Own-Motion Investigation Karamu: A report of an own-motion investigation into the management of the alleged misuse of force against prisoners at the Risdon Prison Complex, Mary Hutchinson Women’s Prison and Hobart Reception Centre between 1 July and 31 December 2023

Summary

The report's own summary: Executive summary, pages 9 to 10

Findings 46

Allegations are not findings. A commission's finding or opinion of corrupt conduct or misconduct is not a finding that a person is guilty of a criminal offence, and the commissions say so in their reports.

1. Findings

   Finding

   All uses of force for the relevant period were visible for this investigation.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 43, Findings and recommendations

2. Findings

   Finding

   Data and information held by the Tasmania Prison Service were not regularly reviewed or assessed to determine any strategic or training benefit.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 43, Findings and recommendations

3. Findings

   Finding

   The implementation of the Use of Force Review Panel appears to have resulted in better and more constructive feedback being given to officers.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 51, Findings and recommendations

4. Findings

   Finding

   The referral of matters to the Director of Prisons is in its infancy and not supported by a procedure, resulting in an ad hoc application and outcome.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 58, Findings and recommendations

5. Findings

   Finding

   The delays in amending the Director’s Standing Orders and Tasmania Prison Service’s tactical training manuals pose a significant risk to the Tasmania Prison Service and the protection of officers.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 59, Findings and recommendations

6. Findings

   Finding

   Mechanical hand restraints are regularly and successfully used for routine movements or in response to incidents to maintain good order and control.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 63, Findings and recommendations

7. Findings

   Finding

   There are escalations of force when prisoners are in mechanical restraints that require documentation and assessment due to the inherent risk that they could be applied as a form of punishment.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 63, Findings and recommendations

8. Findings

   Finding

   Several situations were identified where escalated force used on prisoners under mechanical hand restraints were unnecessary and amounted to excessive force.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 63, Findings and recommendations

9. Findings

   Finding

   Chemical agents such as oleoresin capsicum spray are not regularly used as physical control and restraint techniques.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 67, Findings and recommendations

10. Findings

    Finding

    The use of oleoresin capsicum spray is an important tool for correctional officers to avoid engaging in the application of higher levels of physical force, preventing potential instances of injury for both prisoners and officers.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 67, Findings and recommendations

11. Findings

    Finding

    Some deployments of oleoresin capsicum spray were ineffective.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 67, Findings and recommendations

12. Findings

    Finding

    The lack of audio recordings in the Tasmania Prison Service’s CCTV makes it difficult to review use of force incidents and does not protect either the officer or the prisoner in relation to what is said during an incident.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 68, Findings and recommendations

13. Findings

    Finding

    The presence of the Dedicated Response Team is a use of force option in and of itself.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 69, Findings and recommendations

14. Findings

    Finding

    Using the Dedicated Response Team, with members having specialised tactical training in use of force incidents, will result in fewer injuries to prisoners and general correctional officers.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 69, Findings and recommendations

15. Findings

    Finding

    The Tactical Response Group are an essential and specialised response resource within the Tasmania Prison Service.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 73, Findings and recommendations

16. Findings

    Finding

    One of the Tactical Response Group’s roles is to apply force. Accountability measures need to be strengthened to ensure their actions are fully reviewed by the Use of Force Review Panel.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 73, Findings and recommendations

17. Findings

    Finding

    Tasers are rarely used in the Tasmania Prison Service.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 75, Findings and recommendations

18. Findings

    Finding

    CCTV footage shows that some targeting of tasers has been imprecise and has required multiple deployments before being effective. This may have been due to the limited confines of cell entryways or inadequate practical training.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 75, Findings and recommendations

19. Findings

    Finding

    There is no evidence that spit hoods were being used within the Tasmania Prison Service during the relevant period.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 77, Findings and recommendations

20. Findings

    Finding

    There is no evidence that batons were being used on prisoners within the Tasmania Prison Service during the relevant period.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 77, Findings and recommendations

21. Findings

    Finding

    The content of incident reports is poor.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 80, Findings and recommendations

22. Findings

    Finding

    There is an absence of appropriate direction, training and oversight, which impacts the quality of incident reports.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 80, Findings and recommendations

23. Findings

    Finding

    The current incident report template is not fit for purpose.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 80, Findings and recommendations

24. Findings

    Finding

    The requirement for all officers to complete incident reports before the end of their shift is a significant impost on officers and resourcing.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 80, Findings and recommendations

25. Findings

    Finding

    The Confidential Complaints Register is not as useful as it could be and is open to abuse.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 82, Findings and recommendations

26. Findings

    Finding

    The division of complaints between the operational and confidential complaints registers appeared accurate.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 82, Findings and recommendations

27. Findings

    Finding

    A complaint about a use of force does not trigger a notification or review action from the Use of Force Review Panel or reference in other data systems, such as the Use of Force Register.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 82, Findings and recommendations

28. Findings

    Finding

    The Use of Force Register is not an accurate overall record of use of force incidents, partly because it is not updated after the Use of Force Review Panel conducts its initial review.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 84, Findings and recommendations

