Combined inspection report for youth detention centres

Our inspection focus

This is a combined report on our 2024 inspections of 3 Queensland YDCs – West Moreton, Brisbane and Cleveland.  

Brisbane YDC is the state’s largest, built to accommodate 162 children. Cleveland YDC was built to accommodate 112 children and is the only centre in north Queensland. West Moreton YDC is in south-east Queensland and was built to accommodate 32 children. 

In May 2025, the average daily number of children held at each centre was:

• West Moreton YDC: 31.32
• Brisbane YDC: 148.13
• Cleveland YDC: 93.54.

Most YDCs are close to their full capacity. At the time of our inspections, children were waiting in watch-houses across the state until they could be accepted at Brisbane or Cleveland YDC. In some instances, children were accepted directly to West Moreton YDC from a watch-house if there was space available and Brisbane YDC was unable to transfer a suitable child to West Moreton YDC. This is not the usual practice. 

In accordance with the Inspector of Detention Services Act 2022, we are required to inspect YDCs annually. Our 2024 inspections focused on 4 areas:

1. separations
2. use of force and restraint
3. personal searches of children
4. health.

We will explain and discuss each of these areas in the report.

Our inspections show that Queensland’s YDC system is under significant pressure. Queensland has more children in detention (and under community-based supervision, which allows young people who have committed offences to stay out of detention) than any other state in Australia (see Table 1).

Table 1: Children in detention and under community-based supervision, by state

^{Source: Report on Government Services 2025, 17 Youth Justice, Table 17A.1. ROGS note: totals may not equal the sum of individual cells due to rounding and/or unpublished data.}

The safe capacity of each centre is set at 85% of its built capacity (how many children it can accommodate in total). The safe capacity provides centres with options to move children for behavioural management, manage infrastructure maintenance and accept children if there is an increase in the number of children in watch-houses. 

In 2023–2024, the overall YDC utilisation rate (that is, how much of the accommodation of the youth detention centre is used) in Queensland was 99.6% – well above the safe capacity. This was the highest utilisation rate in Australia (see Table 2). In comparison, New South Wales has the highest number of permanently funded beds (344 compared with 288 in Queensland), the second-highest average nightly population (212.9 compared with 286.8 in Queensland) and a utilisation rate of 61.9%. 

Table 2: Utilisation of detention centres

^{Source: Report on Government Services 2025, 17 Youth Justice, Table 17A.2. Note: Any errors in totals are from the original ROGS table.}

The pressure on Queensland’s youth detention system to manage and support children was evident in our inspections. With increased numbers of children, YDCs experience significant challenges in maintaining the staff-to-child ratio, allowing children to take part in required daily activities and recreation (referred to as ‘the structured day’), and ensuring health supports are provided.

Separations

Separation is the practice of locking children alone in a room. In August 2024, our report – Cleveland Youth Detention Centre inspection report: Focus on separation due to staff shortages – highlighted the impact that extended separation can have on children’s psychological wellbeing. It also addressed the human rights impacts of extended separations. 

That report focused on staff shortage separations (those caused when there are not enough staff members to allow children out of their rooms). However, children in YDCs experience other separation types as well. These include separations used to structure the daily routine such as locking children in their rooms to clean or to shower or to rest, respond to incidents and respond to children’s requests. They are being used to manage high numbers of children, low numbers of staff, and behavioural issues.

Use of force and restraint

Our inspections included a focus on the use of force and restraint. The use of force refers to physical contact used on a child to protect them or others or property. Restraints are physical items such as handcuffs, which are applied to prevent children from escaping, harming themselves or others or disrupting the security of the centre. The use of force and restraints are restrictive practices. 

YDCs use restrictive practices to maintain safety and security for both staff and children. The United Nations Rules for the Protection of Juveniles Deprived of their Liberty (the Havana Rules) allow the use of force and physical restraint. However, Rule 64 states that force and restraint should only be used in exceptional cases, where other control methods have failed, for the shortest time possible, and only as explicitly authorised by law and regulation. 

Our standards reflect the Havana Rules and maintain that force and restraint must be subject to clear guidelines and be closely monitored. If used inappropriately, force and restraint can exacerbate challenging behaviour and impact children’s health and wellbeing. Children in youth detention can experience force as painful, distressing and retraumatising.

Personal searches of children

Queensland’s YDCs conduct personal searches of children, including wand searches, clothed searches, cavity searches and partially clothed searches (more commonly known as strip searches). Cavity searches are the most invasive search method and may only be conducted by a medical professional and when no other approach will effectively address the risk.

While searches help to maintain safety and security, they have the potential to harm children, particularly if the search involves touching the child or asking the child to remove their clothes. For this reason, it is important that searches are conducted in response to a genuine need and in a respectful and minimally intrusive way, and that accurate records of searches are kept. 

From a human rights perspective, partially clothed searches are of particular concern, as they have the potential to be demeaning, humiliating and retraumatising for children with previous experiences of physical or sexual abuse. 

Health

Health services in YDCs provide an opportunity to deliver health support, improve children’s wellbeing and prepare them for reintegration into the community. Children in YDCs are likely to have complex health needs, as noted by the Queensland Family and Child Commission. In its report – Exiting youth detention: Preventing crime by improving post-release support (June 2024) (p. 7) – it found:

The experiences of young people who enter into custody are characterised by multiple and complex issues, including poverty, family breakdown and dysfunction, unstable housing, drug and alcohol use and ‘mixing with the wrong crowd’.

The commission’s report also found that alcohol and drug use were connected to offending behaviour in young people. 

Role of Inspector of Detention Services

The role of the Inspector of Detention Services was established under the Inspector of Detention Services Act 2022 (the Act) to provide independent oversight of detention services and places of detention in Queensland. 

The Act promotes the improvement of detention services and places of detention, with a focus on the humane treatment of detainees and on preventing them from being subject to harm. 

Key functions of the Act involve inspecting detention services and places of detention (once every year for YDCs and once every 5 years for adult prisons) and reporting to the Legislative Assembly with advice and recommendations. 

As required by the Act, in August 2023, the Inspector of Detention Services published the Inspection standards for Queensland youth detention centres (the standards). These are designed to provide consistent assessments of YDCs and protect the basic rights of children in YDCs. We refer to the relevant standards throughout this report.

Our inspection process

Our inspection process included:

• reviewing information from relevant reports 
• reviewing relevant legislation and policies
• assessing data held on the information systems of the Department of Youth Justice and Victim Support (the department) – the Detention Centre Operational Information System (DCOIS)
• obtaining information from the entities responsible for providing YDC services, including the department, West Moreton Hospital and Health Service (HHS) and Townsville HHS
• seeking submissions from other government bodies
• engaging with services who attend the centres
• seeking submissions from community organisations 
• engaging with community service providers including Aboriginal organisations and/or Torres Strait Islander organisations
• interviewing and engaging with staff at the centres, including managers and operational and therapeutic staff
• attending the centres to conduct onsite inspections (see Table 3)
• observing (during the onsite inspections):
  • accommodation units
  • separation rooms
  • education rooms
  • health service facilities
  • recreational facilities
  • visitor facilities (observed on weekends, when most visits occur)
• listening to the children detained at the centres.

Table 3: Review period and onsite attendance dates

The data request periods occurred some time ago, indicating the length of time it has taken to prepare the report. As part of Chapter One, we provide a 2025 update on separations to identify recent changes in the time children spend in staff shortage separations.

A note about the data and terms we have used in this report

Some sections of this report rely on data obtained from the department or the department’s DCOIS. We provided the department with an opportunity to review the data we used in this report, and it expressed concern about the reliability of the data drawn from DCOIS. 

Where we found errors that may affect the data, we sought to find clarifying evidence in DCOIS to support the data drawn. If we were able to confirm it was a data entry error, we removed it from our data analysis. 

We also noted slight variances in data when we accessed DCOIS on different dates. The department told us that the data is accurate at the time it is accessed; however, it may change over time due to routine review, internal monitoring and oversight. 

Where possible, we have noted the date the data was accessed on DCOIS, but some of our analysis involved accessing the data over significant periods of time. Including these dates within this report would provide little value. 

While we acknowledge the department’s concerns about the information contained in DCOIS, it is the department’s main recordkeeping system and should be able to be relied upon to draw information accurately and clearly. As it is the only database directly available to us, we have used its data for our inspection. We have been advised a newer version of the system is being planned.

Areas in which children are accommodated in YDCs are commonly referred to as ‘sections’ or ‘units’ depending on the centre. These areas usually contain the children’s rooms, a common room and a kitchen. We have used both terms throughout this report when discussing children’s accommodation areas.

Acknowledgements 

We acknowledge the support and assistance we received throughout the inspection process from the department and its staff at each centre. 

We also acknowledge the assistance of staff from West Moreton HHS and Townsville HHS and the medical centre staff at each YDC.

A range of government and non-government stakeholders provided valuable information during the inspection process, and we thank them for their assistance. 

Finally, we thank the children who took the time to speak to us and share information about their experiences at the YDCs. 

Submissions

As required by s 24 of the Act, on 26 August 2025 we provided a consultation draft of this report to a number of entities to allow them to make submissions. The following submissions were received:

Table 4: Submissions received

We carefully considered each submission before finalising this report. Where we considered it relevant, we included some of the information provided in the submissions in this report. 

We have included the submission of each entity, in full, at the end of this report.

In this chapter we focus on the use of separation in Queensland’s youth detention centres (YDCs). Separation occurs when a child is placed alone in a locked room (and is also known as isolation or segregation). It can occur in a special separation room or in the child’s own room.

Our August 2024 report – Cleveland Youth Detention Centre inspection report: Focus on separation due to staff shortages – concentrated on the amount of separation that occurs and the impacts extended separations can have on children in detention. 

This report considers all types of separations that can be used in YDCs. Our 2026 inspection report will look at how separation impacts on access to services in YDCs.

We found that extended separations are still occurring at Cleveland YDC and that more than half of the separations at Brisbane YDC occur on a weekend. We looked at the conditions of separation and how the wellbeing of children is monitored while in separation.

In Queensland’s YDCs, separation occurs when a detention centre employee places a child in a locked room alone. There are 2 broad reasons why separation is used:

• a child may be locked in a room for a specified time in response to an incident or due to staff shortages. In these circumstances, separation is designed to protect people or property or restore order
• a child may be locked in a room for non-incident-related reasons. This can occur if the child is ill, at the child’s request, or for routine security purposes.

Depending on the circumstances, separation may affect one child, all children in an accommodation unit, or all children in the centre.

A centre-wide lockdown occurs each evening from 7:30pm to 7:30am, when children sleep in their rooms. This is a routine overnight separation and is considered an appropriate form of separation that allows children to rest.

The Productivity Commission’s Report on Government Services 2025 does not report on the amount of time children in youth detention centres spend out of their own rooms (referred to as ‘out-of-room time’), and there is no nationally agreed definition of ‘separation’. This contrasts with adult prisons, where consistent definitions and reporting are in place. 

Our Cleveland Youth Detention Centre inspection report: Focus on separation due to staff shortages captures our concerns about separations due to staff shortages, noting that extended separation can affect children’s psychological wellbeing. It refers to the Queensland Child Death Review Board’s 2022–23 annual report, which concluded that separation can impact a child’s health and wellbeing in severe, long-term and irreversible ways. 

Our report noted several court decisions that highlighted the duration and impacts of separations at Cleveland YDC. The issues we raised in our report continue to impact Queensland’s 3 YDCs, and we note that Cleveland YDC continues to be more severely affected by staff shortages than Brisbane YDC or West Moreton YDC.

The use of separation in youth detention centres

Separation policies and practices in Queensland’s youth detention centres

Sections 21 and 22 of the Youth Justice Regulation 2016 set out:

• reasons a child can be placed in separation
• the necessary approvals required for continuous separation
• recordkeeping requirements for separation.

Children in a YDC may be placed in separation for any of 5 reasons: 

• Type A: the child is ill
• Type B: at the child’s request
• Type C: for routine security purposes under a direction issued by the chief executive (these include staff breaks and meetings, searching the centre, shower and hygiene breaks for children, and overnight lockdowns)
• Type D: for the child’s protection or the protection of another person or property
• Type E: to restore order in the centre.

The Department of Youth Justice and Victim Support’s D-3-8 Youth Detention – Separation policy indicates that staff shortage separations are classed as Type D, as they relate to the protection of people.

Using data from the department’s Detention Centre Operational Information System (DCOIS), we reviewed the number of separations under each type to determine how separation is used, and the longest and shortest recorded periods of separation. (Tables 5–7). 

We have also added the median period of separation to balance extremes in short and long periods of separation. That said, we are concerned that even one child experienced the extended periods of separations we have identified below. 

We excluded the ‘overnight lockdowns’ category from the data, as they are recorded inconsistently at each centre. However, we are aware that they occur each day from 7.30pm to 7.30am. 

We also noted that for separation types A–C, the overnight lockdowns are counted as part of the longest period of separation, but not for types D–E. 

Table 5: Summary of separations for West Moreton Youth Detention Centre, 1 December 2022 – 30 November 2023

^{*This data was not able to be found due to limited data filter options for this separation type.
Source: Compiled by the Inspector of Detention Services from DCOIS separation information accessed on 2 July 2025.}

This review indicated that the greatest number of separations at West Moreton YDC were at the child’s request. For the longest separation, the separation notes did not identify the actions taken to resolve the issue where one child refused to undergo mediation with another child, and as a result asked to be separated from the rest of the unit. 

Table 6: Summary of separations for Brisbane Youth Detention Centre, 1 March 2023 – 29 February 2024

^{*This data was not able to be found due to limited data filter options for this separation type.
Source: Compiled by the Inspector of Detention Services from DCOIS separation information accessed on 1 and 2 July 2025.}
**This is both the median and longest period as the time was recorded 8 out of 10 times.

Hygiene breaks were the most common separation at Brisbane YDC and were mostly brief. However, the YDC also experienced separations due to staff shortages. During our inspection, children and staff told us that most staff shortage separations occur on weekends. We confirmed this by reviewing DCOIS data, which showed that 50% of the 2–12-hour separations occurred on a Saturday or Sunday, with Monday as the next highest day.

The separation recorded above as a response to an incident on the oval (Type D: 1 day, 11 hours and 43 minutes) does not include overnight separations. If we include these, the child was actually separated for 3 days continuously. We discuss the approach to recording separations in more detail later in the chapter.

Table 7: Summary of separations for Cleveland Youth Detention Centre, 1 August 2023 – 31 July 2024

^{*This data was not able to be found due to limited data filter options for this separation type.
Source: Compiled by the Inspector of Detention Services from DCOIS separation information accessed on 1 July 2025.}

At Cleveland YDC, we found that some staff breaks were recorded as lasting for as little as one minute. However, it is likely these were entered to record the separation, rather than as an accurate record of the separation length. Most of the staff break separations were for less than 1 hour and 50 minutes.

We noted the ongoing significant number of staff shortage separations, with Cleveland YDC recording more than West Moreton and Brisbane YDCs combined. Children who are spending significant stretches of time in separation are unlikely to require additional hygiene breaks. The low number of hygiene breaks and high number of extended separations indicate that Cleveland YDC is under significant pressure.

In our August 2024 report – Cleveland Youth Detention Centre inspection report: Focus on separation due to staff shortages – we discussed the separations terminology used by staff. Cleveland YDC referred to ‘night mode’ and ‘continuous cell occupancy’. These terms are not official and do not appear in policy documents but are used at that YDC to determine the extent of separation. We described these separations in detail in our 2024 report, noting that:

• ‘Night mode’ separation is a restrictive daytime separation similar to the routine overnight separation. Children are locked in their rooms, but may be escorted from their accommodation unit to attend a visit, medical appointment or program. They are usually given short times out of their room to make phone calls. All other contact occurs through their room’s locked door.
• ‘Continuous cell occupancy’ means that children in an accommodation unit are placed in separation for part of the day. Enough staff are present to allow children to leave their rooms in small groups and spend time in the common areas. Children are typically rotated out of their rooms in groups of 4.

We note the limitations of separations data due to data entry issues and the way counting rules are set in DCOIS. As noted earlier, we excluded overnight lockdown information from our summary of separations data. 

However, for Cleveland YDC, we noted a significant number of overnight lockdowns recorded in DCOIS. There were 9,799 overnight separations in DCOIS (compared with 120 for West Moreton YDC and 269 for Brisbane YDC).

Some of the separation records for Cleveland YDC reflect overnight lockdowns that occurred for extended periods. The longest separation of this type recorded during our review period was 2 days, 11 hours and 59 minutes. The reason given was simply ‘overnight lockdown’.

We reviewed several individual separation records in the overnight lockdown option at Cleveland YDC and found that units had been placed in ‘night mode’ separation – that is, a separation for a period of between 2–12 hours during the day. Use of this terminology at the centre explains why staff had selected Type D as the separation subtype in DCOIS, incorrectly entering 2–12 hour ‘night mode’ separations as overnight lockdowns. 

This raises concerns about the reliability of DCOIS separations data.

Staff shortage separations

We analysed staff shortage separations at Cleveland YDC during its review period. We excluded the independent living units Sandpiper and Osprey, because they were vacant for much of the period. Our analysis revealed that children at Cleveland YDC were subjected to staff shortage separations of 2 hours or more for an average of 53% of the time (see Graph 1). 

Graph 1: Percentage of days between 1 August 2023 and 31 July 2024 in which children at Cleveland Youth Detention Centre were subject to staff shortage separations of greater than 2 hours but less than 12 hours

Source: Compiled by the Inspector of Detention Services from DCOIS separation information.

We analysed a subset of the Cleveland YDC data (covering 1 June – 31 July 2024) to consider instances where staff shortage separations extended for 11 hours and 59 minutes or longer. This equates to children being separated for 24 hours or more (given the routine overnight separation). Our analysis revealed that, in June and July 2024, children at Cleveland YDC were subjected to extended staff shortage separations of 11 hours and 59 minutes or longer for 61% of the time. On 5 occasions, children were subjected to staff shortage separations for 6 consecutive days, totalling 144 hours of separation.

Given the potential harm caused by separations, we conclude there is a serious risk to the safety, care and wellbeing of children at Cleveland YDC due to staff shortages. The YDC acknowledges its severe staff shortages and lacks effective contingencies to mitigate the disadvantages these create for children. 

We raised the issue of extended staff shortage separations with the department through a section 17(2) notice under the Inspector of Detention Services Act 2022 (the Act). On 16 February 2025, the department told us that separation practices continue to be a focus area, including:

• workforce sustainability and capability
• legislation, policy and practices, including a planned review of operational policies relating to separation practices
• information systems and reporting, by working through the limitations of DCOIS
• infrastructure planning and enhancements, by upgrading existing facilities and designing purpose-built YDCs
• improving oversight by strengthening the management, reporting and training relating to separation to minimise its use and enhance oversight.

In relation to the specific period of 1 June – 31 July 2024, the department told us that Cleveland YDC was experiencing high levels of staff shortage separations, with 75% of children and 66% of accommodation units affected by separation on an average day. This extended into August 2024. 

We were told that overall separation levels started to decline by September 2024, with the proportion of children affected falling from 61% to 51% in September, and to 44% in October. However, separations increased again, with 66% of children affected in November and 68% affected in December.

The department told us that the number of extended separations at Cleveland YDC decreased after our review period. We were told that 6 children were separated consecutively for 4 to 5 days in September 2024. The number affected by extended separations then significantly increased to 32 in October 2024 and 30 in November 2024. We were advised that one child experienced an extended separation period in December 2024.

We acknowledge the department’s continuing focus on addressing staff shortage separations. We will continue to monitor these separations and their impact on the daily lives of children. 

There are various reasons why children may be separated. However, the most common reasons appear to be staff shortages, incident responses and at the child’s request. We support children being able to self-select out of common environments if they need to, but we were unable to determine what supports are provided to those children. 

Of most concern are the extent of staff shortage separations at Brisbane YDC on weekends and the ongoing separations at Cleveland YDC. 

An update on the use of separations in 2025

Given the amount of time that has lapsed since our initial information request, we reviewed separation data in DCOIS to understand the use of separations for the period 1 January – 31 July 2025. Graph 2 compares the percentage of days sections were in staff shortage separation for between 2 and 12 hours during this period with the same period in the previous year. 

