my knowledge. 

The psychiatrist could see and talk to her but didn't change anything. JC told me that she was still struggling with her mental health. She told me that she had got some help for her addictions and anger management on the inside, but it wasn't enough because she wasn't linked up with any support services when she was released to continue her care so she wouldn't relapse. 

She was known to the mental health mob on the outside, but she would forget to make appointments with them, and the prison didn't help her by organising appointments or referrals. JC also had problems with her heart and told me she didn't get much help for that at all. I have come to learn from her medical records that JC had also been referred to NDIS multiple times while in prison. However, she was repeatedly told that she did not meet the criteria and denied the support she should have had. 

During a sentencing hearing in May 2018, Justice Jenkins urged Bandyup Prison to assess JC formally for FASD. JC told me this at the time. She wasn't screened for FASD by the prison as far as I was told, and I have come to learn that the Department has since confirmed there was no routine FASD screening at that time. She wasn't diagnosed with FASD until around 2019, after she had asked to see the psychiatrist at Bandyup to talk about her mental health issues. An earlier diagnosis would have helped JC in many ways and may have helped her receive care specific to her FASD symptoms both while in custody and when returning to the community. It would have made a difference, as she could have had more support. 

Some of the screws were okay but others weren't. Screws saw her poor mental health and they didn't want to help her. They would lock inmates up and put them in an isolation cell. JC went into isolation a couple of times when she stood up to screws, but she would try and keep her head down to avoid it. When she was at Bandyup, a screw slammed the cell door on her finger. It was such a bad injury that she had to have it amputated. This happened around a year before her death. I know all of this because she told me. But JC wouldn't always come to me for help. She would try to deal with these problems on her own. 

I think that in addition to improving these conditions, the prison should have provided JC with the following support which she didn't have access to: (a) mental health and addiction support which continued from prison to the community through referrals to mental health and drug and alcohol teams in the community; (b) proper screening to identify her health conditions early, including FASD and access to appropriate supports; (c) programs in both prisons which helped her mental health; and (d) cultural support such as access to speak with elders. 

Prison systems neglect upon release. Failure to link to services. While JC was neglected in prison, it was when she got out that they failed her the most. JC's return to prisons and hospitals show how the prison system failed to equip her with the tools necessary for release and to provide her with continuing access to appropriate services. Improvements need to be made so that people in prison are prepared for and supported in their release. 

The majority of JC's treatment in prison was the prescription of medication. When she was released, I didn't know whether she was meant to stay on the medication or not. I didn't know how much she should be taking. I wasn't told anything. So, with no follow-up from the prison, JC would stop taking the medication. She struggled with drug and alcohol addictions from a very young age, but they didn't link her up with drug or alcohol services when she left prison. No. 

She told me that they didn't refer her to any addiction support services in the community and didn't arrange for any appointments for her. They knew about her mental health and FASD in 2019, but did they link her up with the appropriate support in the community? No. She told me they didn't refer her to any mental health services in the community and didn't arrange any appointments for her. They didn't give her any information about how to get a job or help her with permanent housing either. 

She told me that instead, she was put on the long housing wait list and told to wait, wait, wait. JC told me she did reading and writing classes in prison and had some training and anger management sessions. These programs weren't run in Greenough Prison, nor were they run on JC's country. To participate in classes, JC would have to be sent to Bandyup, away from country and connection. I see the same thing still happening. People being sent away to prisons off their country just to access these programs. 

She would also attend church in Bandyup on Sundays for her peace of mind. There was no access to church at Greenough. When they're released, nobody follows up to see if they are alright. I know this from JC's experiences and the experiences of others who continue to be failed. 

Conclusion. I am hoping by sharing JC's experiences, we can push for inmates, especially those with disabilities and struggling with their mental health and trauma, to receive the support they need in both prison and when released back into community. 

CHAIR: Yes, thank you, Ms Johnson. Mr Griffin. 

MR GRIFFIN: That's the final evidence for today. Can we adjourn until 9 am Perth time tomorrow, to commence with the evidence of Tina Powney and Trevor Barker in relation to Gallawah. 

CHAIR: Yes, thank you. We will adjourn, then, until 9 am tomorrow Perth time. Thank you.