29. Findings

    Finding

    The compliance ratings that are assigned to an incident reviewed by the Use of Force Review Panel were misleading.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 84, Findings and recommendations

30. Findings

    Finding

    The Use of Force Register is not producing use of force intelligence for organisational consideration.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 84, Findings and recommendations

31. Findings

    Finding

    The compliance areas did not sufficiently address the requirements of using force outlined in legislation, policies and procedures. While operational safety and tactics are important, the Use of Force Review Panel focused on these components to the detriment of accurately assessing the use of force.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 89, Findings and recommendations

32. Findings

    Finding

    The referral of matters to the Director of Prisons is in its infancy and not supported by proper processes and documentation.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 90, Findings and recommendations

33. Findings

    Finding

    The lack of a full-time, designated training manager and allocated staff impacts the entire organisation and increases the risk associated with the application of force.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 96, Findings and recommendations

34. Findings

    Finding

    The current training facility is not fit for purpose and poses significant occupational and welfare concerns.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 96, Findings and recommendations

35. Findings

    Finding

    The content of the tactical manual and the policies and procedures are inconsistent.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 96, Findings and recommendations

36. Findings

    Finding

    The amount of noncompliance with mandatory training, including chemical agent certification, was surprising and unacceptable. Restricting mandatory training to one day per week provides no additional opportunity for mandatory training.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 96, Findings and recommendations

37. Findings

    Finding

    The Tasmania Prison Service does not view excessive use of force by correctional officers with the requisite degree of seriousness.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 104, Findings and recommendations

38. Findings

    Finding

    No matters involving an alleged excessive use of force during the scope of this investigation led to formal disciplinary processes by the Tasmania Prison Service or referrals to Tasmania Police. The lack of formal processes has created an environment where there is a lack of accountability and transparency. It would appear that the impact of this informal model is that correctional officers are held to a lower standard than other public officers. Given that these officers receive training and use force in a way that other public officers cannot, they should be held to a higher standard of review and accountability, the same as Tasmania Police officers who use force.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 104, Findings and recommendations

39. Findings

    Finding

    Based on all the evidence, the Tasmania Prison Service must change how they view and respond to excessive force. They must provide clear directions about standards, expectations and how they will respond to allegations of excessive force. The Tasmania Prison Service should have clear standards about proper conduct and what formal action will be taken when standards are not met.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 104, Findings and recommendations

40. Findings

    Finding

    The Tasmania Prison Service’s Director’s Standing Orders are outdated and in need of review.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 105, Findings and recommendations

41. Findings

    Finding

    Director’s Standing Order 1.02: Use of Force requires an urgent review to ensure it aligns with the new tactical training.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 105, Findings and recommendations

42. Findings

    Finding

    Expected priority standards should be highlighted within the Director’s Standing Orders.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 105, Findings and recommendations

43. Findings

    Finding

    The Tasmania Prison Service’s failure to separate the roles of correctional officers in the use of force review and complaint process creates at least apprehended bias, if not actual bias.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 107, Findings and recommendations

44. Findings

    Finding

    Strip searches after incidents where force was used on a prisoner appeared to be unnecessarily applied.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 109, Findings and recommendations

45. Findings

    Finding

    The current accommodation, resources and management of prisoners with complex mental health needs is unsatisfactory or inadequate.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 113, Findings and recommendations

46. Findings

    Finding

    Unsecured hair poses a risk of assault or prolonged assault on officers.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 114, Findings and recommendations

Recommendations 92

1. Recommendation 1

   The Tasmania Prison Service should consider regular internal reporting and analysis of data that could inform a regime of continuous improvement and be used for strategic or training purposes, including feedback to the Use of Force Review Panel.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 120, Appendix 2. Recommendations

2. Recommendation 2

   The Use of Force Review Panel is fairly new. Nonetheless, it is an integral accountability process for identifying and managing an excessive or unlawful use of force. It should be the main method of identifying such potential misconduct. The current terms of reference need to clearly state this role and the expectations relating to excessive or unlawful force, as well as other serious misconduct.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 120, Appendix 2. Recommendations

3. Recommendation 3

   The Use of Force Review Panel should be responsible for identifying: • exceptional conduct by a correctional officer • excessive or other unlawful use of force by correctional officers – unlawful use of force could extend to the use of unauthorised tactics or techniques • conduct so adverse or contrary to policies and procedures by correctional officers that it creates an organisational risk • misrepresentations or dishonest conduct by correctional officers, and • attempted misrepresentations or dishonest conduct related to the reporting of a matter and attempts to cover up what actually occurred.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 120, Appendix 2. Recommendations

4. Recommendation 4

   If any of the above are identified, the matter must be referred to the Director of Prisons. The Use of Force Review Panel can make recommendations but, ultimately, the decision in relation to action from these matters needs to sit with the Director of Prisons.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 120, Appendix 2. Recommendations

5. Recommendation 5

   Matters involving operational safety and tactical considerations can still be actioned by the Use of Force Review Panel.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 120, Appendix 2. Recommendations