Graph 2: Percentage of days between 1 January – 31 July 2024 and 1 January – 31 July 2025 in which accommodation units at Cleveland Youth Detention Centre were subject to staff shortage separations of between 2 and 12 hours 

Source: Compiled by the Inspector of Detention Services from DCOIS separation information accessed 8–14 August 2025.

The period of time in 2025 shows some reduction in the percentage of days children were in staff shortage separations of 2–12 hours at Cleveland YDC. However, for some accommodation sections, such as Kestrel and Kingfisher, there has been an increase.

As noted above, between June to July 2024, children at Cleveland YDC were experiencing extended staff shortage separations of 11 hours and 59 minutes or longer, 61% of the time. We reviewed the staff shortage separations for the June to July 2025 period and noted some improvements.

Graph 3: Percentage of days between 1 June – 31 July 2024 compared with 1 June – 31 July 2025 in which accommodation units at Cleveland Youth Detention Centre were subject to extended staff shortage separations of 11 hours and 59 minutes or longer

Source: Compiled by the Inspector of Detention Services from DCOIS separation information accessed 8–14 August 2025.

When the full days of separation are compared across the 2 months, one year apart, there is a reduction in the number of full-day separations affecting children at Cleveland YDC. 

What these graphs show is that the extended separations that we saw in 2023–24 have significantly reduced; however, they are still occurring. 

The use of 2–12 hour separations has also slightly reduced for some accommodation units, but it has increased for others. This may indicate a greater reliance on short-term separation. This is when children in a unit may miss some activities of the day such as education or recreation due to a separation, but they are not separated for the entire day. They have some time either in the unit or in scheduled activities.

Extended staff shortage separations

We also looked at the number of staff shortage separations of 2 consecutive days or longer for each of the accommodation sections at Cleveland YDC in July 2025. As a positive, we found no instances of staff shortage separations that went over 3 days. 

In July 2025, we found 28 instances of children at Cleveland YDC being kept in separation due to staff shortages for 2 consecutive days. This does not mean that all of the children at the centre were subject to staff shortage separation 28 times. These are instances where an accommodation unit was in separation due to staff shortages, as Graph 4 demonstrates.

Graph 4: Number of instances of staff shortage separations for 2 consecutive days in the accommodation sections at Cleveland YDC in July 2025

Source: Compiled by the Inspector of Detention Services from DCOIS separation information accessed 8–14 August 2025.

We found that the Kestrel unit was subject to these extended separations on all 4 weekends in July 2025.

We also considered the use of extended separations at West Moreton and Brisbane YDCs.

Graph 5 indicates that Cleveland YDC is still, on average, using this type of separation more frequently than Brisbane and West Moreton YDC combined.

Graph 5: The average percentage of days each youth detention centre had extended staff shortage separations for the period 1 June – 31 July 2025

Source: Compiled by the Inspector of Detention Services from DCOIS separation information accessed 8–14 August 2025.

West Moreton YDC had minimal use of extended staff separations during this 2‑month period. 

There has been a significant improvement in the use of extended staff shortage separations in the YDCs, but there still appears to be a reliance on separations for periods between 2 and 12 hours to manage staff shortages. 

This indicates that YDCs have an ongoing need for more staff. This will ensure children are not subjected to the types of extended separations we discussed in our 2024 report and the number of shorter separations currently being experienced.

In its submission to this report, the Department of Youth Justice and Victim Support advised us it has completed The Youth Justice Strategic Workforce Plan 2025–28, which is intended to address system-wide challenges for the workforce. It also discussed specific recruitment strategies for Cleveland YDC (Appendix A).

Recordkeeping for separations

The policy relevant to recordkeeping for separations, YD-3-8 Youth Detention – Separation, requires operational staff to keep accurate and timely records of events. It provides examples of what is required, including:

• time spent out of room
• provision of meals
• medication
• provision of phone calls
• visits by support staff.

Despite this, we found the recording of separation activities to be inconsistent and inadequate, and it was not always clear if operational requirements were followed.

Lack of individualised and detailed separation records

At West Moreton YDC, our review of separation records found that they do not individualise each child’s management throughout the separation period. For example, we found records indicating that psychologists or nurses attended the unit during the separation period, but not who they saw. 

Some records at West Moreton YDC provided insufficient detail to demonstrate that observation requirements were met or to show the times when children were outside their rooms. Some records did not provide enough detail about the activities children engaged in while out of their rooms. 

This inconsistency in the records meant we were unable to confirm that staff ensure the safe custody and wellbeing of children during separation. We were also unable to confirm how staff ensure children are regularly rotated out of their rooms during staff shortage separations and keep children busy with activities during these separations.

The separation policy requires that individual children subjected to continuous separation have their behaviour assessed and reviewed. This must include regular communication between operational staff and therapeutic staff. 

Staff should engage therapeutically with the child to understand and address the underlying causes of the child’s behaviour. In addition, if a child is separated during structured day activities, staff must consider whether it is safe and appropriate to provide the child with educational work or activities. 

We found that visits by multidisciplinary staff, such as case workers, psychologists, cultural team members and external service providers, were not consistently reported in separation records. For example, we reviewed 17 individual separation records of longer than 2 days at West Moreton YDC and found:

• no evidence that children received the required daily health assessment from a nurse
• no evidence of visits by case workers or other members of the multidisciplinary team 
• poor documentation about the activities children engaged in while outside their rooms. (Most records stated the children were out on rotation but provided no details about their activities.) 

We are unable to determine whether the reports reflect poor recordkeeping practice or failure to follow policy. The lack of detail also makes it impossible to assess whether children are engaging in physical activity or meaningful contact.

While the discussion above specifically relates to West Moreton YDC, we found the same lack of recordkeeping at Brisbane and Cleveland YDCs. 

Having accurate records allows for transparency and accountability of internal processes. Records are also an important source of evidence in disputes, audits, investigations and regulatory reviews. 

Recordkeeping on the Detention Centre Operational Information System

As we noted in the Cleveland Youth Detention Centre inspection report: Focus on separation due to staff shortages, DCOIS was introduced in 2011 and is now classed as a legacy system. Its reporting functionality is limited, and its design does not support youth detention centres’ growing complexity and reporting requirements. 

DCOIS is also limited by the quality of the data that is recorded. Individual detention youth workers are responsible for entering data on DCOIS, and it varies in quality and reliability.

We found that DCOIS has several platforms within the system for capturing information. Staff can misunderstand the appropriate platform for recording an incident, leading to data loss. For example, during our inspection at Cleveland YDC, we found several examples where data could not be logically located within DCOIS, as illustrated in Case study 1.

Recordkeeping requirements for different separation types

As in the case study, we found that DCOIS data about separations is not always linked to an individual child’s record. This is because Type A and B separations are only required to be recorded in section logs, and this information is only linked to the unit in which the child is accommodated. 

When separation data is linked to the unit but not the individual child, it is difficult for staff to monitor the child across time to assess trends and consider underlying issues.

To ensure appropriate oversight, separations records should be easily accessible and consistently recorded. Improved data would support the review and evaluation of trends and ensure separation practice aligns with policy.

In its submission to this report (Appendix A), the department provided feedback on the proposed recommendation, which stated:

The Department of Youth Justice and Victim Support ensures:

• compliance with the requirements in the Youth Justice Regulation 2016 and the YD-3-8 Youth Detention – Separation policy regarding recordkeeping, including by conducting regular audits
• separation records are linked to individual children’s files to ensure transparency and the ability to determine how long a child has been subjected to separation.

The department advised us that it did not accept the second part of the above recommendation because the case study reflects a Type B separation (at the child’s request). It stated that under the Youth Justice Regulation, this is not a prescribed purpose and, under the relevant policy, is only required to be recorded in section logs. 

The department advised us that requiring recording of the types of separations that occur multiple times a day and may be brief, such as the one in our case study, would impose an administrative burden that would affect the amount of time operational staff spend with children. 

It advised us that children are observed and supported during self-separation, and if requests to self-separate continue or are prolonged, children are assisted through multi‑disciplinary teams and harm assessments. 

We acknowledge that the Youth Justice Regulation currently only requires Type D and E separations to be recorded, and we have considered the impact of this recommendation on service delivery to children. 

However, our case study shows children may be separated for extended periods of time under a different separation type with no requirement to record it, aside from in section logs. This makes oversight of these separations difficult. We will consider this issue further in our next inspection report on youth detention centres.

Separation room facilities and cleanliness

Children can be separated from others by being locked in their own room or by being placed in a separation room. Separation rooms are intended for short-term separations and are used to manage risk. Most accommodation units have one.

The separation rooms are small and empty, with bare floors and walls, no toilet, no basin with running water and no furniture. They are devoid of basic amenities. 

Photo 1: West Moreton Youth Detention Centre separation room, Photo 2: Brisbane Youth Detention Centre separation room

Photo 3: Cleveland Youth Detention Centre separation room

The separation policy describes the conditions applying to children in separation rooms:

• Staff must ensure there is no unreasonable delay in the child accessing water and bathroom facilities, while being mindful of any safety risks when facilitating this.
• Separation must occur for the minimum time possible. As soon as it is possible and safe to do so, the child must be moved to an accommodation room.

When deemed safe and appropriate, children can be separated in their own room instead of the separation room. This is a preferable practice because it gives the child access to running water and a toilet.

We believe the practice of placing children in empty rooms with no basic amenities is inhumane. The environment is unsuitable for an adolescent’s cognitive development and may be particularly inappropriate if the child has previously experienced trauma. In comparison, separation rooms in New South Wales and Western Australia provide children with access to toilets and running water.

The 3 YDCs have similar separation rooms. Each is a concrete box with a camera on the ceiling and an intercom through which staff can speak to children. 

At the time of the inspections, the separation rooms at West Moreton YDC and Brisbane YDC were covered in graffiti. Cleveland YDC had repainted its separation rooms; but we noted children had already started to scratch into the paintwork, especially on the doors.

During our site visits, children told us that they are not always given bathroom visits and drinking water when requested. Staff at Cleveland YDC told us that children do not always call out and ask staff to take them to the bathroom, particularly when they are in the separation room overnight. Children may choose to urinate in the drain, with the room being cleaned the following morning.

During our onsite inspections, we observed that some separation rooms were left dirty. We concluded that cleaning schedules are not routinely followed and that centres are not clear about who is responsible for cleaning.

On 20 December 2024, we wrote to the department under section 17(2) of the Act in relation to our concerns about the extended separations of children at Cleveland YDC, the state of the separation rooms, and the lack of intercom access for children within the separation rooms. (We discuss intercoms in more detail in the next section.) 

We acknowledge the department’s comprehensive response to the notice, in which it said the incident described in Case study 2 had been reviewed, and the department was committed to addressing systemic factors contributing to the incident. These included enhanced cleaning regimes, proactive maintenance and improved accountability measures. 

During our onsite inspection at Cleveland YDC, children told us about: 

• being placed in a separation room with urine left on the walls by a previous occupant
• being forced to urinate in the drain when their request for the bathroom received no response
• being left in separation rooms for extended periods (including overnight), with requests to use the bathroom ignored
• threatening they would complain to family members if they did not receive bathroom access.

Staff at Cleveland YDC told us that if a child urinates on the floor or wall and refuses to clean it up, staff may choose to leave the child in the separation room for longer than planned.

During our onsite inspection at Brisbane YDC, we observed 3 dirty separation rooms:

• Cedar A – a brown substance on the wall, floor and door (Photo 4)
• Paperbark A – a large pool of unknown fluid on the floor (Photo 5)
• Paperbark B – fluid in the corner of the separation room (Photo 6).

It was unclear whether the rooms had been dirty for a long time. However, the rooms were vacant throughout the 5 days of our inspection and remained uncleaned. 

It is inappropriate for separation rooms to be left dirty if children are to be separated in a clean and dignified environment.

Photo 4: Cedar A, Photo 5: Paperbark A, Photo 6: Paperbark B

Separation rooms become soiled with urine because the rooms lack minimum facilities such as running water and a toilet. Based on reports from children and staff, it seems likely that staff do not facilitate children’s bathroom access in a timely way. 

As stated earlier, this inhumane conduct may force children to urinate in a drain while being monitored via CCTV, and they may be left in an enclosed room with urine or faeces. These practices increase the exposure of children to serious biohazards.

In our August 2024 Cleveland Youth Detention Centre inspection report: Focus on separation due to staff shortages, we made several recommendations to address issues identified in this section:

Recommendation 5
The Department of Youth Justice recognises the importance of ensuring that children are not locked in rooms that do not have basic facilities, including a toilet, a basin with running water, and a bed or seat, for any length of time. 

Recommendation 6
The Department of Youth Justice ensures that all separation rooms and holding cells in new youth detention centres (including those at Cairns and Woodford) have basic facilities in them, including a toilet, a basin with running water, and a bed or seat. 

Recommendation 7
The Queensland Government and the Department of Youth Justice provide funding to improve the centre’s separation rooms and holding cells to ensure that they have basic facilities in them, including a toilet, running water, and a bed or seat. 

Recommendation 9
The Department of Youth Justice ensures the centre immediately improves the condition of all separation rooms, including by removing graffiti, scheduling regular maintenance of the rooms, and adding appropriate soft furnishings.

In its submission to the report, the then Department of Youth Justice responded to Recommendations 5–7 and 9 by noting:

• There are safeguards in place that ensure separation rooms are only used when necessary and for the shortest possible time; young people have access to staff via an intercom and can request water and to use the toilet and these requests must be actioned; separated young people are either frequently observed or under constant observation.
• The department commits to undertake a practice review into how a toilet, basin with running water, and a bed or seat could be provided.
• The department commits to consider including these facilities in the new YDCs at Woodford and Cairns, noting the significant cost implications and the need for consultation with staff and industrial unions to address workplace health and safety concerns.
• The department commits to exploring the feasibility of modifying current infrastructure at Brisbane, West Moreton and Cleveland YDCs, noting the cost implications, current infrastructure and construction limitations, and required consultation with staff and industrial unions to address workplace health and safety concerns.
• All YDCs have a routine and regular maintenance schedule which helps to identify required maintenance including the removal of graffiti.

While we acknowledge the department’s response, we reiterate the recommendations in this combined report.

The (now) Department of Youth Justice and Victim Support provided an update to its implementation of the above recommendations for the Inspector of Detention Services’ Annual operational report 2024–25 and in its submission to this report (Appendix A). It indicated that, while accepted in principle, the cost of the infrastructure changes to existing YDCs is prohibitive, so it is not possible to implement Recommendations 5–7. 

The department advised us the design of the Woodford YDC will have the same separation rooms as the existing YDCs. This is due to construction progressing to the point where making the changes to the separation rooms is not feasible based on the site space, the impact on engineering services for the centre and the re-approval processes, which would delay delivery of the centre.

We acknowledge the information provided by the department; however, we maintain that the continued lack of basic facilities in separation rooms significantly impacts the humane conditions of detention. We will continue to monitor the implementation of these recommendations in future inspections and annual reports.

Intercoms in separation rooms

The policy related to the separation of children, YD-3-8 Youth Detention – Separation, states that if the use of a separation room or holding cell is necessary, staff must ensure there is no unreasonable delay in the child accessing water and bathroom facilities. However, separation rooms do not have intercoms that enable a child to contact staff. The same policy outlines that ‘Young people must be able to contact staff at all times while in separation (e.g. via intercom)’ (p. 4).

The department advised that all separation rooms have an intercom in the ceiling, allowing staff to speak with the detained child. However, the intercom is initiated by staff from the accommodation unit office or master control room. The detained child can knock on the door or call out to staff, but they cannot initiate intercom contact. During our onsite inspections, children told us they have to shout and bang loudly to attract staff attention. As stated earlier, some children commented that staff do not respond when they call for assistance.

We note that when children are separated in their own room rather than a separation room, they can initiate contact with staff via intercom. 

The lack of a child-initiated intercom in separation rooms poses a significant risk to children in the case of an emergency. For example, it may hinder swift access to medical assistance. In addition, it poses the risk of degrading or inhumane treatment if children require access to water or toilet facilities between observation periods and cannot attract staff attention. 

Section 21(5) of the Youth Justice Regulation states that if a child is separated in a locked room at the child’s request, they must immediately be let out when they request it. However, if the child is in a separation room in any of the YDCs, they must find a way of attracting staff attention between observations for this to occur.

In response to our s 17(2) notice under the Act, the department told us that separation rooms are used sparingly and only when necessary, and that children only stay for the minimum time necessary. The department acknowledged that children cannot initiate contact with staff via an intercom, but stated this decision was made due to persistent tampering and intentional damage by children. Children’s wellbeing during separation is monitored through physical observations and electronic checks. 

The department told us that children in separation rooms can communicate their needs during observations, can knock on the door to get staff attention or can communicate with staff between checks. We were also told that the existing intercom system can be left in a continuous ‘listen/monitor’ mode, which means that staff can hear if a child is talking.

Adults in prisons have access to intercoms within their cells (whether in accommodation, safety or detention units) and they can make requests and seek assistance. We find it unacceptable that children who are locked in a separation room cannot initiate contact with staff via an intercom. 

We acknowledge the importance of regular observation of children in separation. We are also aware that these observations are not always conducted as required. It is, therefore, essential that children have another way of seeking assistance that does not rely on staff initiating the contact. 

Time out of room during staff shortage separations

Children being held in separation should receive a minimum of 2 hours outside their room every day. This is most relevant during staff shortage separations, as they can extend for long periods. We found evidence that children do not always receive the required minimum time out of their rooms.

West Moreton Youth Detention Centre

At West Moreton YDC, we identified 17 occurrences between 1 January and 21 November 2023 of a child being subject to separation for longer than 2 days due to staff shortages. We noted that in 16 of these occurrences, the child did not receive the required 2 hours out of their room each day. 

For example, on Saturday 13 May 2023, 8 boys were accommodated under separation conditions in Koala unit. One child declined the opportunity to leave their room to make a phone call and received no further offers of time out of their room for the rest of the day. 

Of the remaining 7 boys, 3 attended visits. These 3 boys were offered further opportunities for phone calls in the afternoon and were out of their rooms for times that ranged from 1 hour and 23 minutes to 1 hour and 31 minutes. Of the remaining 4 boys in Koala, 2 were out of their rooms for 12 minutes for phone calls, one was out for 3 minutes for a phone call, and one was out for 2 minutes for a phone call. 

The staff shortage separation in Koala unit continued on Sunday 14 May 2023, and the time out of room for the boys ranged from 10 minutes to 21 minutes for the entire day.

We also reviewed Possum, a girls’ unit at West Moreton YDC, for the same dates. We found that staff shortage separations significantly affected the girls’ time out of their rooms for the weekend. 

On Saturday 13 May 2023, one of the 4 girls did not receive any time out of their room after declining an opportunity to make a phone call. The remaining 3 girls received time out of their rooms ranging from 15 mins to 57 minutes in total throughout the day. On Sunday, one girl received a total of 12 minutes out of her room, 2 received 30 minutes and one received 31 minutes.

Our review identified that, during extended staff separations, children were offered minimal opportunities to leave their rooms. If a child did not want to make a phone call (or was unable to make a phone call because their phone allowance was used and had not yet reset), they did not get time out of their room. 

Brisbane Youth Detention Centre

Our review of separations at Brisbane YDC identified that from Friday 23 – Sunday 25 February 2024, Grevillea B was subject to 3 consecutive days of separation.

We looked at these 3 separation days to determine children’s out-of-room time. Table 8 summarises our findings of the least and most amount of time out of room provided to a child during the period.

Table 8: Grevillea B unit time out of room, 23–25 February 2024

^{Source: Compiled by the Inspector of Detention Services from separation records on DCOIS.}

At Brisbane YDC, we found that, during extended staff shortage separations, a child is unlikely to receive time out of their room if they do not want to make a phone call (or is unable to) and does not receive a visit. 

Cleveland Youth Detention Centre

Given the high number of separations at Cleveland YDC, we reviewed separations across a full week, from 8 to 14 June 2024. Graph 6 summarises the average time out of room the children in each unit received. To express this as a percentage, we calculated out-of-room time on days with separation and out-of-room time on normal days (not in separation). 

Graph 6: Total time out of room, Cleveland Youth Detention Centre, 8–14 June 2024

Source: Compiled by the Inspector of Detention Services from separation records on DCOIS.

Most children used their out-of-room time for phone calls, medical appointments or visits. We found that some children had several consecutive days with no time out of their rooms for fresh air or sunlight. 

Later in this chapter, we address the impacts of how separation is recorded.

