For as long as I have been in my role as Ombudsman, allegations of excessive force against prisoners have been high on the list of themes complained about to my office.
Despite their frequency, none have resulted in my reporting to Parliament - until now.
Prisons are inherently challenging environments. Allegations are hard to investigate, and harder to substantiate. The imbalance of power between a prisoner and prison officer is acute. Prisoners may be reluctant to co-operate for fear of reprisal. The culture of silence within prisons makes it harder to obtain objective evidence than in other environments.
Many prisoners have complex needs, which can result in behaviour that endangers themselves, prison officers or other prisoners. The use of force by prison officers may frequently be necessary in the interests of safety and good order of the prison. Allegations may also be vexatious.
However, when there is a justifiable complaint about unreasonable force, prisoners face uniquely difficult circumstances.
My report examines eight separate incidents alleging excessive force in two Victorian prisons.
We substantiated four of the eight cases, but all showed concerning behaviour or poor decision making by officers. The incidents present a disturbing picture; even when allegations were not substantiated, we found officers used force on people with acquired brain injuries or other vulnerabilities, because the prison environment had created a situation where it became necessary.
The evidence of our investigations - in the context of previous reports, reviews, and the overall data - illustrates the persistent and endemic nature of the problems, despite the best efforts of Corrections Victoria to address them.
A culture of silence in which officers do not report wrongdoing by their fellows has long been known to exist within the prison environment. However, as the evidence also shows, strong leadership within a prison can help shift this culture and support greater accountability for officers who cross the line.
There is no easy fix for these longstanding and sometimes intractable issues, and this report does not purport to solve them.
Its purpose is to expose what is too often hidden behind prison walls and to encourage actions in addition to words, in the interests of everyone's safety.