6. Recommendation 6

   The Tasmania Prison Service should amend its policies and procedures to: • address data integrity issues through better documentation and guidance • assign an independent person to the Use of Force Review Panel – it would be of most benefit for that person to be from an integrity entity and/or preferably with a background in use of force or tactical training; however, it is vital that at least 2 members originate from the Tasmania Prison Service to bring a practical work assessment perspective • reduce the number of Use of Force Review Panel members with decision-making input to a minimum of 3, maximum of 4, people • generally, not permit the superintendent or general managers to be on the Use of Force Review Panel in a decision-making capacity – they can and should provide evidence but should not be decision-makers in matters involving their own areas • document input to the Use of Force Review Panel from the superintendent and general managers • create a standing agenda item requiring that Use of Force Review Panel members declare any interest/association before commencing their meetings, which are then assessed and managed • direct the Use of Force Review Panel to first focus on use of force and strategic issues, rather than tactical considerations • set key performance indicators at 14 days to be listed before the Use of Force Review Panel, rather than for the Use of Force Review Panel to finalise the matter • identify and document action options for the Use of Force Review Panel • review compliance areas to align with the State Service Code of Conduct and Director’s Standing Order provisions and define terminology, and • amend the Use of Force Review Panel’s terms of reference to remove the aspects that are not currently being undertaken.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 120, Appendix 2. Recommendations

7. Recommendation 7

   Correctional officers should be reminded of the requirements of providing and enforcing lawful and reasonable directions to a prisoner.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 121, Appendix 2. Recommendations

8. Recommendation 8

   The compliance rating systems should be reviewed, and consideration should be given to a secondary review for low compliance ratings.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 121, Appendix 2. Recommendations

9. Recommendation 9

   There is an opportunity for the Tasmania Prison Service to consider a streamlined and staged process into the future to address current efficiency and effectiveness issues facing the review process. However, with the number of issues identified in this report, it may be prudent to focus on optimising the current process.

   Report of the Integrity Commission No. 1 of 2025 (Karamu), page 121, Appendix 2. Recommendations

10. Recommendation 10

    There is scope to triage some minor force matters away from the Use of Force Review Panel’s deliberation. However, at this stage, it is not recommended, again requiring focus and embedding of the current process. Triaging away from the Use of Force Review Panel comes with risks but could be considered with the introduction of widespread body worn cameras. Random audits should still occur. If Use of Force Review Panel responsibilities are to be delegated in the future, this must be accompanied by: • random audits for every reporting period (each Use of Force Review Panel meeting period) should occur • effective training for the role • sound administrative arrangements and clear directions in policies and procedures, and • formal assignment of risk ownership and clear accountability for a lack of accuracy, mistakes, errors, or care and diligence for assessments and actions.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 121, Appendix 2. Recommendations

11. Recommendation 11

    A formal process should be established for referrals from the Use of Force Review Panel to the Director of Prisons within policies and procedures, as well as the process to be undertaken by the Director of Prisons. This is discussed further below in the ‘Director of Prisons’ Review Report’ section of this report.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 121, Appendix 2. Recommendations

12. Recommendation 12

    The policies and procedures should be clear that the Use of Force Review Panel can identify potential misconduct and make recommendations to the Director of Prisons but cannot impose formal outcomes.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 121, Appendix 2. Recommendations

13. Recommendation 13

    Priority should be given to developing a Tasmania Prison Service training manual that accurately represents the teachings and standards of the Tasmania Prison Service relating to the use of force and tactical training. The Tasmania Prison Service’s policies and procedures must align with these practices and standards.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 121, Appendix 2. Recommendations

14. Recommendation 14

    Any amendments to training manuals, policies, procedures and form templates must be clearly marked with the applicable date. An electronic register that explains why amendments were made should be kept in a central location. These records will be important in external investigations and inquiries.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 121, Appendix 2. Recommendations

15. Recommendation 15

    The new use of force model should be displayed in appropriate areas within the Tasmania Prison Service’s facilities and act as a reminder to staff of its operation. It may also be helpful to develop and display posters relating to simple decision-making about the use of force in appropriate areas for staff.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 121, Appendix 2. Recommendations

16. Recommendation 16

    The Director’s Standing Orders should include provisions that document the escalation of force using mechanical restraints.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 121, Appendix 2. Recommendations

17. Recommendation 17

    The escalation of force on restrained prisoners, whether for routine movement or after situational use of force, must be included in an incident report and reviewed by the Use of Force Review Panel.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 122, Appendix 2. Recommendations

18. Recommendation 18

    Incident reports must include provisions to report against the escalation of force levels, as well as other requirements for their use. Examples have been provided to the Tasmania Prison Service.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 122, Appendix 2. Recommendations

19. Recommendation 19

    The deployment of chemical agents such as oleoresin capsicum spray is currently designated as a soft technique in the force model. Because of its impact and potential for longer term effects, the model should be amended to describe the use of chemical agents as a hard technique, similar to a striking action such as a taser deployment or physical strike.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 122, Appendix 2. Recommendations

20. Recommendation 20

    Warnings about the potential deployment of a chemical agent coinciding with the drawing of the chemical agent from a holster should be recorded in an incident report. This occurs in other jurisdictions, where it is recorded as a use of force but not reviewed.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 122, Appendix 2. Recommendations