Our Cleveland Youth Detention Centre inspection report: Focus on separation due to staff shortages, included a recommendation to address time out of room:

Recommendation 2 
The Department of Youth Justice works with staff of the Cleveland Youth Detention Centre to identify how to make improvements to the amount of time children spend out of their rooms and the meaningful contact they experience.

We reiterate this recommendation and note its applicability to all 3 YDCs. We also note the need for ongoing monitoring and oversight of out-of-room time for children in youth detention.

The Department of Youth Justice and Victim Support provided an update on its implementation of the above recommendations for the Inspector of Detention Services’ Annual operational report 2024–25 and in its submission to this report (Appendix A). The department told us that work to improve the amount of time children spend out of their room and the quality of meaningful contact is continuing. This is supported by reductions in staff shortage separations at Cleveland YDC and by a recent departmental initiative, Detention with Purpose.

In future inspections, we will monitor the impact of these changes on the amount of time out of room and meaningful engagement opportunities provided for children.

Observations of children in separation

The separation policy requires that all children in separation be observed at a minimum of every 15 minutes, or more often if required by a suicide prevention plan or behaviour observation plan. This includes regular observations during the routine overnight separation. 

All observations must be conducted and recorded as outlined in the operating manual. The observing staff member should physically identify each child and make sure the child is settled. 

We found that staff do not consistently conduct routine or suicide risk observations and record the information in DCOIS. (We discuss suicide risk observations in greater detail in Chapter 4.) 

The Youth Detention Centre Operations Manual Chapter 4 – Security management (p. 46) states that when young people are confined to their rooms, staff must:

• conduct physical checks of young people every 15 minutes 
• conduct observations in accordance with suicide or self-harm risk level or behavioural observations
• physically identify each young person 
• make sure the young person is settled 
• make sure that all young people are accounted for and observed to be settled.

YDCs conduct audits to ensure staff meet observation requirements for overnight separations and suicide and self-harm risk observations. All centres are required to audit the observations conducted in one unit, on one day per month during a select period of time.

West Moreton Youth Detention Centre

A review of audit records for observations at West Moreton YDC for January – December 2023 shows that audits are conducted regularly (Graph 7). We noted that, in most months of 2023, between 3 and 7 days of overnight observations were audited by the centre, more than the number of audits required. West Moreton YDC consistently audits the period between 10:00pm and 2:00am. The graph shows the average percentage of observations that were conducted as required.

Graph 7: Percentage of required observations conducted, averaged by month – West Moreton Youth Detention Centre

Source: Compiled by the Inspector of Detention Services from audit data supplied by West Moreton YDC.

The audits reflect a significant and ongoing issue with compliance with observation frequency. Also, the audits do not separate base level observations (15-minute overnight checks) and suicide and self-harm risk observations, which are more frequent. 

The centre management identified several practice issues through these audits:

• Some children were not checked for more than 4 hours, though gaps of one to 2 hours were more common.
• Data records indicated that all observations were conducted as required, but CCTV checks confirmed that not all observations were conducted.
• Staff conducted checks without torches or body worn cameras.
• Not all children were observed.
• Some staff were not visible on CCTV or appeared to be asleep on duty.

We reviewed the observations recorded at West Moreton YDC for 4 accommodation units between 10:00pm on 6 November 2024 and 2:00am on 7 November 2024, including recorded observation times, swipe card access and CCTV. We found that in:

• Echidna unit – observation times were prefilled into an observation sheet and initialled. Of the 16 observations required during the period, only 4 were conducted
• Wombat unit – observation times were prefilled into the observation sheet and one child in the unit was on high observations due to suicide and/or self-harm risk. Of the required 120 observations for the suicide and/or self-harm risk child and the 16 base level observations, only 4 observations were completed during the period. The detention youth worker pre-initialled all the observation times
• Possum unit – all observation sheet times were prefilled and initialled by the detention youth worker. Of the required 24 low suicide risk observations and 16 base level observations, only 9 were conducted
• Koala unit – all observation sheet times were prefilled and initialled. Of the required 24 low suicide risk observations and 16 base level observations, only 2 were completed.

During the onsite inspection, we observed staff conducting observations. Staff spoke of the difficulty in conducting physical observations overnight when children are asleep. They said that children could be observed through the CCTV cameras without disturbing them. We understand this, but staff are required to conduct physical checks. 

Staff told us that when they check on children on suicide risk observations, they look for the rise and fall of the children’s chests. They said this is difficult to do without opening the room door and pointing a torch at the child, but if the staff member is alone in the accommodation unit, they cannot open the door. 

While we acknowledge that disrupted sleep is harmful for children, children under suicide risk observation are at particularly high risk. Observations should be conducted in a way that does not disturb the children but provides assurance they are in good health.

We reviewed the suicide risk observation sheets for 2 children and found that both sheets had the observation times prefilled to prompt staff to complete them. We are concerned that prefilling times provides no guarantee that observations will occur as planned. In fact, it may discourage accurate recording of the times when observations are conducted. 

We received information from the centre indicating that referrals had been made to the Professional Standards Unit of the then Department of Child Safety, Seniors and Disability Services, based on non-compliance with observation requirements. 

Despite the time between the 2023 audits and our follow-up check in 2024, West Moreton YDC continued to demonstrate non-compliance with observation frequencies. We consider the risk to children’s wellbeing because of this to be unacceptable. 

Brisbane Youth Detention Centre

We reviewed the observation audit records for Brisbane YDC for January 2023 to February 2024 (Graph 8). The records indicate that audits are conducted regularly The centre audited up to 5 days of overnight observations for some months. It audits a 10-hour period during the overnight lockdown. 

Graph 8: Percentage of required observations conducted, averaged by month – Brisbane Youth Detention Centre

Source: Compiled by the Inspector of Detention Services from audit data supplied by Brisbane YDC.

We excluded 2 audits from the sample provided due to incomplete records.

The audits conducted by Brisbane YDC identified that:

• Not all checks completed were physical checks and some were assumed to be conducted via CCTV monitoring of the child.
• Some checks were considered partial (that is, the detention youth worker did not observe all children in the unit).
• The longest identified gap between observations was 8 hours and 55 minutes.
• Some checks were so brief that it was unlikely the worker could have determined the child was in good health.

We reviewed the observations recorded at Brisbane YDC. We requested bed check records and CCTV footage for 12–13 December 2024 for 7 units and reviewed the period from 10:00pm to 2:00am (Table 9).

Table 9: Review of observations, Brisbane Youth Detention Centre, 12–13 December 2024

^{Source: Compiled by the Inspector of Detention Services from audit data supplied by Brisbane YDC.}

Our review indicated improvement in completing the observation rounds, with several units carrying out the required number of observations.

In relation to suicide risk observations, the Brisbane YDC audit noted:

• Staff did not conduct observations of children at the increased frequency.
• Forms were filled out for the increased observations, but this was not supported by CCTV footage.

We discuss the need for compliance with suicide risk observations in greater detail in Chapter 4.

Cleveland Youth Detention Centre

Information provided to us by the centre indicates that, for the period 15 October 2023 – 23 July 2024, observation audits were conducted monthly, generally with a selection of 4 units reviewed across 4 hours (10:00pm – 2:00am, 11:00pm – 3:00am or 12:00am – 4:00am). However, the audits records use a different format to those provided by West Moreton and Brisbane YDCs and are not as easy to interpret.

The audits reveal that scheduled observations are generally not conducted as required. In some instances, base level observations are conducted but not suicide risk observations. The audits also identify inaccurate records about observations. 

For Cleveland YDC, it is not possible to provide monthly average percentages. However, the audits reveal significant and recurring non-compliance with observations that warrant referral to the Professional Standards Unit.

We reviewed observations at Cleveland YDC and requested CCTV footage for 5 accommodation units for 9–10 October 2024, between 10:00pm and 2:00am. We summarise our findings in Table 10.

Table 10: Observation review for 5 units, Cleveland Youth Detention Centre, 9–10 October 2024 

^{Source: Compiled by the Inspector of Detention Services from CCTV footage supplied by Cleveland YDC.}

During our onsite inspection at Cleveland YDC, we saw observations being conducted in accommodation units during the day and night and noted examples of both compliance and non-compliance. In instances of non-compliance, we were mindful of children’s safety and wellbeing and prompted staff to complete observations after a lapse of 20 minutes. 

Several detention youth workers informed us that it is difficult for one staff member to complete the more frequent suicide risk observations – particularly the medium and high observations – which require observations at 5-minute or 2-minute intervals. 

On 18 November 2024, we raised our concerns about the failure to conduct mandatory observations of children at Cleveland YDC with the department under section 17(2) of the Act. Our concerns centred around:

• base level observation requirements not being met
• suicide risk observation requirements not being met
• gaps between recorded observations being excessively long
• evidence of fraudulent completion of observation records
• staff continuing to fail observation requirements even after the issues had been directly addressed.

The department’s response was comprehensive. It noted that it will:

• continue to implement strong internal controls and monitor compliance with observations
• take action to address non-compliance, including referrals to the then Professional Standards Unit
• operate systemically to improve compliance with night-time and suicide risk observations by developing a stand-alone observation policy and targeted leadership training, regularly communicating requirements to officers, and establishing a professional standards unit within the department.

On 20 December 2024, we informed the Minister for Youth Justice and Victim Support and Minister for Corrective Services (the Minister) under section 17(5)(b) of the Act of our concerns about the serious risk to the safety, care and wellbeing of children at Cleveland YDC. We reinforced our support for the actions identified by the department.

We made 3 recommendations to the Minister, which are included in this report as Recommendations 9–11. Since the notice was sent, we have been advised that the department has established an Ethical Standards Group.

We conclude that observations of children in separation are not conducted as required, despite YDC oversight of the process through audits. Staff must be supported to undertake the required observations through appropriate staffing and clear communication of policy requirements. 

In its submission to this report, the department confirmed it has developed and published a stand-alone observation policy. (Previous observation requirements were included in other existing policies – see Appendix A). We would like to acknowledge the policy as it consolidates observation requirements, reinforces expectations and clarifies actions for non-compliance.

The department advised us that the YD-1-1 Youth Detention – Observations policy will be used to clarify thresholds for referral of matters to its Ethical Standards Group and that the relevant training will be provided to support compliance with the required observations.

Counting separation time 

The separation policy defines time limits for separation and the approval required when separation is used for protection or to restore order (Types D or E). This policy was updated in August 2023, with more stringent approval requirements. 

Under the current policy, the following approvals apply to separations:

• up to 2 hours – must be approved by shift supervisor or higher
• more than 2 hours – must be approved by an executive director
• more than 12 hours – must be approved by an executive director, and senior executive director must be informed
• more than 24 hours – senior executive director must give prior approval
• each subsequent, consecutive 24-hour period – senior executive director must give prior approval and be informed about the number of consecutive days of separation.

Separation time is calculated differently, depending on its cause:

• For incident-related separations, the department does not count the overnight separation period (7.30pm to 7.30am) when calculating separation time.
• For staff shortage separations, the department does not count the overnight separation in its calculation, and consecutive days are recorded as separate events in DCOIS. However, when staff shortage separations extend for consecutive days, they are classed as continuous for approvals and notification. This means that 2 consecutive days of staff shortage separation (7:30am to 7:30pm across 2 consecutive days plus the routine overnight separation) count as a 24-hour separation for approval purposes.

The approval and counting rules regarding the length of staff shortage separations are complex. We show an example in Figure 1.

Figure 1: An example of how overnight separations and continuous staff shortage separations are counted and approved

Source: Prepared by the Inspector of Detention Services.

Using the example in Figure 1, when children are affected by a continuous staff shortage separation between Saturday and Monday (and therefore are mostly locked alone in their rooms): 

• The overnight lockdowns are considered a routine separation and do not require additional approval.
• The 7:30am to 7:30pm separations (during the day, when children would otherwise be mostly out of their rooms) are considered continuous for the purpose of approval. However, only the daytime periods are counted as continuous. In the Figure 1 example, children would be separated for 36 hours for approval purposes (3 sets of 12 hours).
• DCOIS records each daytime separation as a separate event. In the Figure 1 example, this would be recorded as 3 distinct 12-hour separations. 

Figure 1 shows that, for impacted children, the approval process and DCOIS records significantly under-represent the time they are locked in their rooms. In this example, children are separated in their rooms for 84 continuous hours, with the only exceptions being any short breaks to make phone calls or attend a visit.

During separation, children may spend time outside their locked room for specified activities, meals or phone calls. This time is included in the overall separation time.

In December 2022, the then Department of Youth Justice, Employment, Small Business and Training inspected Queensland’s 3 YDCs and identified inconsistent recordkeeping about separations, both between centres and within centres. The inspection report recommended clearer processes for recording separations within DCOIS and enhanced recordkeeping.

We are concerned that the current data collection process under-represents the hours that children are continuously separated in a room. We consider that the inclusion of the overnight separation period when calculating and recording the total period of continuous separation would provide a more transparent approach to reporting on the time that children have experienced continuous separation.

In its submission to this report, the Department of Youth Justice and Victim Support provided feedback on the proposed recommendation (Appendix A), which stated:

The Department of Youth Justice and Victim Support changes the process for calculating periods of separation to include the routine overnight lockdown in the calculation and ensures this is reflected in DCOIS. This calculation process should apply to all types of separation.

The department told us it does not accept this recommendation for the following reasons:

• Current recording of separation duration aligns with legislative requirements, which exclude overnight lockdowns from being counted.
• Including the overnight lockdown in the count would create administrative burden by increasing the number of separations that require approval.
• The department’s tracking of separations includes weekly monitoring conducted at half‑hour increments and regular reporting to executive leadership.
• DCOIS entries are accurate and compliant, and cumulative separation data is recorded through a departmental dashboard.

We acknowledge the information provided by the department and have decided to withdraw the recommendation. However, the amount of time children spend in separation, especially as it relates to extended separations, remains relevant when considering the humane treatment and prevention of harm to children in youth detention centres.

We will work with the department to consider this issue further and will return to it in our next inspection report.

Admission holding cells used for separation at Brisbane Youth Detention Centre

In most circumstances, children are separated in a separation room attached to their accommodation unit or, for staff shortage separations, in their own room. However, during our onsite inspection at Brisbane YDC, we observed a child being held in separation in the admissions holding cell. 

We were advised the child was ‘section bound’ due to a behavioural incident. This is explained in Youth Detention Centre Operations Manual Chapter 3 – Incident Management as the child being allowed out of their room but not out of their accommodation unit (section) due to risks they may pose to other children, staff, property or the security of the centre. Staff told us this means the child is confined to their section because they have ‘done the wrong thing’ and are therefore ‘unable to attend [the] structured day [the daily activities such as education and recreation]’. 

In the example we observed at Brisbane YDC, the section-bound child was moved to the admissions holding area, where there were staff to monitor them, to enable the other children in the unit to attend the structured day with the required staff-to-child ratio. 

We accept that the centre sought a solution to allow the greater number of children to participate in the structured day and not be impacted by one child. However, structured activities include up to 5 one-hour sessions per day on weekdays. This suggests that the section-bound child could be held in an admissions holding cell for more than 5 hours while other children participate in activities. 

The separation policy requires separations of more than 2 hours to be approved by an executive director. In this case, however, the child was separated for multiple periods of under 2 hours, which did not require executive director approval. The compounding effects of these section-bound separations mean that a child could be separated for more than 17 hours in a 24-hour period (including the routine overnight separation) without executive director approval.

In its submission to this report (Appendix A), the department advised us it is reviewing the YD-3-8 Youth Detention – Separation policy. The review will include a new scenario in relation to children being temporarily separated during the structured day. It states that when the cumulative time separated exceeds 2 hours, a 2–12-hour separation approval should be sought. 

We acknowledge the actions the department has taken to address this recommendation and will monitor the implementation of this change when the policy is published.

In this chapter we consider the use of force and restraint in Queensland’s youth detention centres (YDCs). We specifically cover the following issues:

• the process used by YDCs to review use-of-force incidents
• use of restraints
• use of unapproved techniques
• use of body worn cameras.

Most of the examples of use of force we reviewed did not indicate that children are subjected to it arbitrarily. However, we noted some examples of non-compliance with policy, with staff reverting to previously approved techniques (which are no longer considered suitable for use).

We also identified that Cleveland YDC effectively applies verbal de-escalation techniques that are part of the use-of-force response model.

Standards, rules and reports

Rule 64 of The United Nations Rules for the Protection of Juveniles Deprived of their Liberty (the Havana Rules) refers to the use of force and physical restraint. The rule states that force and restraint should be used only in exceptional cases, where other control methods have failed, for the shortest time possible, and only as explicitly authorised by law and regulation. 

The Australasian Juvenile Justice Administrators’ National Standards for Youth Justice in Australia 2023 require that responses to unacceptable behaviour are fair, consistent and proportionate. They also require that the least intrusive, most developmentally appropriate options are used in responding to safety and security risks. Force or restraint should only be used:

• in accordance with legislation
• when absolutely necessary
• as a last resort
• for the shortest possible time.

In March 2022, an internal inspection report of the 3 YDCs by the Department of Children, Youth Justice and Multicultural Affairs addressed the use of force and restraints. It identified that centres had well-defined processes for monitoring the use of force and restraints, with rigorous quality assurance mechanisms to review incidents and address issues. However, it noted that training was needed to address the requirements for high-quality incident reports, with sufficient details and clear rationales.

The report also identified differences between YDCs in their responses to incidents and their use of separation as a result of incidents. The inspection noted that physical force was frequently used, supported by mechanical restraints when necessary. The different YDCs used different mechanical restraints.

In 2016, the Australian Children’s Commissioners and Guardians compared the legislative and policy frameworks relevant to the use of force in YDCs across Australia in their report Human rights standards in youth detention facilities in Australia: The use of restraint, disciplinary regimes and other specified practices. The report identified 4 themes about the use of force in Australia’s YDCs:

• It must be reasonable: force can be used if necessary, but only as a last resort.
• Some forms are prohibited: specific forms of force (for example, striking, shaking and physical violence) are not allowed to be used.
• It must be documented: incidents involving force must be recorded.
• It must comply with ethical standards: force should be justifiable and proportionate, and should avoid causing harm or humiliation. 

Use of force and restraint – policies and practices in Queensland’s youth detention centres and in other jurisdictions

In Queensland, the authority to use force in YDCs is derived from the Youth Justice Regulation, not the Youth Justice Act 1992. In contrast, Queensland’s adult prisons derive their authority to use force from the Corrective Services Act 2006. Other Australian states and territories have legislated for the use of force and/or restraints in the following ways:

• Victoria’s Youth Justice Act 2024 ss 475–477 outline the circumstances in which force can be used on a child in detention and identify which physical restraints can be used and those that are prohibited. 
• Western Australia’s Young Offenders Act 1994 ss 11C and 11D reference the use of force without significant detail; however, they do outline when restraints can be used and the types of restraints not permitted unless approved by a medical practitioner. 
• Tasmania’s Youth Justice Act 1997 s 132 states that the use of physical force in detention centres is prohibited except in certain circumstances. Section 25J addresses the use of force while conducting a search of a child in a custodial facility.
• South Australia’s Youth Justice Administration Act 2016 ss 33–33A outline the circumstances in which force can be used on children in detention facilities and ban the use of spit hoods.
• Australian Capital Territory’s Children and Young People Act 2008 ss 223–226 outline the circumstances in which force is managed, used, where authority to use force is derived from, and the use of restraints. 
• Northern Territory’s Youth Justice Act section 10 addresses the use of force generally on children. Section 153 prohibits the use of force to discipline a child in detention; s 151AB identifies approved restraints; and ss 154–155 identify the circumstances in which force and restraints can be used. 

The authority to use force and restraints, and the approved types and methods of force and restraints used in Queensland’s youth detention centres, should be set out in principal legislation. 

The use of force in Queensland’s YDCs is guided by policies including the Youth Detention Centre Operations Manual Chapter 3 – Incident management and the youth detention operational policy YD-3-4 Youth Detention – Communication and Resolution Techniques. 

The Youth Justice Regulation s 16 briefly outlines when reasonable force can be used on a child as a consequence of the child’s poor behaviour:

• the employee has completed physical intervention training
• the employee reasonably believes a child, person or property cannot be protected in another way.

A record must be made of the use of force. 

The youth detention operational policy YD-3-7 Youth detention – Use of mechanical restraints states that mechanical restraints can only be used on a child in youth detention if: 

• it is reasonably likely the child may attempt to escape, seriously harm themselves or seriously disrupt the order and security of the centre, and 
• youth detention staff reasonably believe there is no other way to stop the child from engaging in this behaviour. 

The responsibility for determining whether mechanical restraints are appropriate in the circumstances is a delegated authority under the Youth Justice Regulation. It is limited to section (unit) supervisors and above.

Mechanical restraints are relevant when children leave a YDC on a leave of absence (for example, for a medical appointment). The YD-3-7 Youth detention – Use of mechanical restraints policy states that all leaves of absence must be subject to a security risk assessment to determine whether mechanical restraints are required to manage the identified risk.

The youth detention operational policy YD-1-6 Suicide and non-suicidal self-injury (NSSI) risk management acknowledges that using physical interventions, restraints or separation on a child engaging in non-suicidal self-injury or suicidal behaviour may cause further harm and contribute to increased trauma for both staff and children. The policy requires that all other less restrictive means of addressing this must be attempted before these responses are used. 

The Youth Justice Regulation section 19 empowers the chief executive to approve permissible restraints for children held in youth detention. The regulations do not approve or prohibit specific restraints, including restraint chairs and spit hoods. In contrast, legislation in South Australia and New South Wales specifically prohibits the use of spit hoods. 

These are designed to prevent spitting and biting – both to reduce injury and minimise the transmission of communicable diseases. However, they have been designated as ‘inherently cruel’ and the United Nations report Current issues and good practices in prison management – Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment and punishment (2024) called for a legislative ban.

There was no evidence of spit hoods being used at Queensland’s YDCs during the review period. Staff appear to understand the preventive measures they can use to avoid being spat on. For example, Brisbane YDC has introduced protective face shields, which can be placed on a child. We observed a child in a protective face shield while reviewing body worn camera footage. 

Given the human rights concerns about spit hoods and the availability of alternative protection measures, we conclude that spit hoods are not needed in Queensland’s YDCs and should be banned.

The Youth Justice Regulation and the Department of Youth Justice and Victim Support’s policies prescribe the requirements and processes for the use of force and restraint and recording of their use. However, we consider that practices such as the use of force and restraint, which can affect the humane treatment of children and subject them to harm, should be included in principal legislation. 

Review of use-of-force incidents

One of the significant changes experienced in 2021 by detention youth workers was a shift away from the use-of-force technique called the Protection Actions Continuum (PAC), which provided options for escalating responses. 

The new use-of-force technique, called Communication and Resolution Techniques (CART), relies heavily on verbal de-escalation strategies. It then allows the detention youth worker to determine the most appropriate course of action if verbal de-escalation does not work. Detention youth workers have been gradually trained in the new technique, but PAC techniques are still being used. These techniques have been replaced and are no longer approved.

Staff must record all use of force as part of the reporting requirements for incidents. The Youth Detention Centre Operations Manual Chapter 3 – Incident management states the report of the incident should explain why the physical intervention was necessary and how the amount of force used was reasonable in the circumstances.

YDC policies require that all incidents are recorded in the Detention Centre Operational Information System (DCOIS) and rated for their severity. The system offers 4 levels of incident severity, with defined possible responses:

• Level 1: critical incidents and those with serious adverse outcomes to people, property or the order/security of the centre. These include sexual assault, property damage of more than $10,000, or incidents that require overnight hospitalisation 
• Level 2 (high): incidents that have a high impact on people, property or the order/security of the centre
• Level 2 (moderate): incidents that have a moderate impact on people, property or the order/security of the centre
• Behavioural: incidents involving misbehaviour or anti-social behaviour that has little to no impact on others.

We reviewed DCOIS incident data across the 3 YDCs with a focus on incidents involving use of force. We identified the total number of incidents involving use of force for each centre during its review period:

• West Moreton YDC – 320
• Brisbane YDC – 1,753
• Cleveland YDC – 1,588.

The level of each incident involving the use of force are shown in Table 11. 

Table 11: Use-of-force incidents by level during each centre’s review period

^{Source: Compiled by the Inspector of Detention Services from DCOIS incident data (West Moreton YDC, 1 December 2022 – 30 November 2023; Brisbane YDC, 1 March 2023 – 29 February 2024; and Cleveland YDC, 1 August 2023 – 31 July 2024).} 

We note the Youth Detention Centre Operations Manual Chapter 3 – Incident management states that an incident involving harm, separation or a physical intervention cannot be classified as a behavioural issue/report. However, we found behaviour reports with force being used.

Incident review practices at each centre

Each YDC has implemented an oversight process for incidents involving the use of force. We sought to determine what guidance is available to support: 

• the review of use-of-force incidents 
• referral to each centre’s incident review group/panel as required. 

We concluded that there was very limited guidance. 

Our inspection identified different practices at the 3 YDCs. 

West Moreton Youth Detention Centre

• The systems support officer (who is part of the intelligence team) reviews all recorded incidents.
• If the systems support officer is concerned, they elevate the incident to an intelligence officer for review. The intelligence officer decides if the incident should be referred to the incident review panel.
• The incident review panel includes the systems support officer, the intelligence officer, unit managers and the assistant director.
• If the incident involves corrupt conduct, misconduct or poor employee conduct, the incident is referred to the executive director for referral to the (then) Professional Standards Unit.
• All other matters require the panel to identify management strategies to address any performance issues.

Brisbane Youth Detention Centre

• All incidents are reviewed by a practice support officer for excessive use of force, unapproved techniques or actions not in compliance with policy/practice directives.
• If issues are identified, the incident is elevated to the practice support manager for review.
• If the practice support manager identifies concerns in the incident response, the matter is referred to the incident review group/panel.
• If the panel review identifies misconduct, poor performance or corrupt conduct, the incident is referred to the executive director who decides whether to refer the matter further or to take internal action. 

Cleveland Youth Detention Centre

The model follows Brisbane YDC’s approach.

Our concerns

We are concerned at the current practice of having the initial incident review conducted by one person. The system-wide process should not be relying on (any) one person for this.

This places a great deal of responsibility on one person. It may mean serious matters are not escalated when they should be. There is also a risk of unconscious bias and even corruption. 

Further, without appropriate guidance that applies across all YDCs, the elevation of matters to the panel could be subject to an individual’s interpretation about what constitutes misconduct or practice deficiencies. 

Even when incidents are escalated to a centre’s internal review panel, the panel’s decisions lack oversight and review. For example, we noted one incident at West Moreton YDC where the panel identified concerns about an incident but decided to manage it internally rather than refer it to the then Professional Standards Unit. 

We conclude that the current incident review process lacks accountability and transparency.

We noted that the overwhelming volume of incident footage to be reviewed is creating backlogs and delays. At Brisbane YDC, for example, we were told that the officer had 10,000 hours of video footage awaiting review. Footage is retained for only 30 days unless manually saved. This means there is a risk that it may be deleted or lost due to competing priorities, given the volume of work undertaken by the practice support team. 

Incident review group meetings

We were unable to observe an incident review group meeting at West Moreton YDC as we were advised there was not one scheduled. While our inspection team were onsite, staff were reviewing an incident that had occurred immediately prior to our onsite inspection. However, our officers were refused permission to observe the review process. We reviewed meeting minutes after the site visit.

We observed incident review group meetings at Brisbane and Cleveland YDCs. We found the groups were comprised of managers and the deputy director. Once the footage relevant to an incident had been reviewed, the group decided whether to respond with no action; application of an internal management process; referral to the then Professional Standards Unit; or, if serious enough, referral directly to the Queensland Police Service. 

We observed some confusion among group members in relation to a use of force incident that had been reviewed and referred to the Professional Standards Unit. The Professional Standards Unit had then referred the matter back to the centre for action; however, group members could not understand why it was returned for local action. This created a perception among the group members that the workload of the Professional Standards Unit was too great, leading to matters not being dealt with at that level. We found this was not the case. 

Incident review group/panel members may benefit from further education about the decision-making process of external review units, including the newly established Ethical Standards Group (which replaced the Professional Standards Unit). This may assist each centre’s incident review group/panel to determine what action is required if a matter is returned to the centre for local action.

Sample review of use-of-force incidents

We reviewed incident footage to determine how force is used in YDCs. We also compared records and footage to incident review panel/group meeting minutes to understand how concerns are identified and addressed by the centres.

West Moreton Youth Detention Centre

For West Moreton YDC, we reviewed a sample of 50 use-of-force incidents, including 25 incidents that had been escalated to the incident review panel. We added 2 additional incidents that occurred during our onsite inspection, giving us a test sample of 52. We requested the supporting body worn camera footage for the incidents.

Of the 52 incidents reviewed, we identified:

• 5 incidents (9.8%) where de-escalation techniques or verbal negotiation were not appropriately used
• 8 incidents (15.4%) where the physical interventions used were not CART-approved techniques (indicating the use of force was not proportionate given the circumstances)
• 2 incidents (3.8%) where the use of force may not have been necessary
• 3 incidents (5.8%) where the use of force did not appear safe and humane (we observed the 3-point technique and leg placement, mandibular pressure, continued use of PAC techniques rather than CART techniques, and the use of hip toss)
• 2 incidents where no body worn camera footage was uploaded
• 2 incidents where the incident review group determined no further action was needed and we considered the staff member should have been spoken with for engaging poorly with a child. 

The incidents reviewed provided no indication of any inappropriate use of mechanical restraints. Handcuffs were the only form of mechanical restraint we observed.

Brisbane Youth Detention Centre

We reviewed 77 incidents involving the use of force. We compared these incidents with available body worn camera footage and noted whether the incidents were referred to the centre’s incident review group/panel. 

Our review found: 

• 6 incidents (7.79%) where body worn cameras were activated in accordance with policy
• 22 incidents (28.5%) where there was no available body worn camera footage
• 49 incidents (63.6%) where body worn camera footage was available but not all staff involved activated their cameras (the most common reasons for non-activation were the rapid escalation of incidents and forgetting to activate the camera)
• 40 incidents (51.95%) where we considered the use of force was consistent with incident management policy (We were unable to make a determination about the remaining incidents due to a lack of footage and/or insufficient details within incident reports.) 
• 3 (7.79%) incidents that were referred to the incident review group/panel for review, with decisions that were appropriately justified in the meeting records. 

We note that centres have little guidance about what incidents should or must be referred to an incident review group/panel. At Brisbane YDC, we identified 23 (29.87%) incidents that could have been considered by the group/panel but were not referred. These involved non-activation of body worn cameras, camera footage not matching the incident description, or staff not intervening early enough.

The incidents we reviewed provided no indication that force and/or restraints were used as a punishment. 

Cleveland Youth Detention Centre

We reviewed 139 incidents involving the use of force. We compared these incidents with the available body worn camera footage and considered whether the incidents were referred to the centre’s incident review group/panel.

Our review found:

• 49 (35.25%) incidents where body worn cameras were activated in accordance with policy
• 21 (15.1%) incidents where there was no available body worn camera footage
• 69 (49.6%) incidents where body worn camera footage was available, but not all staff involved activated their camera (the most common reasons for non-activation were rapid escalation of the incident, the incident being resolved before having an opportunity to activate the camera, and forgetting to activate the camera) 
• 94 (67.63%) incidents in which we considered the use of force was consistent with policy 
  one (0.72%) incident that appeared to involve an unapproved technique being used on a child (when the child complained of pain, the staff member stated they slipped, but then made a comment that the child should not have kicked a staff member. The centre’s initial review by a supervisor deemed the force as proportionate to the risk posed)
• 44 (31.65%) incidents where we were unable to assess the use of force due to lack of body worn camera footage or incomplete records, or because our review showed there was no actual physical contact during the incident)
• no incidents that were referred to the incident review group/panel.

As noted above, centres have little guidance about what incidents should or must be referred to an incident review group/panel. We identified 20 (14.39%) incidents that could have been considered by the group/panel but were not referred. These related primarily to non-activation of body worn cameras and staff behaviour during a leave of absence escort (situations where a child is removed from the centre, for example to attend court or a hospital). This last matter was managed by the centre locally with additional training. 

The incidents we reviewed provided no indication that force and/or restraints were used as a punishment.

The commencement of the incident review process at YDCs relies heavily on a single person’s interpretation of policy, ability to identify unapproved techniques and willingness to report how an incident was responded to. Such a process risks failing to identify when inappropriate practices are introduced and widely used.

We note that Queensland Corrective Services has implemented a process that clearly identifies which incidents involving the use of force are to be reviewed by a panel that includes senior leaders, supervisors and use-of-force trainers. Queensland Corrective Services also provides an option to elevate an incident beyond the prison to a corporate‑level review group – including those incidents requiring procedural changes.

Use of restraints

As discussed above, the chief executive is responsible for deciding which restraints are approved for use. 

We saw no use of spit hoods or other restraints that could be considered torture. Policy YD-3-7 Youth detention – Use of mechanical restraints outlines the 3 types of mechanical restraints approved for Queensland’s YDCs:

• hinged or chain handcuffs (with no conditions about their use)
• safety escort cables (used for escorting large numbers of children outside the centre such as during evacuations; and the executive director must be notified before their use)
• ankle cuffs (used only during a medical emergency leave of absence).

As Brisbane and Cleveland YDCs are the largest centres, with the most significant use-of-force incidents reported, our review of restraints focused on those centres.

Brisbane Youth Detention Centre

At Brisbane YDC, mechanical restraints were recorded as being used on 562 occasions during the review period, with all occasions involving handcuffs. As illustrated in Graph 9, in most cases handcuffs were applied for one to 5 minutes. 

Two of the instances of use of mechanical restraints recorded the restraint removal time as earlier than the restraint application time, which meant the data was inaccurate and was removed from further review.

Graph 9: Restraint use by length of time at Brisbane Youth Detention Centre during the period 1 March 2023 – 29 February 2024

Source: Compiled by the Inspector of Detention Services from information provided by the Department of Youth Justice and Victim Support.

We looked at the reasons why restraints were applied by reviewing the incident codes recorded (Table 12). In many instances, more than one reason was provided (giving a total that exceeds 562). 

Most of the restraint uses were linked to the incident codes ‘assaults and risk causing behaviour’ (80.14%) or ‘security threats’ (19.86%). 

Table 12: Incident types and restraint use at Brisbane Youth Detention Centre

^{Source: Compiled by the Inspector of Detention Services from information provided by the Department of Youth Justice and Victim Support.}

For restraint use linked to ‘attempted self-harm and suicide’ or ‘minor self-inflicted injury or self-harm threats’, we typically found other linked codes, suggesting the restraints were used in circumstances with other risk factors as well. We only identified 3 uses of mechanical restraint where ‘attempted self-harm and suicide’ or ‘minor self-inflicted injury or self-harm threats’ were the only reasons for restraint use. All instances were for 5 minutes or less and referenced the use of restraints to mitigate risk. 

We reviewed the 19 occurrences where restraints were applied for longer than 20 minutes. Significantly, 12 of these appeared to exceed 20 minutes because of inaccurate recordkeeping. When we reviewed the relevant reports about the related incident in DCOIS, we excluded these 12 records from further analysis because the reports stated the restraints were removed after a short time.  

Of the remaining 7 records of restraints being applied for longer than 20 minutes, the longest restraint use was 650 minutes (10 hours and 50 minutes). Records indicate the child was transferred to hospital and was ‘predominantly handcuffed at all times’ while accommodated at the hospital (for 8 days). We consider it likely that the record under‑represents the time the child was mechanically restrained. 

The other 6 records of restraint exceeding 20 minutes range from 53 minutes to 180 minutes. These were for medical escorts or for escorts around the centre after incidents had occurred.

Most records showed appropriate approval of mechanical restraint use, in accordance with policy. There were 2 exceptions to this, where it was unclear from the DCOIS record who had approved the restraint and whether it was in accordance with delegations. 

We were pleased to observe that most restraint applications were for a short time. 

Cleveland Youth Detention Centre

At Cleveland YDC, mechanical restraints were used on 693 occasions during the review period. Handcuffs were used in all restraint records. Ankle cuffs were also used in 9 restraint records relating to leaves of absence to hospital for children. 

As shown in Graph 10, most restraints were applied for between one and 5 minutes.

Graph 10: Restraint use by length of time at Cleveland Youth Detention Centre during the period 1 August 2023 – 31 July 2024

Source: Compiled by the Inspector of Detention Services from information provided by the Department of Youth Justice and Victim Support.

We identified data errors in 17 (2.45%) of the restraint records. For 4 of these, this was due to the restraint removal time being recorded as earlier than the restraint application time. The remaining 13 data errors recorded the restraint time as 0 minutes, with the application and removal time recorded as exactly the same time (including seconds). 

We reviewed the incident codes linked to each use of restraints to determine the reasons (Table 13). In some incidents, more than one reason was linked. Most restraint uses were linked to the incident code ‘assaults and risk causing behaviour’ (81.82%), ‘minor damage’ (17.75%) or ‘security threats’ (15.15%). 

Table 13: Incident types and restraint use at Cleveland Youth Detention Centre

Source: Compiled by the Inspector of Detention Services from information provided by the Department of Youth Justice and Victim Support.

There were 30 occasions where restraints were linked to ‘attempted self-harm and suicide’. For 6 of these, ‘attempted self-harm or suicide’ was the only listed reason for restraints being used. Our review of these records identified:

• On all 6 occasions, a restraint was used for 5 minutes or less.
• In 4 of the 6 records, it was unclear who approved the use of restraints.
• In one of the 6 records, there was no information listed in the justification tab of the restraint record. 

Given the department’s acknowledgement that restraint use in circumstances related to attempted self-harm or suicide could cause further harm to already at-risk children, this is a concern. Records should include both the justification and endorsement.

We found 11 occasions where ‘minor self-inflicted injury or self-harm threats’ was recorded, with more than one incident code nominated. This indicates there were several presenting risks at the time. 

Our review identified 42 occasions where restraints were used for longer than 20 minutes. However, 12 of these records appeared incorrect when cross-referenced with the reports related to the incident (that indicated a reasonably swift removal of restraints). We excluded these 12 records from further analysis due to apparent data inaccuracy. 

Of the remaining 30 occasions where restraints were used for longer than 20 minutes, the longest period a child was subjected to mechanical restraint was 15 days, 10 hours and 40 minutes. This related to a child being accommodated at a hospital. The leave of absence record states that the child was required to remain in restraints throughout their absence from the centre. 

The other occasions of restraint exceeding 20 minutes ranged from 26 minutes to 4 days 6 hours and 4 minutes. In total, 16 of the 30 uses of mechanical restraint exceeding 20 minutes were due to medical leaves of absence from the centre. We found the approvals for restraints used on medical leaves of absence were well documented and justified.

In contrast, we found recordkeeping in relation to approval of restraint use for non-medical reasons to be less clear. For 5 of the records, we were unable to determine who approved the restraint use. In multiple other records, we could only identify the approver by reviewing various incident reports, because it was not documented within the restraint record. 

We found the use of restraints on children to mainly be for a minimum period of time. In situations where restraints were applied to children in relation to attempted self-harm or suicide, the children presented with additional risk factors leading to the use of restraints. 

For longer instances of restraint use, it is not clear who approves their use and what is considered when deciding how long restraints should be applied for. Greater oversight is needed to ensure that decisions to apply restraints and the duration of their use are recorded clearly and accurately. 

Use of unapproved techniques

As discussed previously, Queensland’s YDCs use the Communication and Resolution Techniques (CART) approach to guide their intervention in incidents. CART was adopted in 2021 to replace the previously used Protection Actions Continuum (PAC) approach. 

CART was introduced to bring YDCs in line with practices used by the Queensland Police Service and to address concerns about the lack of a clear focus on communication and de‑escalation in PAC. 

Detention youth workers receive 10 days of CART training during their induction course, plus a 3-day refresher course every 2 years. We were told that CART training has gradually rolled out across the 3 YDCs, with more than 95% of staff now trained in it. 

CART provides staff with flexibility in responding to incidents. The model gives intervention options for responding to misbehaviour and incidents, with a strong focus on communication and verbal de-escalation. It helps staff to consider their options and justify their chosen approach. 

CART supports 3 physical interventions: 

• defensive tactics
• open-hand tactics
• restraints.

CART prohibits:

• using more force that required in the circumstances
• improvising or altering the approved techniques
• using a transport wrist lock (the way in which the child is held to be moved)
• pinching a child
• striking a child’s groin area
• using elbows or closed fists to strike or apply pressure to a child
• using choke holds
• using hard shields to deliberately touch, move or pin a child
• the hard shields being joined together. 