21. Recommendation 21

    Many chemical agent deployments were not to the appropriate standard. Precision is required to deploy oleoresin capsicum spray, and this can only be achieved through practice and use. The standard viewed in this investigation was concerning, and all officers should receive additional practical training. Further, there should be more regular practical and targeted refresher training following poor deployments.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 122, Appendix 2. Recommendations

22. Recommendation 22

    All chemical agent deployments require in-depth review by the Use of Force Review Panel.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 122, Appendix 2. Recommendations

23. Recommendation 23

    Supervisors should not be able to authorise their own planned deployments.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 122, Appendix 2. Recommendations

24. Recommendation 24

    Before using chemical agents, officers should specifically consider the appropriateness of using a chemical agent in confined locations, as well as the effect on other officers and uninvolved prisoners, and reference it in their incident reports.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 122, Appendix 2. Recommendations

25. Recommendation 25

    All relevant CCTV footage needs to be secured and provided to the Use of Force Review Panel. This extends to all relevant recordings leading up to the application of force to provide context of the incident and evidence of the length of negotiations.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 122, Appendix 2. Recommendations

26. Recommendation 26

    Officers should be provided with body worn cameras for use during their shifts. Priority rollout should be given to the members and unit supervisors of the Dedicated Response Team. Body worn cameras are known for: • exonerating correctional officers against vexatious complaints • reducing reactive responses by prisoners to the use of force and complaints • tempering the wearer’s conduct or communication • providing a safer work environment for all • providing evidence for internal investigations or prison disciplinary or court hearings about offences in prison, and • providing additional evidence to the Use of Force Review Panel for review purposes and to independently assess the level of communication and de-escalation techniques used by officers.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 122, Appendix 2. Recommendations

27. Recommendation 27

    Even if body worn cameras are rolled out, CCTV will need to be maintained because it provides for a wider view. Officers engaged in a ground wrestle will more than likely have their cameras obscured.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 122, Appendix 2. Recommendations

28. Recommendation 28

    The Dedicated Response Team should be retained as a full-time use of force option, with their presence recorded in the force model. Their presence is not required to be recorded in an incident report unless they engage in a situational use of force.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 122, Appendix 2. Recommendations

29. Recommendation 29

    It should be clarified in policies, procedures and training that the Dedicated Response Team are a specialist resource to be used in force situations when timing allows for their presence. If the Dedicated Response Team has been advised of an incident, general duty officers should actively seek their estimated time of arrival and wait for them to assist with an incident, if it is reasonable in the circumstances and would not threaten the safety, security or good order of the prison.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 123, Appendix 2. Recommendations

30. Recommendation 30

    Any Dedicated Response Team operating manual should be reviewed to ensure it is contemporary and aligns with current training. Relevant policies and procedures should be updated accordingly.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 123, Appendix 2. Recommendations

31. Recommendation 31

    The Use of Force Review Panel should report against additional fields, specific for the Dedicated Response Team’s operatives, in a Dedicated Response Team use of force review. Additional fields should be drawn from the Director of Prisons’ additional requirements for the Dedicated Response Team in policies and procedures.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 123, Appendix 2. Recommendations

32. Recommendation 32

    The Tactical Response Group’s operating manual needs to be reviewed as a priority to ensure their practices, procedures, force and tactics are contemporary and, if necessary, aligned with the new tactical training model.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 123, Appendix 2. Recommendations

33. Recommendation 33

    The Tactical Response Group’s commander or unit leader for a planned incident where force is applied should review the incident to determine how it proceeded against any plans and whether there are any learnings. This should be provided to the Use of Force Review Panel as part of their review.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 123, Appendix 2. Recommendations

34. Recommendation 34

    The Use of Force Review Panel must not evaluate any use of force by the Tactical Response Group until it has received all individual helmet footage and incident reports, as well as the Tactical Response Group’s report or Tactical Response Group commander’s report, and the prisoner extraction or other documented plan.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 123, Appendix 2. Recommendations

35. Recommendation 35

    The authority for the Tactical Response Group to use specialised equipment and be de-identified when dealing with prisoners requires an overt review by the Use of Force Review Panel of all matters involving the Tactical Response Group. Tactical Response Group commanders should provide or be available to give evidence to the Use of Force Review Panel about an incident, but they should not be part of the decision-making.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 123, Appendix 2. Recommendations

36. Recommendation 36

    The Use of Force Review Panel should report against additional fields, specific for Tactical Response Group operatives, in a Tactical Response Group use of force review. Additional fields should be drawn from the Director of Prisons’ additional requirements for the Tactical Response Group in policies and procedures.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 123, Appendix 2. Recommendations

37. Recommendation 37

    Precision is required to deploy a taser, which is only obtained through practice and use. The standard of deployment in tight spaces as observed in this investigation was concerning. It is recommended that all Tactical Response Group operatives receive additional practical training and targeted refresher training following poor deployments.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 123, Appendix 2. Recommendations

38. Recommendation 38

    Prior to use, Tactical Response Group operatives should specifically consider the appropriateness of using a taser in confined locations or narrow doorways and address it in their plan and incident report.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 123, Appendix 2. Recommendations