The de-escalation component of CART training does not currently include specific modules addressing culturally informed, trauma-informed or disability-informed approaches. We were advised that these topics are touched on during the induction course but are not covered in depth. We consider this an oversight in CART training that should be addressed.

At each YDC, we reviewed a test sample of incidents involving CART techniques. We are concerned that PAC techniques continue to be used, even though PAC was discontinued in 2021. 

West Moreton Youth Detention Centre

At West Moreton YDC, we reviewed 320 incidents in which use of force was recorded as having been used. We found incidents involving unapproved PAC techniques, incidents where mechanical restraints were used without appropriate CART interventions, and incidents where health or harm assessments were not completed. 

A health assessment is conducted by a nurse to assess the child’s health and wellbeing after an incident. A harm assessment is completed by a case worker or psychologist to assist in determining if psychological or emotional harm is suspected because of the incident.

Given that these incidents all involved force or restraints, we consider it crucial that full details about CART interventions and health/harm assessments are recorded in each incident report. 

Our sample review identified 8 incidents where unapproved techniques were used. The incident review group specified a number of actions as a result, including:

• escalation to the executive director for referral to the Professional Standards Unit
• formal and informal conversations with the staff involved
  retraining 
• a practice directive emailed to all staff.

Brisbane Youth Detention Centre

We reviewed a sample of 77 incidents at Brisbane YDC and reviewed the incident reports, meeting notes and body worn camera footage.

In our sample review, we were unable to determine whether appropriate verbal de‑escalation techniques were used before physical intervention, due to limited camera footage and a lack of detail in occurrence reports. 

When communication was recorded in the footage we reviewed, we heard children being told to ‘calm down’ and observed a staff member approaching a physical altercation yelling ‘hey, hey, hey … stop that’. We conclude that CART’s communication strategies are not consistently used by staff.

We received mixed reviews from staff at the centre about the value and practicality of the CART model. Staff who had been previously trained in PAC were more likely to describe CART as ‘not useful or safe’. Staff who had been trained only in CART were confident in their abilities, based on the training they received. 

As of 26 April 2024, 77% of Brisbane YDC staff had up-to-date CART training and 87% of staff had up-to-date training in using body worn cameras. We understand that CART training refresher courses had been delayed for existing staff due to the large numbers of new recruits.

Cleveland Youth Detention Centre

At Cleveland YDC, we reviewed 136 use-of-force incidents from the review period. Of these, we identified 105 (77.2%) incidents where unapproved PAC techniques were used. The most common unapproved technique was the escort position which is the position the child is held in while being moved. 

The limited information recorded in DCOIS does not identify why unapproved techniques were used. We were told that CART techniques, when applied correctly, are effective in reducing voluntary movements due to the application of pressure onto certain points of a child’s body. In some of the incidents we reviewed, it was difficult to visually confirm whether the techniques were applied correctly due to the footage available. 

We identified an incident involving the use of force where a child was held in the 3-point pin on the ground by 2 staff. The 3-point-pin involves the detention youth worker putting one knee on the child’s shoulder blade while the child is on the ground and the other knee on the child’s buttocks. The child’s arm is placed across their lower back and the detention youth worker holds the child on the wrist and forearm with both hands. In this situation a third staff member removed the child’s shoes before the child was escorted to separation (with the child struggling and kicking). 

Body worn camera footage revealed that the staff member removing the child’s shoes placed the child’s left ankle behind his right knee (an unapproved PAC leg lock). When the child continued to struggle, the staff member appeared to push the child’s leg into the ground and the child cried out in pain. The staff member apologised and said that they had slipped, and then added ‘Maybe you shouldn’t have kicked [staff member].’ We confirmed that the incident was reviewed and no formal action was taken.

The changeover to CART began in 2021, and PAC techniques were not allowed to be used from September 2023 (allowing a 2-year grace period). However, we identified that a detention youth worker who was untrained in CART dealt with children for 8 months after September 2023 before receiving CART training. 

Centre staff told us that staff may revert to PAC techniques due to muscle memory or stress. However, we would have expected to see fewer incidents involving PAC techniques by now, given that the techniques have not been allowed since September 2023.

As stated earlier, CART prioritises communication as a de-escalation technique. Our inspection at Cleveland YDC shows that communication can be used successfully to de‑escalate incidents. 

Of the 136 incidents involving use of force we reviewed at Cleveland YDC, we found that 87 (63.97%) involved de-escalation techniques prior to physical intervention. Of these, 12 (0.82%) incidents were resolved with communication, without requiring any use of force or physical intervention. 

Of the remaining incidents, 33 (24.26%) showed some attempt at de-escalation but not prior to the use of force. However, we acknowledge that de-escalation attempts may have been made before the recordings started. 

Only 4 of the incidents we reviewed showed no evidence of de-escalation techniques.

We conclude that at Cleveland YDC, communication is now consistently used first as a de‑escalation technique. This is encouraging.

In September 2024 we were advised that 14% of the Cleveland YDC staff were overdue for CART training and 12% were overdue for body worn camera training. The department needs to ensure all staff undertake the required training. This, combined with training in trauma‑informed communication and in communicating with children with disability, could improve staff engagement with children.

Use of body worn cameras 

The Youth Detention Centre Operations Manual Chapter 4 – Security management indicates that the department is committed to ensuring staff are equipped with body worn cameras and makes it clear that staff are to collect a camera at the start of their shift and retain it for the entire shift. The operations manual indicates that staff should activate their cameras:

• when witnessing or responding to an incident
• when witnessing or responding to incidents involving force
• when the staff member reasonably considers there is a need to record the interaction. 

While body worn cameras are not normally used to record footage in accommodation rooms, they should be activated if there is an incident that threatens safety and security. 

Body worn cameras are intended to provide an accurate record of an incident and improve accuracy, accountability and transparency in YDCs. They have the potential to improve professional standards and reduce the use of excessive force. They are also a useful de‑escalation technique, as staff warn children before activating their cameras. 

When body worn cameras are worn in ‘ready’ mode, they record in the background but do not retain the footage. When a staff member activates their camera, the device starts to store the recording from 30 seconds before the activation. 

During our onsite inspections, we identified issues with body worn cameras:

• They do not easily mount on clothing or personal protective equipment (PPE).
• Staff do not always activate them.

In our review of body worn camera footage for use-of-force incidents, we noted that the recorded footage is sometimes obscure.

Body worn camera mounting on vests or personal protective equipment 

We observed that body worn cameras do not always mount securely on appropriate clothing or PPE. PPE includes protective clothing, helmets and shields aimed at protecting the staff member from injury. All 3 YDCs experience difficulties in mounting the cameras onto PPE.

At West Moreton YDC, for example, we observed that the PPE available to staff does not allow mounting of the body worn cameras used at the centre. Staff need to wear a large (4XL) vest over the PPE to mount the camera, and this is rarely done. This means that emergencies at West Moreton YDC rely on CCTV footage or body worn camera footage recorded by staff from a distance. Close-up camera footage and audio is not recorded when staff use full PPE. 

At Brisbane YDC, we observed that body worn cameras dislodge easily from their locked positions and come off the mounts on staff vests. Dislodged cameras cannot record incidents and could harm people if they fall. 

Staff at Brisbane YDC told us that children sometimes unlock body worn cameras and remove them from staff vests as a joke. Children’s ability to unlock the cameras and staff reluctance to challenge this behaviour suggests a lack of professional boundaries between staff and children. 

Body worn cameras are not always activated at West Moreton and Brisbane youth detention centres

Body worn cameras are not consistently activated at West Moreton and Brisbane YDCs during incidents that involve CART responses. Cleveland YDC has a higher rate of body worn camera activation.

West Moreton Youth Detention Centre

At West Moreton YDC, we identified 404 incidents during the review period where CART techniques were implemented but staff did not activate their body worn camera. We also tested a sample of 51 DCOIS reports and found that in 34 of the incidents (66.6%), only some involved staff activated their body worn camera. 

One recorded incident illustrates the reasons staff gave for not activating their body worn camera: 

• I attempted to activate my BWC [body worn camera] but it did not work.
• The incident was resolved before I could activate my BWC [body worn camera].
• I was unable to activate my BWC [body worn camera] due to rapid escalation of incident/physical intervention.
• [Body worn camera] not required.

Brisbane Youth Detention Centre

At Brisbane YDC, we identified 402 incidents during the review period involving the use of force without body worn cameras being activated. 

We further tested a sample of 77 use-of-force incidents (discussed previously) and found that of those incidents, 22 (28.6%) had no body worn camera footage available. Only 6 (7.7%) had body worn camera footage recorded by all staff members involved. Reasons given by staff for not activating their cameras included:

• I forgot to activate my BWC [body worn camera].
• I attempted to activate my BWC [body worn camera] but it did not work.
• The incident was resolved before I could activate my BWC [body worn camera].
• I was unable to activate my BWC [body worn camera] due to rapid escalation of incident/physical intervention.
• BWC [body worn camera] not issued to staff member.
• BWC [body worn camera] not required as per the incident controller.

While we were at Brisbane YDC, we observed staff not wearing body worn cameras and staff wearing cameras that were not in ‘ready’ mode. It was unclear whether staff fully understood the purpose of the ‘ready’ mode; it is possible they think ‘ready’ means the camera is recording. 

Given that recording of non-incident-related conversations is not allowed, staff may be reluctant to wear body worn cameras in ‘ready’ mode. They may need additional training to ensure they understand the ‘ready’ mode and ensure they always use it. 

Cleveland Youth Detention Centre

At Cleveland YDC, we noted that staff have a high activation rate for body worn cameras. Of the 2,731 CART interventions recorded at Cleveland YDC during our review period, 2,158 (79%) had attached body worn camera footage. We reviewed the CART interventions with no linked footage and found 149 incidents (5.5%) where cameras were not activated or the automatic upload had malfunctioned. 

During our onsite inspection, we observed that nearly all staff equipped with a body worn camera had it in ‘ready’ mode, enabling the camera to be activated quickly. Staff at Cleveland YDC advised that a simple reminder to ‘activate cameras’ over the radio during an incident has been highly effective in raising activation levels.

Issues with mounting body worn cameras to vests, having them in ready mode and being ready to activate them appear to be reducing the number of incidents with attached footage for review at West Moreton and Brisbane YDCs. The strategy implemented at Cleveland YDC of reminding staff to turn on their camera when an incident code is called appears to have worked. 

In its submission to this report, the Department of Youth Justice and Victim Support told us that the policy addressing the use of body worn cameras and PPE includes advice that if the camera cannot be mounted, footage must be captured by other strategically placed staff when safe and practicable (Appendix A). 

While we acknowledge this, in our review we did not identify any footage from staff placed close enough to capture audio footage of incidents when PPE prevented the mounting of a body worn camera. We will monitor the effectiveness of this approach in future inspections.

This chapter focuses on the use of personal searches in Queensland’s youth detention centres (YDCs). The YDCs use searches to reduce risk and increase safety and security by identifying and removing items that have the potential to harm people and/or property. Four types of personal searches are used: wand searches, clothed searches, partially clothed searches (also called strip searches) and cavity searches.

Rules, statements and reports on searches of children

The United Nations Standard Minimum Rules for the Treatment of Prisoners (the Mandela Rules) state that searches must respect human dignity and privacy, and be conducted in line with principles of proportionality, legality and necessity (Rule 50). 

Administrators should keep appropriate records of searches, including the reasons for searches and the identity of the officer conducting the search (Rule 51). The Mandela Rules also state that intrusive searches, such as strip searches and body cavity searches, should be conducted only when absolutely necessary, and should be conducted in private by trained staff of the same sex as the prisoner. Body cavity searches should only be conducted by healthcare staff or staff with appropriate training (Rule 52). 

The Australian Children’s Commissioners and Guardians Statement on conditions and treatment in youth justice detention (2017) states that searches of children should only be conducted when reasonable, necessary and proportionate to a legitimate aim, and that searches should be publicly reported to an independent oversight body. 

In 2020, The Human Rights Law Centre’s Explainer: Routine strip searching of kids in prisons, noted that most states in Australia permit routine strip searching of children, with these searches typically conducted when children first enter a detention centre, after contact visits with family and after court appearances. It cited evidence suggesting that strip searching rarely identifies contraband. 

The Human Rights Law Centre describes strip searching as retraumatising and dehumanising, particularly given the number of children in detention who are victims of abuse, trauma or neglect. They also note that strip searching is unnecessary, ineffective and easily replaced with safer and more effective alternatives such as X-ray body scanners. It argues that Australian states should legislate to prohibit routine strip searching.

The Royal Commission into Institutional Responses to Child Sexual Abuse, Final report (2017) recommended best practice approaches to searches in youth justice settings (Recommendation 15.4), including: 

• adequate communication between staff and the child before, during and after a search
• clear protocols for when searches are permitted and how they are performed
• accessible information for children
• staff training about the potentially traumatising effect of searches on children.

In its May 2022 report Strip searches in youth detention, the New South Wales Ombudsman recommended prohibiting fully naked body strip searches of children and requiring that searches are conducted in the least intrusive way possible to achieve their purpose. The Ombudsman’s report also proposed that partially clothed searches not be routinely conducted.

In 2015, the Inspector of Custodial Services in New South Wales released the report Making connections: Providing family and community support to young people in custody, in which it recommended that strip searches should not be routine and should be replaced with a rigorous risk-based assessment process to target the trafficking of contraband. 

It described strip searching as ‘an invasive and humiliating procedure for anyone, but especially so for vulnerable adolescents. It may invoke hostile or violent reactions or emotional trauma’ (p. 25). 

In 2016, an internal youth justice inspection report of Brisbane YDC found that unclothed searches were routinely conducted during admissions. The report recommended leasing electronic contraband detection equipment to reduce unclothed searches. It also recommended that unclothed searches should only be conducted when considered reasonable and necessary. 

We note that Queensland Corrective Services is currently trialling body scanner technology at Brisbane Women’s Correctional Centre to reduce the need for strip searching.

In a submission to us (22 January 2024), Sisters Inside raised concerns about personal searches of children. They were responding to our inspection of West Moreton YDC. Their submission mentioned girls experiencing: 

… deep discomfort and feelings of violation during ‘dignified’ strip searches at WMYDC, … the presence of CCTV [closed circuit television] cameras exacerbates their sense of shame and discomfort in what is described to be a private and ‘dignified’ procedure.

Searches in Queensland’s youth detention centres

The Department of Youth Justice and Victim Support (the department) has a legislative responsibility to ensure YDCs are safe and secure environments. It uses searches to identify, eliminate and control items that could harm people and/or property. In this way, searches are a risk-reduction strategy. 

While searches help to maintain safety and security, they have the potential to harm children, particularly if the search involves touching the child or asking the child to remove their clothes. For this reason, it is important that searches are used in response to a genuine need, with all searches conducted in a respectful, minimally intrusive way; and that accurate records are kept.

The youth detention system has a long history of using partially clothed searches to identify concealed items and contraband. Partially clothed searches are of particular concern from a human rights perspective. They have the potential to be demeaning and humiliating and may be retraumatising for children with previous experiences of physical or sexual abuse. 

In Queensland’s YDCs, searches are addressed in section 272 of the Youth Justice Act and sections 23–28 of the Youth Justice Regulation. They are also addressed in the YD-4-2 Youth Detention – Searching of a Young Person policy and the Youth Detention Centre Operating Manual Chapter 4 – Security Management (the operations manual). The operations manual provides guidance about approvals, risk assessments and recordkeeping. 

Four types of personal searches can be conducted in YDCs: 

• wand searches – the child remains clothed and is searched with a handheld metal detector or ion scanner (Only the child’s hands will come into contact with the ion scanner.)
• clothed searches (also called pat searches) – the child remains clothed but is asked to remove their shoes and empty and turn out their pockets. Staff use a pat-down technique to search the child
• partially clothed searches – a search of the child’s clothes and body is conducted without touching the child, in a way that permits the child to remain partially clothed (their upper body remains clothed while their lower body and clothes are searched and vice versa). Staff conducting partially clothed searches must turn off and remove their body worn camera. Completely unclothed searches of children are prohibited under the regulation
• cavity searches – a visual, manual or instrument inspection of a child’s body cavities. These searches must be approved by the executive director and conducted by a medical practitioner.

We reviewed Detention Centre Operational Information System (DCOIS) data of searches conducted at each YDC during its review period, as summarised in Table 14.

Table 14: Summary of searches at youth detention centres during their review periods

^{Source: Compiled by the Inspector of Detention Services from DCOIS search records.}

There were no records of cavity searches conducted during the review period, and the DCOIS records do not indicate that force was needed to compel a child to comply with any search during the review periods. 

The electronic body scans recorded refer to a Milliwave scan machine, which is only installed at Brisbane YDC. The number of body scans recorded may not be accurate, as we identified 4 children linked with one recorded occurrence, suggesting that the actual number may be higher. We were advised that the Milliwave scan machine became non‑operational from around 26 May 2023, which was during our review period. 

We also note that Brisbane YDC has significantly more partially clothed searches than Cleveland YDC, despite both centres accepting children directly from the watch-house during the review period. 

West Moreton YDC has more partially clothed searches than Cleveland YDC, even though it is a smaller centre and typically does not accept children directly from the watch-house. We discuss this further below.

Partially clothed searches at West Moreton and Brisbane youth detention centres

The operations manual does not provide any standing (ongoing) approval for partially clothed searches. However, it includes guidance about partially clothed searches being conducted after an individual assessment of a child’s risk. 

It states that a partially clothed search can be conducted if staff have reasonable grounds to believe it is needed in circumstances such as: 

• before a child transfers to police custody
• on admission or readmission to the centre
• on transfer from another YDC
• on return from a leave of absence
• following contact visits with personal visitors
• when a child is on the Special Interest Young Person list (a list of children who may pose a risk to the safety and security of the centre and/or have complex needs and challenging behaviours).

The operations manual requires staff to turn off and remove their body worn camera during a partially clothed search. However, the operations manual does not detail requirements for conducting a partially clothed search in an area that is in CCTV view. 

Searches must be recorded in DCOIS. The only searches excluded from this are clothed searches and wand searches conducted as part of general operations, such as when children move from education classes to accommodation units. These searches should be recorded in the relevant section log for the unit. 

For searches recorded in DCOIS, the record must include the:

• child’s name
• reason for the search
• name of the person conducting the search
• name of each person helping with the search.

The record must show whether there were reasonable grounds for conducting a search, including details about:

• risk assessment (as part of an admission process)
• whether the child was subjected to a search while in police custody.

We found that West Moreton and Brisbane YDCs routinely conduct partially clothed searches during admission. 

West Moreton Youth Detention Centre

At West Moreton YDC, we found evidence that staff complete a risk assessment to decide whether a search is needed and what type of search is appropriate. The level of risk depends on depends on whether the child has been sentenced or is on remand (awaiting sentencing). For example, during admission, staff consider the likelihood of the child concealing a contraband item. 

However, given the number of partially clothed searches conducted at West Moreton YDC, we believe they are doing more searches than they need to. 

During its review period, West Moreton YDC admitted 163 children and recorded 120 partially clothed searches during admissions. These searches were conducted on children entering West Moreton YDC from another detention centre or the watch-house. For 30 of the children admitted during the review period, we found no record of a search being conducted and are unable to conclude whether a search did not occur or was just not recorded in DCOIS. 

Brisbane Youth Detention Centre

During its review period, Brisbane YDC conducted 1,300 partially clothed searches, with 1,157 (89%) conducted during admissions. We reviewed DCOIS data and noted that most search records do not state why a partially clothed search was chosen instead of a clothed search. We found only one record that stated the reason for a clothed search. In this case, the child’s arm was in a plaster cast and the child was unable to easily undress.

We found that children are subjected to a search when they return to Brisbane YDC following a leave of absence to attend a court appearance or medical appointment, despite being accompanied by a detention youth worker throughout the leave of absence. 

Cleveland Youth Detention Centre

At Cleveland YDC, in contrast, we found that partially clothed searches are not routinely conducted during admissions. Children may be subjected to a partially clothed search if they are recorded on a contraband list and/or are acting suspiciously. We were told that partially clothed searches are rarely conducted during admissions, and we did not observe one during our time in the centre.

We believe that routine reliance on partially clothed searches prioritises security procedures over the dignity and wellbeing of children. We believe that greater weight needs to be placed on risk assessment processes when determining whether a partially clothed search is required.

Partially clothed searches to identify contraband

DCOIS data suggests that partially clothed searches rarely find contraband.

At West Moreton YDC, during its review period, only 6 records (out of 172 partially clothed searches) indicate the search found contraband. These included a shiv (improvised weapon), needles, 2 pieces of metal, a sandwich bag with the remains of a brownie, a rock and make-up. 

Only the make-up was found during an admissions search (the search record does not indicate where the make-up was concealed, so we are unable to conclude whether a less-intrusive clothed search would have found it). The other 5 searches that identified contraband were conducted because of an incident or concerning behaviour by the child.

At Brisbane YDC, during its review period, 7 records (out of 1,157 partially clothed searches conducted during admission) indicate the search found contraband. These included a makeshift cigarette, vapes, a permanent marker and an iPad.

During our onsite inspection at Brisbane YDC, we observed staff conducting 2 partially clothed searches. The search was conducted by a detention youth worker and observed by a second detention youth worker. Our inspection officers were positioned behind the second detention youth worker. 

Both searches were conducted when the children were readmitted following a leave of absence. We considered both children to be compliant with staff instructions (see Case studies 4 and 5).

Scanning technology to identify contraband

Electronic contraband detection equipment such as X-ray body scanners could greatly reduce the need for partially clothed searches. While this equipment is readily available and widely adopted in other settings, it is not used in Queensland’s YDCs.

Brisbane YDC purchased a Milliwave body scanner in 2020, but it was not in use at the time of our onsite inspection. (As noted above, it was recorded as broken in May 2023.) Staff reported that the body scanner was out of order and considered decommissioned. If repaired, it could replace most partially clothed searches and could be used routinely for searches on admission. 

During our onsite inspection, we observed that the body scanner was clearly not in regular use and its room was being used to store equipment. Staff told us the scanner had a calibration fault with the under-foot mat. We were unable to determine whether the fault was logged or whether any efforts had been made to repair it.

At the time of our inspections, West Moreton and Cleveland YDCs did not have access to body scanning technology.

The department advised that it supports the use of body scanners and is incorporating them into the design of the new YDC at Woodford. It further advised it is seeking funds for a feasibility study about installing X-ray body scanners at existing YDCs.

We are concerned about the practice of partially clothed searches and their lack of effectiveness in identifying contraband, and particularly the routine nature of partially clothed searches at admissions for Brisbane and West Moreton YDCs. The potential for trauma through these searches is not insignificant. There are risks that partially clothed searches are not respectful of the child’s dignity and have the potential to be demeaning and degrading. The use of body scanning technology could reduce these risks.

In its submission to this report (Appendix A), the department advised it did not accept recommendation 22 due to limitations and historical issues with the Milliwave scanner. These included:

• the scanner not being able to detect items hidden internally or between skin folds
• use of the machine requiring children to change into smocks, which it considered impacts on the child’s dignity
• children deliberately hiding items in places they know the machine will miss. This reduces its effectiveness. 

We acknowledge the response provided by the department, but we consider partially clothed searches impact on a child’s dignity and contribute to retraumatisation. We argue that partially clothed searches also would not detect items hidden internally – although they may identify items hidden in skin folds.

Recommendation 21 was accepted by the department, and we welcome this response. However, until it installs x-ray body scanners in all youth detention centres in Queensland, it should explore other options, such as the Milliwave scanner, to reduce partially clothed searches and their impacts. 

Inconsistent use of clothed and wand searches

Approval for searches to be conducted for routine security purposes is recorded in the operations manual. These can include clothed searches and wand searches conducted:

• following a visit
• following participation in a program before returning to the accommodation unit
• following access to areas of the detention centre where restricted and/or prohibited articles may be found
• upon leaving or returning to the centre
• prior to a child being separated (isolated) 
• prior to entering a bedroom if the child is on high suicide prevention observations.

The standing approval also extends to searches of rooms, areas of the detention centre, and vehicles entering and leaving the centre.

At Brisbane and Cleveland YDCs, we observed that wand searches are routinely used when children finish structured activities and return to their accommodation unit. These searches involve a wand run over the clothes to detect metal, and clothed (pat) searches involving a detention youth worker running a hand over a child’s clothes. These searches are designed to ensure the accommodation units remain free of contraband, dangerous goods and weapons. 

Our observations suggest that these searches are not sufficiently thorough and are conducted in a way that does not align with policy.

Wand searches and pat searches usually focus on dangerous goods, which are items that could cause significant harm and are monitored during structured day sessions. 

One area of risk highlighted to us by staff was the lack of monitoring of tools in a construction class. In one construction classroom, we observed a checklist of available tools, but we were told that sometimes the checklist is not completed at the end of a session. We were also told that additional tools are sometimes brought into the classroom but are not recorded on the checklist. This poses a risk to children and staff, as it may be possible for children to take tools back to accommodation units.

Our observation of searches conducted

We observed 2 routine wand and pat searches during our site visit at Brisbane YDC.

The first was a routine search conducted at the end of a construction education session. Children were wand searched by a detention youth worker at the end of the session, then asked to wait outside while the dangerous goods were counted. After the count was complete, children were escorted to their accommodation units. When they arrived at their accommodation unit, each child received a perfunctory pat search, consisting of a single pat to their shoulders and waist. This search was inadequate for identifying concealed items.

The second search we observed was at the end of a hospitality class. Two education workers completed the dangerous goods count while the detention youth worker remained at the door to conduct the wand search. After their wand search, the children returned to the kitchen area while education workers finished cleaning. No further wand searches were conducted when the children left the kitchen. 

The children then returned to their accommodation unit, where they were searched with a single pat of their shoulders and waist band. The pat search of 12 children took approximately one minute. We heard a staff member ask a child to remove their hat, but the child ignored the request and was permitted to enter the building. We also observed a child remove several packets of coffee grounds from their waist band when entering the accommodation unit. While coffee grounds do not constitute a significant threat, the ability of a child to easily carry them into an accommodation unit shows the inadequacy of the pat search practice. 

The searches we observed did not require the children to remove their shoes or turn out their pockets. We also did not see staff wearing personal protective equipment (PPE, such as gloves) while conducting these searches.

We found similar practices at Cleveland YDC in relation to pat searches when children returned from their structured day activities. The pat search involved a tap on the shoulders and waist of the child before they were allowed to enter the accommodation unit.

The operations manual provides detailed procedures for wand and pat searches, including information about how and where staff can touch children during a pat search. Searches must be conducted in a sterile area, away from other children. During pat searches, children should remove their shoes and hats and turn out their pockets. 

To prevent children from bringing potentially harmful items back to the accommodation units, the process for wand and pat searching must be improved. 

The searches we observed did not follow the required procedures and were not thorough. We conclude that the wand and clothed searches were conducted as part of a routine, were not sufficient for identifying dangerous goods, and did not comply with the operating policies and procedures.

In this chapter, we look at the health services provided to children in youth detention centres (YDCs), how children at risk of suicide or self-harm are managed and observed, and the mental health services provided to the children.

In partnership with Queensland Health, YDCs ensure that children have access to health care, services and programs that improve and maintain their health and wellbeing; and access to treatment for special health needs. This is guided by the Youth Detention Centre Operations Manual Chapter 1 – Care and management of young people (the operations manual).

The West Moreton Hospital and Health Service (West Moreton HHS) provides medical services for West Moreton and Brisbane YDCs, and Townsville Hospital and Health Service (Townsville HHS) provides them for Cleveland YDC. 

West Moreton Hospital and Health Service

The medical centres at each YDC are made up of consultation rooms, a short-stay ward with one bed, a treatment room and a pharmacy. The medical centre at Brisbane YDC also has a dental treatment room.

The following services are provided at both YDCs: 

• 24-hour nursing availability
• medication rounds (in accommodation units, 3 times per day)
• general practitioner (GP) clinic (with male and female doctors)
• nursing clinic (for wound care, dressings, vital signs, growth monitoring, and medication management)
• vaccinations and health screening (for hearing, vision, sexual health, and blood-borne viruses)
• x-rays (limbs and chest)
• health promotion activities
• women’s health (contraception and antenatal support)
• visiting clinics with dentists, optometrists, dietitians, midwives and other allied health workers. Children at West Moreton YDC attend Brisbane YDC to see the dentist and optometrist, with access once per week and 4 times per year, respectively. 

To support the 24-hour nursing care available to children at these centres, a GP or other medical officer and nurse practitioner are on call outside of normal business hours.

West Moreton and Brisbane YDCs share health staff. The 2 centres do not currently have access to a full-time GP. Increasing GP hours would meet the standards of health care expected in the community and enhance the centres’ capacity to conduct comprehensive health screening for children in detention.

Mental health services are provided separately, with children accessing these services through Children’s Health Queensland’s Forensic Child and Youth Mental Health Service (CYMHS) team. While onsite at Brisbane YDC we observed a clinic run by the Forensic CYMHS team. It was able to see 6 children on that day.

On admission to each centre, the children go through a health assessment process with the nurse. The nurse completes a Young Person Nursing Health Assessment form, asking and recording responses to the questions on the form. At this time, the children are added to the GP waitlist as well as being offered a referral to the Sexual Health Team and Forensic CYMHS. 

We were advised that Aboriginal children and Torres Strait Islander children also undertake a Comprehensive Health Assessment (CHA) based on the 715 Indigenous Health Check available in the community. This health check helps identify if a person is at risk of an illness or chronic condition, to support prevention action. The assessment will be completed as a priority for the children while they are accommodated in a YDC. At West Moreton YDC, for the period 1 January to 17 December 2023, 78 CHAs were completed.

West Moreton HHS told us it was implementing screening for Foetal Alcohol Spectrum Disorder via facial feature analysis, to assist in identifying needs and supporting children involved with the Communications and Psychology Team in each centre.

We found the waitlists to see the medical officer at Brisbane YDC to be the most extensive of the 2 YDCs, and note this is likely due to the number of children held at Brisbane YDC. The waitlist for additional services such as dental and optometry were also higher than at West Moreton YDC. 

Table 15 outlines the waitlist for services at each centre.

Table 15: Waitlists for services through the West Moreton Hospital and Health Service 

^{* Date of waitlist not provided.
Source: Compiled by the Inspector of Detention Services from data provided by West Moreton HHS.}

Townsville Hospital and Health Service 

The medical centre run by the Townsville HHS for Cleveland YDC provides children with the following services:

• 24-hour nursing coverage for assessment; diagnosis and treatment of minor concerns; issue of medication; and management, health screening, vaccinations and pathology
• a visiting medical officer/GP for 12 hours per week, which equates to visits at the centre 3 times per week
• access to oral health services for 8 hours per week and an additional dental hygienist for 8 hours per week
• mental health services, which are available on weekdays through the North Queensland Adolescent Forensic Mental Health Service
• health promotion activities. These are limited due to the turnover of children at the centre; however, if there is a pressing issue in the centre, health promotion activities can be conducted to address the issue.

Children can also access services at Townsville University Hospital, as there are no after‑hours or on-call arrangements with a medical officer or GP.

Townsville HHS advised us that children are assessed on arrival for admission to the centre by a nurse and are then taken to the health centre for a comprehensive health assessment. They are then placed on the waitlist to see the medical officer, which we were advised occurs within 48 hours of admission. The visiting medical officer can see 8 children per visit to the centre.

While at the centre, we observed children being taken for their CHAs. We did not consider it appropriate to observe the assessment; however, we spoke to a child after their assessment. They told us they were very well looked after and that the staff were responsive to their health needs. The child was able to explain to us how they could seek assistance if they needed it.

We were advised the Townsville Aboriginal and Islander Health Service provides medical, oral, sexual health and optometry services at Cleveland YDC. Aside from this service, there is no culturally identified health position appointed to the medical centre, and the health staff rely on Cleveland YDC cultural liaison officers to assist them as required. 

We were not given waitlist information for services provided by Townsville HHS at Cleveland YDC.

Queensland Health

In its submission to our report, Queensland Health advised us that the Comprehensive Health Assessment (CHA) Pilot, which has been funded over 2 years, commencing in 2024–25 has:

• increased the GP and Aboriginal and Torres Strait Islander health workforce for both hospital and health services
• reduced the waitlist for children to access a GP
• standardised the CHA based on the Medicare Item 715 Indigenous Health Check for all children who consent to receiving the assessment
• supported the completion of 390 CHAs since 30 July 2025 across all youth detention centres. This has led to referrals to additional and specialist services. 

We welcome this focus on health services for children in youth detention centres, and we found the health services provided to children were of a high standard. However, improvements are required in terms of: 

• the management and support of children considered at risk of suicide or self-harm
• the process for issuing medication 
• opportunities for children to seek medical advice 
• the cancellation of medical services due to lack of escort staff. 

We discuss this below. 

Non-compliance with mandatory suicide risk observations is occurring

At each YDC, we saw serious non-compliance with suicide risk observations. Failing to conduct the required observations places serious risk on vulnerable children.

Children in contact with the justice system are at a higher risk of suicide than other children in Australia. A survey of children (aged 14–17) in contact with the justice system in Queensland and Western Australia found that nearly 23% had attempted suicide. This is nearly 6 times the rate of their peers in the general population, and 14% reported a suicide attempt in the last 12 months.¹ Aboriginal children and Torres Strait Islander children are at particular risk, with a suicide risk 10 times higher than other Queensland children of the same age.² 

In Queensland’s YDCs, managing suicide risk is discussed in Chapter 1 of the operations manual and in the YD-1-6 Youth detention – Suicide and non-suicidal self-injury risk management policy. These documents provide extensive operational guidelines for assessing and managing children at risk of suicide or self-harm.

When children are admitted to a YDC, they are assessed for suicide and self-harm risk by nursing staff and the shift supervisor. If any risk is identified, the child is automatically placed on high suicide risk, which continues until the child is assessed by the Suicide Risk Assessment Team (SRAT). 

The SRAT is a multidisciplinary team that includes the team leader, psychologist, nurse, shift supervisor (after hours only), cultural unit staff (for discussions about Aboriginal children and Torres Strait Islander children), the section supervisor (or delegate) and the child’s caseworker.

The nurse and shift supervisor develop an interim suicide prevention plan, which outlines immediate actions to mitigate suicide risk. The SRAT must assess the child as soon as possible, and no later than the next business day. 

Children are placed on an observation schedule based on their identified risk: 

• base level (all children) – observed every 15 minutes
• low risk – observed every 10 minutes
• medium risk – observed every 5 minutes
• high risk – observed every 2 minutes 
• high risk – continuous observation. 

These observations should be conducted any time children are separated (isolated) in their rooms, including overnight. Only the SRAT or a nurse can reduce the schedule of suicide observations, and they can only reduce it by one level at a time.

The Department of Youth Justice and Victim Support (the department) is currently reviewing its Suicide risk and self-harm management policy. This is in response to the December 2022 inspection report conducted by the then Department of Youth Justice, Employment, Small Business and Training, which recommended the policy should be updated in line with contemporary evidence. 

The report recommended reviewing practices from other jurisdictions and developing practical resources to support the management and assessment of suicide risk. The report also noted that few staff involved in the assessment process had formal mental health training. 

At each YDC, we observed serious non-compliance with suicide risk observations. The potential outcome of failing to complete regular observations is of the worst possible kind: a child may die in custody.

West Moreton Youth Detention Centre

At West Moreton YDC, we reviewed the observations conducted in 4 accommodation units over a 4-hour overnight period. We reviewed Detention Centre Operational Information System (DCOIS) data and used closed circuit television (CCTV) footage to check the accuracy of the records. 

At the time, 3 units had children on low suicide risk (10-minute observations required) and one unit had children on high suicide risk (2-minute observations required). DCOIS data recorded the full schedule of required observations, signed by both the detention youth worker and shift supervisor. 

However, CCTV confirmed that only 17 of the required 192 observations (across all 4 units) were actually completed, with only 2 observations (of the required 120) completed for the children on high suicide risk. 

Brisbane Youth Detention Centre

At Brisbane YDC, we reviewed the overnight observations conducted in 7 accommodation units on one night, using DCOIS data and CCTV footage. Across the units, 2 children were on high suicide risk (2-minute observations), 6 children were on medium suicide risk (5-minute observations), and 6 children were on low suicide risk (10-minute observations). DCOIS data suggested that overnight observations largely complied with requirements, but this was not supported by CCTV footage. 

The footage showed that some units complied with the base level checks (every 15 minutes), while other units had longer intervals between observations (up to 36 minutes). The CCTV footage showed that no unit conducted all the required physical checks of children on suicide risk observations.

Cleveland Youth Detention Centre

At Cleveland YDC, we reviewed DCOIS records and CCTV footage for 6 accommodation units and confirmed the trend shown in the internal audits discussed in Chapter 1. Cleveland YDC experiences serious non-compliance with both base level and suicide risk observations. We also observed that, at times, it is near-impossible for all observations to be completed, due to low staff numbers and high numbers of children on suicide risk observations. 

We recognise that Cleveland YDC managers have responded to this issue at a local level through formal discussions and, in some cases, by removing individual staff from night shifts for repeated non-compliance. 

Use of CCTV to conduct observations

During the onsite inspection at Cleveland YDC, we identified discrepancies in practice. We spoke with a detention youth worker who was from Brisbane YDC as part of a relief contingent supporting Cleveland YDC due to their staff shortages. We were told that Brisbane YDC completes suicide risk observations through CCTV and only conducts physical checks every 15 minutes. The worker advised us this was possible at Brisbane YDC due to its better-quality camera images. The worker noted they were following the same practice at Cleveland YDC. 

We noted that the quality of CCTV footage at Cleveland YDC does not allow for an appropriate wellbeing check, and particularly not a check of a child on suicide risk observations. We also identified that children on suicide risk observations were placed in rooms without cameras at Cleveland YDC, negating this practice entirely. We raised our concerns with senior managers after the onsite inspection and were told that the process for observations had been clarified with staff multiple times, and training had been offered.

We were told that a security upgrade is currently underway at Cleveland YDC, with enhanced night-vision cameras being installed in all rooms. We support the improved functionality of the cameras, but we are concerned that these will lead to practices that substitute physical checks with CCTV checks. 

These are inconsistent with the department’s current suicide risk management policy, which states that CCTV can only replace physical checks with the approval of the multidisciplinary team or when it is managed through the SRAT process for suicide risk cases.

We recognise that each centre has made serious attempts to address concerns regarding observations. However, these efforts appear to be having limited impact, and we conclude that each YDC is demonstrating serious non-compliance with mandatory suicide risk observations.

Staff shortages and human error provide a reasonable explanation for observations that are a few minutes overdue. We also recognise that confusion about the timing of more frequent observations for children on suicide risk may partly explain why observations are not conducted within required timeframes. 

However, the ongoing and persistent failure to conduct appropriate observations, in some cases meaning that children are unobserved for over an hour, cannot be explained by staff shortages or human error. 

As we noted in Chapter 1 of this report, on 20 December 2024, we informed the Minister for Youth Justice and Victim Support and Minister for Corrective Services of our concerns. This was under section 17(5)(b) of the Inspector of Detention Services Act 2022 (the Act). In this letter, we detailed the serious risk to the safety, care and wellbeing of children at Cleveland YDC due to non-compliance with observations. 

We confirmed our support for the actions identified by the department, and we have included them as Recommendations 9–11 in this report. 

The suicide risk assessment team process is not fit for purpose

If a child has been identified as being at risk of self-harm or suicide, the suicide and non‑suicidal self-injury (NSSI) process is initiated. The process, outlined in the operations manual (v1.15, p. 84), is:

• Step 1: identification and interim suicide prevention plan 
• Step 2: SRAT assessment 
• Step 3: suicide prevention plan 
• Step 4: observations and related search, clothing and program participation protocols 
• Step 5: SRAT review.

In Queensland’s YDCs, suicide and self-harm risk assessments must be conducted by the SRAT. Only the SRAT or a nurse can reduce the schedule of suicide observations recommended for a child. 

As noted previously, children in contact with the justice system face an increased risk of suicide and self-harm. For Aboriginal children and Torres Strait Islander children, these risks are significantly higher.

Internationally, a range of monitoring procedures are used in custodial settings to minimise the risks of suicide and self-harm. Traditional monitoring methods include risk assessments and visual observations (both physical and remote).³ 

A December 2022 inspection report conducted by the then Department of Youth Justice, Employment, Small Business and Training recommended a thorough review of the suicide and self-harm risk management policy, including consulting with partner agencies, researching evidence-based practices, and developing resources to support the assessment and management of suicide risk. 