39. Recommendation 39

    The Tasmania Prison Service should actively monitor new technology or options regarding spit or bite control.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 123, Appendix 2. Recommendations

40. Recommendation 40

    The Tasmania Prison Service should consider installing vertical bolts on hatches to assist with and control movement when restraints are being applied through the hatches. Any phased rollout should start in the maximum-security facilities.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 123, Appendix 2. Recommendations

41. Recommendation 41

    The Tasmania Prison Service needs to urgently address incident report integrity issues.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 124, Appendix 2. Recommendations

42. Recommendation 42

    While there is scope to adopt new purpose-designed and standardised report templates, the priority focus of the Tasmania Prison Service should be lifting the standard of the current incident form, while work is completed on adopting a new incident reporting form that provides more standardised fields.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 124, Appendix 2. Recommendations

43. Recommendation 43

    Initially, correctional officers need to be given directions about what an incident report should include and the quality of the descriptions required. While additional training could address this issue, straightforward written directions could be provided to correctional officers in the first instance. Examples of issues and incident report standards should be available on the intranet for reference by correctional officers if needed.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 124, Appendix 2. Recommendations

44. Recommendation 44

    Two urgent amendments should be made to the current form template while a new one is being developed: 93. a submission date, and 94. inclusion of a statement on the form which identifies the purpose of gathering the information [the DOJ was provided an example of the statement].

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 124, Appendix 2. Recommendations

45. Recommendation 45

    An accompanying guidance document which will assist officers in what to include in the open text fields should ensure that officers include the information required by the organisation. It should specifically refer to components of use of force policies and procedures [the DOJ was provided an example].

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 124, Appendix 2. Recommendations

46. Recommendation 46

    Incident reports must not be visible to other officers to avoid the possibility of collusion.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 124, Appendix 2. Recommendations

47. Recommendation 47

    Mandatory competency-based assessments of the standard of incident reports should occur during recruit training.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 124, Appendix 2. Recommendations

48. Recommendation 48

    Policies should state that disciplinary action may be taken in response to: • significantly inaccurate reports that amount to misrepresentation • omitting use of force content from incident reports • reports containing false information about the application of force without a reasonable excuse, and • a failure to provide an incident report within a designated time after a lawful direction to do so.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 124, Appendix 2. Recommendations

49. Recommendation 49

    Any new form must include standardised fields that prompt responses that align with organisational standards and have efficiency dividends through tick options. This will focus the user’s content and remind staff about the content of policies and procedures. It will provide consistency in reporting, assist with the transfer to other data systems and provide more content for free text fields. Automatic migration with search- and report-generating capabilities should be considered to reduce the reliance on manual input in data systems [the DOJ was provided an example].

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 124, Appendix 2. Recommendations

50. Recommendation 50

    There needs to be one system that registers all matters that could be subject to an investigation or disciplinary action, sourced from external or internal complaints or any other manner, such as internal identification through management review processes. It may be that the Confidential Complaints Register could be adapted for this purpose while a proper electronic complaints management system is considered. The Tasmania Prison Service needs one primary source of information for this purpose.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 124, Appendix 2. Recommendations

51. Recommendation 51

    If the Use of Force Review Panel determines that excessive force occurred during an incident, it should be entered into the Use of Force Register, unless it has already been entered. The Use of Force Register should track outcomes, including the provision of a file note, lawful direction or disciplinary proceedings.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 125, Appendix 2. Recommendations

52. Recommendation 52

    The Tasmania Prison Service should monitor the Use of Force Register to identify officers with multiple entries who may require early intervention strategies to prevent future or escalating misconduct.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 125, Appendix 2. Recommendations

53. Recommendation 53

    The Tasmania Prison Service needs to address data integrity issues by: • ensuring the accuracy of data inputs • ensuring that anything that could be considered a use of force complaint is dealt with as a priority and primary issue field • reviewing all fields in the Confidential Complaints Register and ensuring they are fit for purpose • restricting access to the Operational Complaints Register for all general duty officers • reviewing and further restricting access to the Confidential Complaints Register • stating in the Director’s Standing Orders that confidential complaints must not be managed by the incident area’s superintendent or general manager, providing a level of independence to any investigation • stating in the Director’s Standing Orders that confidential complaint records must not be accessed by any officer or person who does not have a workplace need, and • including provisions that any complaint that relates to the use of force must be referred to the Use of Force Review Panel for an initial or subsequent review of the use of force, regardless of when it is made or whether the Use of Force Review Panel has previously considered it – the Director of Prisons may provide exemptions if it is deemed inappropriate.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 125, Appendix 2. Recommendations

54. Recommendation 54

    The Tasmania Prison Service should consider whether complaints relating to a use of force should trigger additional review processes.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 125, Appendix 2. Recommendations

55. Recommendation 55

    Because excessive force is potentially misconduct, the Tasmania Prison Service is encouraged to provide notifications about the unlawful use of force to the Integrity Commission. This should be referenced in the Director’s Standing Orders to encourage cultural change by providing oversight of potential misconduct investigations involving alleged excessive force against prisoners.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 125, Appendix 2. Recommendations

56. Recommendation 56

    While the Tasmania Prison Service’s complaints process has not been reviewed, it is recommended that the Tasmania Prison Service examine Tasmania Police’s Abacus: Commissioner’s Directions for Conduct and Complaint Management, and Compliance Review process to determine its suitability for their purposes.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 125, Appendix 2. Recommendations

57. Recommendation 57

    The Use of Force Register must be the primary source of information relating to the use of force. As such, the Tasmania Prison Service needs to address integrity issues by: • ensuring the accuracy of data inputs • reviewing the numerical ratings or scores for the compliance area fields to ensure that noncompliance scores are different to partial compliance scores • updating the Use of Force Register whenever there are outcomes and updates from the Use of Force Review Panel or Director of Prisons • documenting any changes in an additional field • ensuring that if a matter is deemed not a use of force incident, it remains on the Use of Force Register, potentially in a different tab, with a corresponding note explaining the decision and who made it • restricting visibility of the Use of Force Register to officers who need access • removing the provision for an involved officer to input an entry into the Use of Force Register and moving it to the Performance and Compliance Unit, and • ensuring there are sufficient reporting fields to capture the required information.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 125, Appendix 2. Recommendations

58. Recommendation 58

    Prisoners who are vulnerable and have force used against them should be identifiable, and trends should be reported within the organisation. This will require an additional reporting category in an incident report or an addition by the Performance and Compliance Unit. Vulnerable prisoners could include Aboriginal or Torres Strait Islander people, people with serious mental health issues, people with a mental impairment or people with a physical disability.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 126, Appendix 2. Recommendations

59. Recommendation 59

    Use of force data should be periodically analysed and used to identify trends, inform the training needs of officers, identify which tactical and use of force options are being used and by whom, as well as where, when and why tactical options are being used.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 126, Appendix 2. Recommendations

60. Recommendation 60

    The Use of Force Review Panel’s report template should be reviewed to ensure that legislation, policies and procedures have been followed. The template should focus the Use of Force Review Panel on assessing the lawfulness of the use of force, who used it and their qualifications and certification, whether proper authorisation was sought to use force or equipment, and whether there were attempts to misrepresent what occurred. This will require standardised fields and should be aligned to the directive provisions of sections 34B to 34E of the Corrections Act 1997 (Tas) and clauses 7.1 to 7.5, 7.7, 8.4, 9.2, 9.4, 10.1 to 10.3, 10.6, 13.2 and 14.1 of Director’s Standing Order 1.02: Use of Force.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 126, Appendix 2. Recommendations

61. Recommendation 61

    If any of the following is identified, it must be referred to the Director of Prisons: • exceptional conduct by a correctional officer • excessive or other unlawful use of force by correctional officers • unlawful use of force that could extend to the use of unauthorised tactics or techniques • conduct so adverse or contrary to policies and procedures by correctional officers that a failure to formally manage it would create an organisational risk • misrepresentations or dishonest conduct by correctional officers, and/or • attempted or actual misrepresentations or dishonest conduct relating to their reporting of the matter and attempts to cover up what actually occurred. To be clear, the Use of Force Review Panel’s role is to identify these issues from an incident review and refer them to the Director of Prisons, not to act in relation to such issues.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 126, Appendix 2. Recommendations

62. Recommendation 62

    The Use of Force Review Panel’s report must include a provision for referrals to the Director of Prisons and the reasons why.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 126, Appendix 2. Recommendations

63. Recommendation 63

    If Use of Force Review Panel members do not agree on an assessment of excessive force, the Assistant Director of Prisons is responsible for considering the broader strategic perspective and reputation of the organisation.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 126, Appendix 2. Recommendations

64. Recommendation 64

    During a review, if the Use of Force Review Panel do not find that excessive force has been used but there is operational safety or tactical concerns, they may then manage what action is taken.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 126, Appendix 2. Recommendations

65. Recommendation 65

    The Use of Force Review Panel’s reports should be provided to Panel members upon request.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 126, Appendix 2. Recommendations

66. Recommendation 66

    The Director of Prisons’ review process should be set out in policies and procedures. There should also be a review form for the Director of Prisons that aligns with the considerations outlined in Employment Direction No. 5: Procedures for the Investigation and Determination of whether an Employee has Breached the Code of Conduct.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 126, Appendix 2. Recommendations

67. Recommendation 67

    The Director of Prisons should first consider the possible criminal conduct, then the potential State Service Code of Conduct breaches and, if appropriate, refer it to the relevant authority. If neither apply, they should consider other formal outcomes such as lawful and reasonable directions or performance management. The report will require accountability for the decision and a copy must be kept within the Tasmania Prison Service.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 127, Appendix 2. Recommendations

68. Recommendation 68

    The new tactical training adopted from New Zealand should be fully and critically assessed within 12 months to ensure it is fit for purpose and that there are no unnecessary injuries to officers and prisoners.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 127, Appendix 2. Recommendations

69. Recommendation 69

    The Dedicated Response Team’s training days should be formalised.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 127, Appendix 2. Recommendations

70. Recommendation 70

    The most significant issue relating to training is the lack of a permanent full-time and qualified training manager who would be responsible for addressing the matters outlined in this report. It is not possible to provide the required responses while undertaking another core role. The appointment of a training manager needs to be prioritised, which may require a review of the remuneration offered for such a position.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 127, Appendix 2. Recommendations