The policy has been under review since that time, with staff continuing to implement the existing policy during the review period. The new policy has been implemented, and we discuss this below.

At each YDC, we observed SRAT processes and found that:

• not all SRAT members attended the meetings (though some submitted reports which were read out)
• some children’s suicide risk levels and associated plans were considered with incomplete information
• SRAT members did not consistently understand the role and purpose of the cultural team
• the cultural team was not expected to attend SRAT meetings involving consideration of risk for Aboriginal children and Torres Strait Islander children.

West Moreton Youth Detention Centre 

At West Moreton YDC, we observed a SRAT meeting during our onsite inspection and confirmed that meetings were scheduled in line with policy (within one day of the initial notification of a concern being raised or as required by the review period). 

The meeting we observed included the child’s case worker, the registered nurse and the case work team leader. No psychologist was available to attend. 

SRAT team members indicated that it can be difficult to achieve full attendance at meetings. They said that attendance was important to ensure that the most relevant and up-to-date information about the child’s presentation was provided to the decision-making team. 

Staff raised concerns with us that the centre psychologist is only involved in the SRAT process at the review stage and not at the acute or initial stage (when the processes start). Some staff were concerned that the psychologist’s skills and knowledge are not adequately used in suicide risk assessments, with the registered nurse and shift supervisor conducting most of the harm assessments.

We noted that staff members of the cultural team were not at the SRAT meeting, despite one of the children who was being reviewed identifying as an Aboriginal child. There is no requirement to notify the cultural team of suicide or self-harm incidents. The cultural team is not involved in the initial assessment and there is little cultural team involvement in the SRAT process for Aboriginal children and Torres Strait Islander children.

In the SRAT meeting we observed, the nurse spoke generally about the child after having a brief meeting with the child that morning. The nurse disclosed confidential information about the child’s medical matters that had no relevance to their current risk. This disclosure was stopped by the team leader, who was responsible for taking notes about the assessments.

The team determined the risk level. However, no-one (for example, a senior psychologist or senior leader) monitors or endorses the assessments and outcomes. 

Brisbane Youth Detention Centre

At Brisbane YDC, we attended 2 SRAT meetings held to review a number of children on suicide risk observations. The meeting included the Communication and Psychology Team leader, case workers, psychologists and section supervisors. There was no representative of the cultural team at the meetings.

The nurse did not attend the SRAT meetings, but their assessments were read out by the team leader and recorded in DCOIS. The section supervisors discussed their observations of each child, case workers discussed how each child had progressed, and the psychologist provided input and recommendations. The group discussed each child and agreed on a risk level.

We observed a lack of involvement by the cultural team in SRAT processes. SRAT meetings are initiated by an email advising relevant teams of the children to be reviewed at the next meeting. A line at the bottom of the email invites the cultural team to attend if they want to. There does not appear to be an expectation of cultural input for Aboriginal children or Torres Strait Islander children.

Cleveland Youth Detention Centre

At Cleveland YDC, the SRAT meets at least once daily from Monday to Friday. The SRAT meetings we observed were brief, with limited discussion before the team decided whether to lower or maintain the child’s suicide risk level. We observed one meeting where the risk levels of 9 children were reviewed in 20 minutes, with little meaningful discussion and no involvement from the cultural team. 

We observed situations where case workers were in accommodation units assessing children while the children were being considered by the SRAT. In 2 instances, an interim decision was made about the child’s risk level without all the required assessments being considered. We raised this with the senior leadership team after our onsite inspection.

We reviewed DCOIS data linked to SRAT meetings and found that the notes supplied by case workers and psychologists included detailed discussion of risk factors and factors that could reduce a child’s risk and keep them safe. However, suggestions for interventions focused on immediate risk reduction measures, such as increased observation or accommodation in a room with a camera. 

We found limited evidence that additional interventions were considered, such as increased contact with family or community Elders, counselling or therapeutic programs.

In line with the other YDCs, the SRAT decisions at Cleveland YDC were not endorsed or overseen by anyone in a senior position outside of the SRAT.

Staff from the cultural team told us they felt uncomfortable about participating in assessments of suicide risk and did not feel adequately trained for the task. They also commented that SRAT members did not understand the purpose of cultural assessments. 

In addition, cultural team members raised concerns that some questions referred to in assessment documents were either culturally insensitive or had no meaning to Aboriginal children or Torres Strait Islander children. 

We raised this feedback from the cultural team with the senior leadership team of Cleveland YDC and were advised that training had been provided to the cultural team about their involvement in risk assessments considered by SRAT. We were further advised that the cultural team contributed to developing the assessment document and had not raised any concerns about the questions during the development process.

We found that SRAT processes across all 3 YDCs were not fit for purpose. The limited involvement of the cultural teams fails to acknowledge cultural harm (discussed further below) and the importance of cultural considerations when addressing risk for Aboriginal children and Torres Strait Islander children. 

The current approach also allows the SRAT to lower a child’s suicide risk without oversight from a qualified, appropriately senior mental health practitioner. The management teams at the YDCs were the ones who told us the Suicide risk and self-harm management policy has been under review since 2022. 

Update to policy for suicide and non-suicidal self-injury risk

On 14 July 2025, the department provided us with the updated policy YD-1-6 Youth detention – Suicide and non-suicidal self-injury risk management (version 2.2). This was approved on 19 June 2025, and it addresses several of the issues we have raised above. A review into research relating to best-practice management of suicide and self-harm risks for children was also provided to us.

The policy identifies limitations with the current initial SRAT assessment (referred to as the ‘interim SRAT’). It is usually conducted by 2 people such as a shift supervisor and nurse. They conduct the initial assessment and plan to manage the safety of the child before the child is considered by the full SRAT panel. This usually occurs as an immediate response to an incident. 

The policy now outlines the levels of observation the interim SRAT can determine and makes it clear the interim SRAT cannot determine if observations are not required until it has consulted with a psychologist or allied health professional. 

The role of the SRAT as a multi-disciplinary group is made clear within the new policy. This now includes reference to the participation of cultural staff to ensure cultural advocacy for Aboriginal children and Torres Strait Islander children, and to support engagement with the child and their family or community in relation to their care.

The policy states that the SRAT must consist of input from a minimum of 3 people from the following list:

• YDC psychologist or allied health clinician
• section supervisor or other operational staff member
• caseworker
• Queensland Health nurse 
• a cultural unit representative.

If any cannot attend the meeting in person, they must ensure their feedback is provided to the SRAT.

The policy outlines several needs and associated risk factors relevant to Aboriginal children and Torres Strait Islander children that are to be considered as part of the suicide and non‑suicidal self-injury (NSSI) management strategy. However, there is little in the supporting documents – specifically the suicidal risk assessment template guide – that indicates how that is to be done by a child not identifying as an Australian First Nations person. 

While we acknowledge the department’s listing of a cultural representative as someone who may provide input into the SRAT process, the importance of creating a culturally safe process is to ensure a cultural perspective is considered for Aboriginal children and Torres Strait Islander children.

There is also still no clinical and management oversight of the SRAT. The policy does not require the SRAT to be chaired by a psychologist or allied health clinician, and they do not have to be one of the 3 positions involved in a SRAT.

We have compared the process of managing children at risk of suicide and NSSI to the process conducted by Queensland Corrective Services (QCS) in managing prisoners with the same risks. The QCS Risk Assessment Team meetings are chaired by a senior psychologist, and the prisoner considered at risk is assessed by a psychologist, interviewed by a correctional supervisor and, if identified as an Aboriginal person or Torres Strait Islander person, interviewed by the cultural liaison officer. 

The occupants of all 3 positions attend the Risk Assessment Team meeting. Their assessments and interview comments are reviewed and recorded and a plan is developed or reviewed. All 3 members and the chair sign the relevant documents, and plans are then endorsed by a higher-level manager.

We identified that YDCs did not include cultural considerations in its processes for managing children at risk of suicide and non-suicidal self-injury.

Decisions were made without all the information about a child being available and were determined by team members with limited clinical experience. There was also no senior management oversight. 

We note the updated policy provided by the department addresses some but not all our concerns.

Harm assessment policies lack meaningful guidance

The Youth Justice Act 1992 (the Act) requires detention centre employees to report any instances of suspected harm. It defines harm as any significant detrimental effect on the child’s physical, psychological or emotional wellbeing. 

YDC policy YD-3-9 Youth detention – Identifying and reporting harm in a youth detention centre allows for an individual’s assessment of the potential emotional or psychological harm that may have been caused to a child during an incident. 

This policy and the Youth Detention Centre Operations Manual Chapter 3 – Incident Management (operations manual) define ‘significant’ harm as being not minor or trivial. It may be reasonably expected to produce a substantial and demonstrable adverse impact on the child. 

No definitive set of criteria exist when staff are determining what constitutes harm to a child, and that staff are required to use their professional judgement to determine this.

Caseworkers and psychologists use a harm assessment report to help determine whether psychological or emotional harm has occurred. The operations manual includes case studies and a harm matrix to support these assessments. 

Cultural harm

The harm assessment report template provides free text boxes with prompts to guide the assessment. However, the operations manual and policy YD-3-9 Youth detention – Identifying and reporting harm in a youth detention centre make no reference to consideration of cultural harm. 

In March 2022, an internal inspection report of the 3 YDCs by the Department of Children, Youth Justice and Multicultural Affairs identified that cultural harm considers the: 

• loss of culture and family contact
• effect of low staff numbers on cultural practices such as Sorry Business
• lack of cultural programs 
• experience of racism from staff and other children. 

The report indicated that the impacts of cultural harm may lead to some children engaging in more incidents in custody, and that the impact of cultural harm had not been considered as part of the harm assessment policy. It recommended that: 

• parents/guardians are informed of the harm
• cultural harm be considered as part of the harm assessment
• suitable implementation plans for the harm assessment process are developed – such as templates, training, communication and consideration of cumulative harm.

When a harm assessment identifies that harm is likely to have occurred, operational policy requires either the executive director or deputy director to oversee and review the process. 

Harm assessment reports

We examined harm assessment reports in DCOIS records at all 3 YDCs. Staff confirmed that the definition of psychological and emotional harm is subjective. They also noted that harm is experienced differently by different children. Because of this, assessing harm relies on professional judgement and an established relationship with the child. 

One caseworker told us that the harm assessment process is not evidence based, and the worker was unaware of any existing evidence-based tools that could enhance the current process. 

We also found that there are currently no defined pathways for the Forensic Child and Youth Mental Health Service (CYMHS) to be informed of harm incidents relating to their clients.

West Moreton Youth Detention Centre 

West Moreton YDC completed 70 harm assessment reports during the review period. We selected 37 (52%) of these for review and found that they were usually completed in reasonable timeframes. Of the 37 reports we analysed, 27 concluded that suspected harm had occurred, and were reviewed by a director within the centre, in line with policy. 

Two of the incidents we reviewed at West Moreton YDC involved a staff member assaulting a child and were referred to the then Professional Standards Unit. We found that one child was involved in several incidents, including a suicide attempt serious enough to require hospitalisation. 

While a harm assessment was carried out after each incident, there was no evidence that the assessment considered the cumulative effect of the incidents. Two of the children involved in harm assessments were current Forensic CYMHS clients, but there is no evidence in the harm assessment reports that these incidents were referred to the Forensic CYMHS team.

Brisbane Youth Detention Centre 

We reviewed 30 harm assessments for Brisbane YDC, which were completed between 1 March and 31 December 2023. We identified that all relevant notifications relating to the incidents were made (for example, to the parents or guardians of the child) and some of the harm assessments included cultural considerations. 

Most of the identified harm related to psychological or emotional harm. We also noted a number of assessments considered the cumulative impact of multiple incidents. 

Cleveland Youth Detention Centre 

At Cleveland YDC, we selected 37 harm assessment reports for analysis, from the 187 completed at the centre during the review period. We found that none of the reports included evidence that the caseworker considered cultural harm or consulted with the cultural unit. 

We found that 2 assessments identified possible harm and were referred to a director, in line with policy. Of these, one was followed up with requests for further information and oversight, while one was not followed up sufficiently. 

Harm assessment

Given the evidence that many routine aspects of the detention environment are harmful to children, it is important to strike the right balance in policy to define when an additional harm assessment is required. 

We are mindful that an overly risk-averse approach to defining and assessing harm would create an unreasonable burden and increase the likelihood that harm assessments are not thorough. However, a less stringent approach creates the risk that incidents of significant harm are not sufficiently assessed. 

We found that harm assessment policies lack meaningful guidance for staff on how to assess psychological harm. The policies rely heavily on professional judgement, leading to inconsistencies in the ways detention centres assess and record potential harm to children. 

We also found that the possibility of cultural harm is rarely or inconsistently considered, and cultural team members are not consistently consulted in harm assessments relating to Aboriginal children and Torres Strait Islander children.

In its submission to this report (Appendix A), the Department of Youth Justice and Victim Support advised us that the YD-3-9 Youth Detention – Identifying, reporting and responding to harm policy had been updated on 20 August 2025 and was supported by a factsheet for client services about reporting harm. 

The policy change recorded is detailed and includes definitions of harm and a matrix on identifying potential, possible and definite instances of harm. The factsheet also contains relevant case studies to support harm reporting.

We acknowledge the work of the department and will monitor the implementation of the policy in future inspections.

Children must be escorted to medical services

As noted above, health services at West Moreton and Brisbane YDCs are provided by West Moreton HHS. A GP attends the centres, and a number of services are able to be provided to the children within each centre. However, due to the size of the centre, children at West Moreton YDC can be escorted to Brisbane YDC to access other clinics and have their medical needs addressed.

West Moreton Youth Detention Centre

At West Moreton YDC, we were told that medical services are frequently disrupted because low staffing levels make it difficult to provide children with an escort. 

During our inspections of West Moreton YDC, staff raised concerns about the low numbers of detention youth workers to support the health centre. They were concerned about children not being able to access health clinics at Brisbane YDC because of this. 

We were told that employing dedicated health escorts at West Moreton YDC, at least 5 days a week, would resolve this issue. When escorts are not available, children are unable to keep their scheduled appointments (at either Ipswich Hospital or Brisbane YDC).

Health staff told us that health and medical appointments are regularly cancelled because there is no escort available. We reviewed DCOIS data but were unable to confirm this because information about cancelled appointments is not routinely collected. However, staff told us that in the 3 months from December 2023 to February 2024, they cancelled 5 medical specialist appointments and 15 internal clinic appointments.

Nursing staff are not typically aware that an appointment will be missed until very close to the appointment (or even at the time when it is due). This means that appointment slots cannot be given to another child on the waiting list.

Brisbane Youth Detention Centre

Health staff at Brisbane YDC did not raise concerns with us about children being impacted by a lack of available escorts. They did, however, talk to us about health assessments being required of children when they arrive at the centre. They said this becomes an issue when children are tired and hungry, especially when they arrive late in the evening.

We consider health assessments on arrival to be essential for the health service to identify any urgent medical needs for the child. We acknowledge that children may not be interested in answering questions about their health needs on arrival, and follow-up assessments may be required. 

Brisbane YDC may need to consider providing children with food on arrival to support their involvement in the health assessment.

Cleveland Youth Detention Centre

In our August 2024 inspection report about the use of separations at Cleveland YDC, we found that health services had not been interrupted by the centre’s prolonged use of separation (isolation). Access to onsite nurses and the medical centre had been prioritised by the centre. Based on the available evidence and our own observations, we assess that this continues to be the case. 

We were informed by health staff that the current staffing shortages have not affected children’s ability to access health services. Even when separated, children can be safely escorted to the health centre, and nurses visiting children in their accommodation units are able to have the door safely opened during the interaction. 

During our onsite inspection at Cleveland YDC, we observed detention youth workers escorting children to appointments at the medical centre and helping the nurse by opening a separated child’s door to facilitate the morning medication round. 

The GP who attends Cleveland YDC 3 times a week informed us that, in some cases, the centre does not have sufficient staff to move children who require 2 escort staff. This means these children may miss out on appointments. 

In these instances, we were advised that the GP attends the accommodation unit to speak to the child directly. While privacy concerns mean these consultations are brief, this is still a good example of flexible practice that maximises children’s access to health care despite the centre’s ongoing challenges with staff shortages and separation. 

In conclusion, we found that children experience delays and cancellations in accessing medical services at West Moreton YDC because there are insufficient escorts to take them to appointments. This is not the case at Cleveland YDC. Even though it experiences significant impacts due to staff shortage separations, the centre continues to prioritise health service delivery to children.

Medication rounds and confidential medical services are rushed and lack privacy at West Moreton and Brisbane youth detention centres

The operations manual reflects the importance of YDC staff and Queensland Health staff working together to ensure children have access to health care. The manual indicates all medications are to be issued to children by Queensland Health staff and must be administered either from a central distribution point or an appropriate place. 

The manual indicates that, working with Queensland Health staff, the section (unit) supervisor or delegated officer must:

• ensure medication issue is conducted in a controlled way
• confirm the child’s identity before medication is issued
• ensure medication is consumed when it is issued
• report any saving of medication or non-compliance to a shift supervisor.

We observed that medication rounds are often rushed and can clash with planned activities for the day. Children lack opportunities to discuss health issues privately with nursing staff during the medication rounds.

West Moreton Youth Detention Centre

At West Moreton YDC, we observed a morning medication round that started at 8:00am. The nurse visited all accommodation units, even if no children in the unit required medication, to ensure children had time to raise issues with them directly. However, we observed that there was little opportunity for children to speak privately with the nurse, because the medication round was rushed.

During our onsite inspection, we also observed nursing staff checking with centre staff about whether they were aware of any children who wished to speak to them (rather than asking children). 

We observed issues relating to privacy when accommodation units were in separation. For example, the nursing staff attended a unit to follow up a medical assessment from an incident the previous night. The nurse was advised that the unit was in lockdown and she could interact with the child only over intercom from the detention youth worker’s station. The child did not engage with the nurse. 

Health staff raised a concern about the administration of Schedule 8 medication (medication that is tightly controlled due to its higher potential for misuse). Health staff informed us that Schedule 8 medication should be administered at the health centre. 

However, it often needs to be administered in accommodation units due to staffing issues and an inability to provide escorts. Two nurses are required to administer Schedule 8 medication, and there is only a small window of opportunity for this to occur (the handover time between day shift and night shift). This affects both children and staff, with the night shift nurse being held up administering day medication.

Brisbane Youth Detention Centre

At Brisbane YDC, we observed inconsistent practices in nursing services. Some nurses provided on-the-spot medical advice and promised follow-up, and other nurses dismissed children’s issues. 

At Brisbane YDC, the morning medication round was rushed to avoid clashing with structured day sessions. The nurses conduct the medication round in a consistent order, proceeding clockwise around the centre. The medication round begins at 8:00am and takes approximately 90 minutes.

The structured day timetable is finalised and released between 8:30am and 9.00am each day. It varies, based on staff availability, and it identifies which units will be attending education and programs, recreation and out-of-room time that day.

To better accommodate the medical needs of children and work more effectively with the structured day sessions, the medication round should be adjusted to suit the structured day program. However, this is impossible due to the late release of the timetable. As a result, there is a significant risk of scheduling conflicts between medication administration and class sessions.

At Brisbane YDC, medications are administered in the accommodation units by 2 nurses, escorted by a detention youth worker. We observed that the available space for administering medication in each unit is not enough to accommodate the nurses, escort staff, additional section (unit) staff and the child receiving medication. 

Figure 2 demonstrates the process we observed in an accommodation unit, where medication was issued from the doorway. The figure illustrates how crowded medication distribution can be. This figure is based on a standard unit design. Jarrah and Wattle units are actually smaller and more cramped. 

Figure 2: Observations of medication issue in a unit at Brisbane Youth Detention Centre

Source: Prepared by the Inspector of Detention Services from onsite observation of the issue of medications.

During separations, nurses, unit staff and escort staff visit children in their individual rooms. We observed medication being issued during separation: the child’s door was opened, the child and nurse spoke, the medication was issued, and the door was closed. The medical escort observed the child take the medication.

In this environment, it is difficult for a child to talk privately to a nurse. We observed that the escort pressured nurses to complete the medication round quickly, because it was nearly time to start the structured day session, and children risked missing their medication if the nurses arrived late. Putting pressure on the nurses detracts from their ability to properly address health concerns.