71. Recommendation 71

    Other recommendations are as follows: • Ensure that the outstanding training positions are advertised and filled. • Create a dedicated Tasmania Prison Service tactical training manual. • Make the training manual a live document, with all versions and amendments documented. • Incorporate the teaching techniques into the manual, policies or procedures. • Include more communication and resilience training for both recruit and mandatory training. Resilience training should focus on ensuring that officers do not react to a prisoner’s verbal taunts, abuse or threats and do not engage in unnecessary, judgemental or provocative communication before, during or after a use of force incident. • Ensure that recruit training includes the use of appropriate CCTV footage to identify tactical issues and provide real-life scenarios. • Ensure that mandatory training explains that officers are accountable for the use of force in accordance with the policies, procedures and tactical training and for use in internal reviews and court proceedings. • Regularly analyse trends arising from the use of force, assaults and complaints registers, as well as the Use of Force Review Panel’s data to inform the tactical training. • Provide adequate training equipment for role-players. • Document and provide clear consequences for not attending and completing mandatory training or recertification within a designated reasonable time. The period could be nominated as 3 months from the date of expiry. However, there must be immediate consequences of expiry, which could include restrictions on overtime or a direction not to use physical force equipment. If, after 3 months, mandatory training or recertification has not occurred and the officer is still working, disciplinary action should occur. • The Tasmania Prison Service should enact proactive measures to ensure early notifications are given to officers that their qualifications to use physical force equipment are expiring. The Training Unit should serve a notice on the officer one month before the expiry of their qualification and direct them not to use physical force equipment past the expiry date unless their qualification has been renewed. • The Training Unit should schedule additional training sessions on days other than Wednesdays to ensure that officers comply with mandatory training or recertification when it has been delayed due to a conflict with their core role.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 127, Appendix 2. Recommendations

72. Recommendation 72

    The Training Unit does not have the resources to appropriately train officers. The skill-based practical training area is not fit for purpose. It will require significant funding to provide a purpose-built and separate contemporary training facility with adequate space for training offices and the capacity to accommodate future increases in recruit or staff numbers. There is an urgent need to separate the training facilities from the Tasmania Prison Service’s administration areas. The Tasmania Prison Service should explore temporary options to conduct all or part of the training at another purpose-built training facility.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 128, Appendix 2. Recommendations

73. Recommendation 73

    Alleged excessive use of force must not be managed informally.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 128, Appendix 2. Recommendations

74. Recommendation 74

    There needs to be clearer instructions about which types of incidents warrant a referral to: • a file note or lawful direction • disciplinary processes, and/or • Tasmania Police as a potential offence.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 128, Appendix 2. Recommendations

75. Recommendation 75

    Code of conduct matters should result in an investigation and include excessive force and other serious relevant matters [the DOJ was provided examples].

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 128, Appendix 2. Recommendations

76. Recommendation 76

    Unlawful use of force that does not amount to excessive force or breaches of the Director’s Standing Orders could result in file notes and lawful directions. These matters require limited investigation and procedural fairness processes. Examples could include: • the use of an unapproved technique that does not result in an injury • the use of a chemical weapon or specialist physical force equipment when the qualification to use such equipment has expired less than 3 months ago • well-intentioned mistakes that result in undesired use(s) of force and do not result in an injury, and • other more minor failures to adhere to the Director’s Standing Orders.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 128, Appendix 2. Recommendations

77. Recommendation 77

    Amend the Tasmania Prison Service’s Code of Conduct to change: • ‘Instigating an investigation into an alleged breach of the Code of Conduct is the most serious action that the Tasmania Prison Service will commence against an employee’, to • ‘Instigating an investigation into an alleged breach of the Code of Conduct is a serious action that the Tasmania Prison Service will commence against an employee’.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 128, Appendix 2. Recommendations

78. Recommendation 78

    File notes and lawful directions can be maintained as an option, but they cannot involve a sanction or punishment and cannot be used in place of disciplinary proceedings. The use of such directions must be justified in each circumstance. It is expected that there will be a defined limit on the number of file notes and lawful directions that can be provided to an employee over a defined period and, if exceeded, this will result in disciplinary proceedings encompassing clauses 9(2) or 9(14) of the State Service Code of Conduct.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 128, Appendix 2. Recommendations

79. Recommendation 79

    Excessive force could amount to an assault, and such matters should be referred to Tasmania Police. It would be useful have a guide developed with Tasmania Police to assist in decision-making.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 129, Appendix 2. Recommendations

80. Recommendation 80

    While the Use of Force Review Panel should be a conduit for referring alleged excessive force to the Director of Prisons, this should also be feasible from any level of the organisation. There needs to be clear instructions for what type of force incident would warrant such a referral and the designated reporting pathways.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 129, Appendix 2. Recommendations

81. Recommendation 81

    As a matter of urgency, all Director’s Standing Orders need to be reviewed and amended to align with the current and expected standards of the organisation: • The Director’s Standing Orders that relate to the use of force should have priority status for review. • All Director’s Standing Orders should include version control tables. • The Director’s Standing Orders should be reviewed annually.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 129, Appendix 2. Recommendations

82. Recommendation 82

    The Director’s Standing Orders should include: • a section relating to excessive force, including • a definition and examples • a definition and explanation of the principles of self-defence and defence of another • a clear statement that excessive force is unacceptable and that there is an expectation that it will be dealt with formally • a list of action options for responding to excessive force, and • a requirement for documented justifications of the decision-making relating to the chosen courses of action for responding to excessive force • a statement that officers must justify their use of force in accordance with legislation and the Director’s Standing Orders • provisions regarding containment and restraints to re-enforce the required authorisation to use force in such circumstances • provisions about the standard expected of formal directions to prisoners, including consistent escalation terminology, the reason the direction has been given and that the use of force to compel compliance is imminent • guidance that when communicating with a prisoner in an incident where force may, is or has been used, staff must not use inflammatory, judgemental, discriminatory, unnecessary and/or inappropriate words due to the nexus between force and the risk to officers and prisoners if an incident escalates • clear guidance that attempts at or acts of collusion between staff members, the deliberate omission of material facts, or the addition of inaccurate or misleading statements in incident reports relating to a material fact will result in formal disciplinary proceedings, and • a clear statement that an officer must not view any video recording or read reports of the incident before submitting their incident report.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 129, Appendix 2. Recommendations

83. Recommendation 83

    Officers cannot be involved in 2 processes, including: • the use of force incident • managing the area/unit where the use of force occurred • reviewing the use of force incident, either on the Use of Force Review Panel or upon request by the Director of Prisons, and/or • investigating a related complaint.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 129, Appendix 2. Recommendations

84. Recommendation 84

    Before commencing any investigation in relation to a complaint, the assigned officers should complete a declaration of interest form that is assessed by the Assistant Director of Prisons, or if it involves the latter, the Director of Prisons.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 130, Appendix 2. Recommendations

85. Recommendation 85

    While there are valid reasons for random searches in prison, the Tasmania Prison Service is encouraged to limit the need for personal searches involving the complete removal of clothing after a situational use of force. The threshold for performing a personal search could be a reasonable belief that there are hidden items on that person. That said, now that body scanners are available in Tasmanian prisons, these should be used in the first instance. Personal searches should be limited to exceptional circumstances only.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 130, Appendix 2. Recommendations

86. Recommendation 86

    Personal searches must only be conducted by officers of the same gender as the prisoner or, in the case of gender-diverse prisoners, by an officer of a gender of the prisoner’s choosing.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 130, Appendix 2. Recommendations

87. Recommendation 87

    If a personal search after force occurs and requires the removal of all or the majority of clothing, it should be treated as a use of force, and an incident report should be submitted or there should be a requirement for a specific reference about the necessity of the search in an incident report.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 130, Appendix 2. Recommendations

88. Recommendation 88

    The Tasmania Prison Service should consider a negotiation and incentive strategy for prisoners who are compliant at the time of entering a cell and being released from mechanical restraints to be lowered onto a mattress on the cell floor. This incentive should not be considered for prisoners who are noncompliant or if there are reasonable grounds to suspect that they will not be compliant.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 130, Appendix 2. Recommendations

89. Recommendation 89

    If the policy is to complete a mandatory strip search of a prisoner after a use of force incident, this must be stated in the Director’s Standing Orders. Similarly, if the policy is to not lower prisoners onto mattresses, it should be stated in the Director’s Standing Orders or a training manual.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 130, Appendix 2. Recommendations

90. Recommendation 90

    The Tasmania Prison Service does not currently have the resources to appropriately manage prisoners with complex mental health issues and needs. This matter has been the subject of numerous reports. Addressing the issue will require significant funding to purpose-build a dedicated mental health unit within the prison to manage and provide treatment to prisoners who require dedicated mental health care. Such a facility would require state-of-the-art features that prevent unnecessary staff entry into cells, adequate camera vision that cannot be covered and appropriate day-to-day equipment. It will need to be staffed with adequate mental health professionals, officers trained as mental health first responders and managers to specifically address prisoners with such complex needs.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 130, Appendix 2. Recommendations

91. Recommendation 91

    In the meantime, the Tasmania Prison Service should immediately explore: • cameras that cannot be covered or can be uncovered remotely, and • limiting, but not restricting, the amount of material available to prisoners that can be used to cover cameras.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 130, Appendix 2. Recommendations

92. Recommendation 92

    The Tasmania Prison Service should address this risk of unsecured hair with a policy and procedure that is enforced by senior officers.

    Report of the Integrity Commission No. 1 of 2025 (Karamu), page 130, Appendix 2. Recommendations

Published responses 1

• Response to draft report from Department of Justice (Appendix 1)

  Agency response · Dated 14 December 2024

  On 14 December 2024, the Secretary of the Department of Justice responded to a draft copy of the report, acknowledging and accepting all recommendations

  Report of the Integrity Commission No. 1 of 2025 (Karamu), page 10, Executive summary

  Status as published

  accepting all recommendations

Official documents 1

• Report of the Integrity Commission No. 1 of 2025

  Report · 138 pages

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