Health staff told us there is no private system for children to book a medical appointment. Children are required to ask either a nurse or a detention youth worker to make an appointment on their behalf, or they can complete a health services request form (which requires them to request a form from staff). 

Cleveland Youth Detention Centre

During our onsite inspection at Cleveland YDC, we observed nurses walking around the centre to provide children with their medication. The process of administering medication was controlled, orderly and safe. We note that most units were in separation the day we observed the medication round, which may have led to a more controlled process in those units. 

In the one unit where children were out for the day, administering medication was noticeably more rushed, and the process of checking the child’s mouth to ensure they had taken the medication was less thorough, as the child seemed eager to return to their peers.

We observed several instances where a child refused their medication, stating their refusal was due to being separated for the day. Nurses explained that some children chose not to take medication for attention deficit hyperactivity disorder (ADHD) during separation, as they believed it would cause an undesirable increase in stimulation while locked in their room with nothing to do. Nurses stated there were no adverse health effects if they refused ADHD medication on an ad hoc basis.

We observed a second medication round at Cleveland YDC, later in the evening. The nurse was accompanied by an escort detention youth worker and unit staff. For each child receiving medication, their door was opened, the nurse issued the medication, and the escort staff observed the child taking the medication. 

During these medication rounds, we noted that children raised health-related issues. Some children were told they would be seen in the health centre the next day. Other matters, such as applying dressings to abrasions or cuts, were completed on the spot. We often heard children call out to the nurse while they were in the unit to ask medical questions. 

In conclusion, we note that the medication rounds we observed when units were in separation were more controlled, with nurses under less pressure to keep to a schedule. 

In units that were not separated, there was significant pressure on nursing staff to complete their rounds as quickly as possible to reduce the impact on the structured day. This rush may limit children’s ability to discuss health matters with health staff. The issue of medication should be prioritised and not impacted by the start of the structured day. 

Children do not always receive their own laundry

The Havana Rules require that detention facilities ensure children have personal clothing suitable for the climate and to ensure good health, and that the clothing should be in no way degrading or humiliating (Rule 33). The Havana Rules also say that every child should be provided with separate and sufficient bedding, clean when issued, kept in good order and changed often enough to ensure cleanliness (Rule 36).

Children in youth detention are not permitted to wear their own clothes. On admission, they are given a clothing pack. Each centre launders the children’s clothing and bedding in line with industry standards. Children’s outer garments are labelled with their laundry number. Children’s under garments are not labelled, and children place them in a labelled laundry bag before sending them for laundering.

At Cleveland YDC, children do not always receive their own underwear back from the laundry service. This is a health and hygiene concern. 

During the onsite inspection at Cleveland YDC, concerns were raised with us about clothing and laundry services at the centre. Children told us their clothes all return in one pile and they sometimes had to share underwear, which they found unhygienic. One child told us they no longer wear underwear because of this problem, choosing to wear 2 pairs of labelled shorts instead.

Cleveland YDC staff informed us that children receive a fresh pack of socks and underwear on arrival. These are not marked with a laundry number, as they will be disposed of after a child’s release. Socks and underwear should be washed in individual mesh bags marked with the child’s personal laundry number. 

All other clothing items, such as shorts, t-shirts and tracksuits, are reused after the child’s release and are marked with a laundry number. Children’s clothes are washed in bulk before being returned to them based on the laundry numbers. 

Photo 7: Laundry return in Jabiru unit.

When we queried the laundry process, staff told us that sometimes the mesh bags come undone due to the force of the industrial washing machine. They also said that, in some instances, children incorrectly place their underwear with the general laundry, which means they are not in the individual mesh bags. 

The centre had started using a rubber clip for the mesh bags to reduce the likelihood of them coming undone. The clips are considered dangerous goods and must be applied by an operational staff member. We were told that they are used inconsistently, undermining efforts to ensure children receive their own underwear after laundering. 

Separations restrict activity levels at Cleveland Youth Detention Centre

In Queensland’s YDCs, the general principles of a structured day are designed to ensure children have a schedule of daily activities that allow them to be out of their rooms for 12 hours per day, with opportunities to engage in a range of physical programs or activities. At Cleveland YDC, we found that staff shortages and separations severely impact on children’s access to daily physical and recreational activity. 

During our onsite inspection, we observed many children who were in separation sleeping, watching TV or talking to each other through the grills at the bottom of their door. 

Operational staff told us that many children choose to sleep during the day when in separation. This increases their energy at night and, after the TV is switched off at 10pm, children’s energy and boredom often lead to increased incidents and property damage.

Staff told us that when the centre is appropriately staffed, they ensure children have as much access as possible to sport. Our review of the weekend timetables and section logs confirmed this. When the centre is operating a normal schedule, children participate in fitness programs and have access to basketball courts and the oval. However, regular separations limit children’s ability to engage in daily sport and recreation. 

Health staff highlighted the harm caused by extended separation and inactivity and suggested it may be worthwhile to find ways to increase children’s physical activity during the day when they are separated. 

We understand that the centre’s focus must be on improving staffing levels and reducing the time children spend in separation. However, while staff shortages and separations remain a chronic issue, we agree that some form of harm minimisation is needed. We understand that staff are making proactive attempts to facilitate programs during separation, with children participating by talking through the grills of their doors to the facilitator and each other.

We also found that Cleveland YDC does not hold centre-wide health promotion and education activities. While health promotion activities have been conducted in the past, they no longer occur regularly due to increased workloads and staff shortages.

Chronic staff shortages and separations at Cleveland YDC severely limit children’s access to physical and recreational activities, undermining both their physical and mental wellbeing. 

Notes

1. C Meurk, et al., Changing Direction: Mental Health Needs of Justice-Involved Young People in Australia, 2020. https://www.kirby.unsw.edu.au/research/reports/changing-direction-mental-health-needs-justice-involved-young-people-australia
2. R Soole, K Kolves & D De Leo, Suicides in Aboriginal and Torres Strait Islander Children: Analysis of Queensland Suicide Register, Australian and New Zealand Journal of Public Health, 38(6), 2015, pp. 574-8. https://doi.org/10.1111/1753-6405.12259
3. R Bosworth, et al., Contactless monitoring to prevent self-harm and suicide in custodial settings: Protocol for a scoping review. BMJ open, 14(10), 2024, e087925. https://doi.org/10.1136/bmjopen-2024-087925.

This chapter considers the impact of centre infrastructure on promoting and upholding the humane treatment of children and the conditions of their detention. 

We discuss the conditions experienced by children at Brisbane and Cleveland youth detention centres (YDCs) and the design of Brisbane YDC, which has 2 accommodation units with no ready access to an outdoor recreation area. 

We also address the importance of professional boundaries. While observing interactions between the children and staff, we identified concerns relating to the blurring of these.

Utilisation rates and infrastructure maintenance

Our August 2024 report – Cleveland Youth Detention Centre inspection report: Focus on separation due to staff shortages – included a recommendation about infrastructure at Cleveland YDC:

Recommendation 14
The Department of Youth Justice develops an infrastructure strategy for the Cleveland Youth Detention Centre to ensure its infrastructure supports a therapeutic operating environment. The strategy should address the following issues: 

• improving the behavioural support unit environments to support their therapeutic goals 
• adding rooms to accommodation units (as is the case at West Moreton Youth Detention Centre) to enable education and therapeutic programs to be delivered to children within accommodation units when necessary 
• reviewing the design of accommodation rooms and doors to ensure they facilitate meaningful engagement between children and officers.

The Department of Youth Justice and Victim Support (the department) acknowledged the infrastructure issues we identified in the report. It agreed that having fit-for-purpose infrastructure is critical to the safe and secure management of YDCs. It said it would explore the feasibility of modifying existing infrastructure but noted that it may not be structurally possible or financially viable. 

Our August 2024 report noted that Queensland’s YDCs operate under extreme pressure due to high demand for detention places. Similarly, the Queensland Audit Office, in its report Reducing serious youth crime (Report 15: 2023–24), found that Queensland’s youth justice system is under pressure and its YDCs operate above safe capacity. This increases the risk of safety incidents, including assaults on detention centre staff. 

Cleveland YDC’s operating capacity is 112 and its safe capacity is 95 (safe capacity is standardised nationally at 85% of the number of children the centre was built to hold).

The Queensland Audit Office found that, between April 2022 and March 2023, the average utilisation rates were: 

• Brisbane YDC – 94% 
• Cleveland YDC – 88% 
• West Moreton YDC – 95%.

Cleveland Youth Detention Centre

We found that the pressure on Cleveland YDC has increased in the time since the Queensland Audit Office report, with the centre operating above its safe operating capacity every month of the review period. The average utilisation rate was 91% (see Graph 11).

Graph 11: Average number of children in custody at Cleveland Youth Detention Centre by month during 1 August 2023 – 31 July 2024

Source: Compiled by the Inspector of Detention Services from data provided by Department of Youth Justice and Victim Support.

We consistently heard from staff and non-government stakeholders that property damage caused by children is a significant safety concern for Cleveland YDC. Damage caused to smoke detectors and ceiling lights is particularly difficult for the centre to manage. 

We were informed that the low ceiling height in many rooms and the building materials used allow the children to easily reach lights and smoke detectors. A large proportion of maintenance and QBuild time is spent repairing these issues. 

Cleveland YDC ensures the damage is repaired immediately. This often requires after-hours contractors to visit the centre at night, as over half of the ceiling damage incidents occurs during or immediately before the overnight lockdown. 

Operational staff showed us a bin full of light fixtures that had been pulled from the ceiling by children the previous night. The broken pieces were large, and some were very sharp. 

Through our review of incidents recorded on the Detention Centre Operational Information System (DCOIS) and discussions with operational staff, we became aware of an incident where a child used a piece of a broken fluorescent light to seriously assault a staff member. 

We spoke to staff who felt that extended separation increased the risk of children damaging fixtures in their room, due to increased boredom and frustration. 

During our onsite inspection, we noted that work had begun to harden the ceilings at Cleveland YDC to prevent children from reaching light fixtures and smoke detectors. One challenge facing the centre in completing the ceiling hardening is the need to move children during building work. The current utilisation rate makes this difficult. 

Incident records

Cleveland YDC had 53 unique incident reports on DCOIS coded as minor damage and property damage for the review period. Of these, 44 (83%) were for property damage to ceilings, with smoke detectors the most common item damaged. Once a smoke detector or sprinkler is damaged, a room is no longer safe, and the child is placed in a separation room until repairs are completed. 

When we discussed the statistics with operational staff, some said the reports were likely to be an under-representation of the true scale of property damage. One staff member explained that incidents where a smoke detector is damaged but not ripped from the ceiling are often recorded under the generic ‘disruptive behaviour’ code in DCOIS, which would not have been captured by our review of incident data. 

We identified that, due to a perceived lack of reporting functionality in DCOIS, a separate property damage record was being maintained by Cleveland YDC. This record contained data from January – October 2024, and showed 1,430 property damage incidents, with 1,211 related to damaged lights, sprinklers and smoke detectors. 

The significant difference between DCOIS reports and this property damage record suggests that YDC staff do not correctly code property damage incidents on DCOIS. 

Facility improvements and maintenance

The department responded to Recommendation 14 of our August 2024 inspection report, stating that all YDCs have routine and regular cleaning and maintenance schedules to ensure all rooms and facilities are in good, clean order. This was not reflected by what we saw at Cleveland YDC.

After our previous inspection at Cleveland YDC, the department made significant attempts to paint and clean a number of areas. Painting had been completed in several of the ferneries (the outdoor areas attached to units) and most separation rooms. However, during our onsite inspection, we saw that many of the newly painted surfaces had already been scratched.

We observed graffiti, rubbish and dirt throughout all the accommodation and common rooms we entered at Cleveland YDC. The graffiti was made by pencils or markers, or by scratching windows. In some accommodation rooms, the graffiti was particularly prolific, making the rooms unsuitable for accommodation. 

We compared rooms in the ‘gold standard’ Koolburra unit with rooms in Hawk unit and found that the Koolburra unit rooms were relatively free of graffiti. Across the centre, we found that graffiti was severe in common spaces, particularly around the phone areas. The level of graffiti shows a lack of care and regard for the shared environment. 

A 2022 internal inspection report highlighted research showing that living in a place that is not well maintained, as seen in the YDCs, can heavily influence how people feel about their environment, particularly their sense of safety. We agree with this and note that subjectively, the extensive graffiti in some parts of Cleveland YDC at the time of our review was unpleasant. 

Photo 8: A room in Koolburra unit

Photo 9: A room in Hawk unit

Photo 10: Jabiru fernery, Photo 11: Ibis fernery

Senior management at Cleveland YDC told us the centre planned to engage professional cleaners to undertake a deep clean of children’s rooms after each child’s release. We were told that, ideally, these deep cleans would be immediately followed by painting. However, this is made difficult because of pressure to accept children from the watch‑house. Rooms are filled as soon as possible when a bed becomes available. 

Professional deep cleaning and painting of common areas is equally challenging, as it requires taking entire units (or at least significant parts of them) out of commission. 

We consider that any attempts to address graffiti will be ineffective until accommodation rooms and shared common areas are cleaned and painted to a suitable standard. Once this happens, the greater challenge will be to address individual incidents of additional graffiti and property damage in a prompt and consistent way. 

Photo 12: Mural in Kingfisher unit common room

The colourful murals featured in accommodation common areas, and across the centre, offer a significant counterpoint to the general poor state of common areas. In most instances, the murals feature an art style that is culturally appropriate for Aboriginal children and Torres Strait Islander children. 

Many murals have been placed high up and out of children’s reach. But even in places where the murals are easily reached, we did not observe any significant graffiti or damage, which is a testament to the value that children place on these artworks. 

Cleveland YDC is to be commended for the prevalence of cultural artwork in accommodation common areas, which is where children spend a significant amount of time.

Brisbane Youth Detention Centre

We reviewed the facilities available to children in their accommodation units, and considered the state of common rooms, children’s rooms, kitchens and outdoor areas.

We found that Brisbane YDC had a significant issue with graffiti and scratched doors across common rooms and children’s rooms. Most of the hard furnishings in common rooms were covered in graffiti. Soft furnishings, such as sofas, were torn, and graffiti was common near the phones in interview rooms and common rooms.

Photo 13: Phone in Ironbark unit, Photo 14: Common room in Ironbark unit

Brisbane YDC has a significant issue with children scratching into floors, tables and seats. Photo 14 shows the Ironbark common room with scratch marks visible on the floor.

Jarrah unit, which can hold 4 children, was being used as a boy’s unit at the time of our onsite inspection. It needed significant maintenance. Holes in the rooms were patched with wood, and the shower area was covered in a lot of graffiti and mould. 

Most of the viewing windows into rooms and the windows to the outside were scratched. Staff told us that these window scratches affect their ability to see children when conducting observations. 

Photo 15: Room in Jarrah unit, with repaired walls, Photo 16: Shower area in Jarrah unit

Cedar is an older-style unit for boys, with rooms coming off a hallway known as a spine. We found most rooms in Cedar had scratched flooring, graffiti or both. The showers in some rooms were mouldy and also had scratched flooring.

Photo 17: Scratched flooring in Cedar room, Photo 18: Cedar room shower area

We found most kitchens were generally tidy, but noted that none of the bins had lids. 

Grevillea unit had a new kitchen installed, which we were advised was the new style of kitchen that would be installed in all units.

Photo 19: Cedar unit kitchen

Photo 20: New kitchen in Grevillea unit

Overall, we found the accommodation units at Brisbane YDC required maintenance to ensure the facility is well maintained and to establish a model of how children are expected to treat the space. Staff told us that it is difficult to stay on top of additional damage such as scratched doors and graffiti when there is already so much maintenance work needed.

Senior management at Brisbane YDC advised us that a full-time painter will begin work at the centre and repaint much of the damaged space.

Cleveland and Brisbane YDCs are older detention centres and require a significant maintenance and infrastructure improvement program. 

They should provide accommodation environments that make children feel safe, reduce opportunities for damage to infrastructure and allow for future incidents of damage to be addressed in a way that models appropriate standards of behaviour.

No outdoor exercise area for 2 units at Brisbane Youth Detention Centre

Brisbane YDC has a bed capacity of 162, spread across 11 units: Waratah, Jarrah, Ironbark, Cedar, Blue Gum, Bunya, Acacia, Oak, Paperbark, Wattle and Grevillea. Oak is the higher-risk unit located within the admissions building; it houses children with higher behavioural needs or concerns. Each unit has a separation room.

Jarrah and Wattle are smaller units that house a maximum of 4 children. The larger units house 8–12. We were told that Jarrah and Wattle were historically referred to as ‘independent living units’, designed to allow children to ease back into the community through a less-structured environment. 

Children living in these units have opportunities to launder their own clothes, engage in cooking classes and demonstrate a level of independence. 

These 2 are the only units at Brisbane YDC that do not have an outdoor recreational space attached to the accommodation. All other sections have basketball courts, multipurpose courts or ferneries available to children to use for exercise and fresh air. 

Photo 21: Jarrah unit

During our onsite inspection, we regularly observed children outside of their rooms. In Jarrah and Wattle, they spent time in the lounge or common room, playing board games, using the phone and cleaning. In other units, children had the same opportunities, but they were also able to play basketball, throw balls and get sunlight and fresh air. 

Photo 22: Wattle unit

The infrastructure of Jarrah and Wattle does not permit children to independently move between indoor and outdoor spaces. Children rely on detention youth workers to move them from their accommodation to external recreational spaces such as the oval or sports centre. 

We reviewed DCOIS activity records between 21 July and 4 August 2024 to determine how and when children in these units were permitted access to fresh air. 

In this time, children in Jarrah never had 2 hours in the open and fresh air during daylight hours. They attended a gym session totalling 50 minutes as part of their structured day curriculum and attended the sports centre once (26 July 2024) for a period of 57 minutes with children from the neighbouring Waratah section. 

If the children in Jarrah received the required minimum of 2 hours access to daylight and fresh air each day, they would have received at least 30 hours outside over the 15-day period. Instead, they received a total of 1 hour and 47 minutes of fresh air over that time. 

For the same review period, children in Wattle attended the sports centre for a period of 55 minutes over the 15 days, giving them even less outdoor time than their Jarrah counterparts.

The infrastructure in the Wattle and Jarrah units at Brisbane YDC prevents children from having access to the required minimum of at least 2 daylight hours of open and fresh air each day. This becomes even more important when staffing is limited, and the structured day sessions do not allow children to access the oval. This issue must be addressed.

Blurred boundaries between staff and children

The Youth Detention Centre Operations Manual Chapter 1 – Care and management of young people states that behavioural support helps children to develop prosocial and positive behaviours. The manual identifies the expected behaviour and clearly defined consequences, including that staff role model these behaviours and are consistent in their responses and management of behaviour.

While we were onsite at Brisbane YDC, we often observed detention youth workers not setting clear professional boundaries, not challenging the children’s behaviour and, in some cases, copying behaviours of the children. 

It is important to note that we did not observe this from all detention youth workers. However, there were many situations where we observed a lack of boundaries, including:

• offensive language used by the detention youth workers in front of children
• detention youth workers engaged in play-fighting with children
• children speaking or behaving poorly towards detention youth workers and not being corrected 
• detention youth workers and children referring to each other as ‘mum’ and ‘bub’.

In one situation when a leave of absence was being undertaken, we observed a child and 3 detention youth workers completing the administrative process. While unrestrained, the child was play-fighting a detention youth worker who did and said nothing to correct the behaviour or set clear boundaries. (The child made physical contact with the detention youth worker, but did not appear to cause any harm.) 

This behaviour was not limited to Brisbane YDC. At Cleveland YDC, we observed a detention youth worker ask a child during a suicide risk observation, ‘What the f**k is wrong with you?’ and tell the child to ‘Shut the f**k up’ when they responded to the question.

One key aspect of a detention youth worker’s role is to demonstrate and promote positive and socially appropriate behaviour to children in detention, to support their reintegration. While the detention centre environment should not operate in the same manner as an adult prison, there are reasonable expectations and requirements of staff within it. 

We acknowledge the complex and diverse role required of detention youth workers. However, the lack of or blurred professional boundaries is detrimental to their ability to execute their professional responsibilities when facing challenging behaviours. 

Blurred professional boundaries may also be detrimental to the centre’s operation. It may normalise poor behaviour and make it harder when staff need to respond to incidents or correct inappropriate behaviour.