1/1/nal OIC/05

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INQUIRY INTO THE MANAGEMENT OF OFFENDERS IN CUSTODY

THE HON DENNIS LESLIE MAHONEY AO QC, Presiding

TRANSCRIPT OF PROCEEDINGS AT PERTH ON TUESDAY, 2 AUGUST 2005, AT 10.27 AM

Continued from 19/7/05

MR PETER QUINLAN, Counsel assisting MS NICOLA FINDSON, Instructing solicitor

2/8/05 938 (s&c)

Spark & Cannon 1/2/nal OIC/05 MAHONEY, MR: This is the resumption of the public sittings of the inquiry. As foreshadowed in the first public sittings in this public sitting the inquiry will deal with the case of Paul Stephen Keating. It will detail at some length what led to the crime with which Mr Keating is now charged and to which he has pleaded guilty. What will emerge will, it is anticipated, illustrate some of the more important aspects of the administration of the prison system at the present time and it will allow judgments to be made as to what defects or deficiencies there may be in it. It's important that government and the public be aware of what is involved and the problems which are posed. The administration of a modern prison system inevitably poses problems . It poses complicated problems, problems for which there are no easy solutions. It illustrates the old truism to every complicated problem there is always a simple solution and it's always wrong. It must be understood that to the prison problems there are no magic wands. The present case is an example of, amongst others, two of these problems. First, men can and do commit brutal crimes. One must ask is it wise to treat them equally brutally or should we recognise that if we treat men brutally we will produce brutes? To produce brutes does us no good in or out of prison. Second, we must try to rehabilitate those who can be rehabilitated in our own interest and, if one continues to speak in these terms, in their own interest and in God's, but who should we try to rehabilitate and when? If our prison system is such that it puts into the rehabilitation process the wrong person or the wrong time we may produce the kind of crime which occurred and will be described in the Keating case. The problem is how is our choice to be made? Must we refuse to rehabilitate the 99 per cent because we may try to rehabilitate the wrong man and lead to what has occurred in the present case? The details of the Keating case will, it is believed, present for public examination the kinds of problems which face those who must administer the prison system and one may ask please that they be understood in what they do. To understand is not necessarily to forgive the mistakes that are made, if mistakes there have been, but it is hoped that the knowledge of what is involved will lead to a lively but an informed discussion of what is involved in the work of those who must administer the prison system. Mr Quinlan will detail the matters involved in the Keating case in due course. Yes, Mr Quinlan? QUINLAN, MR: May it please you, sir. As you have indicated, these public hearings fall to consider the prison management of Paul Stephen Keating, who is a 2/8/05 939

Spark & Cannon 1/3/nal OIC/05 sentenced prisoner within the WA prison system. On 27 July this year Keating pleaded guilty to offences in relation to an incident at Bunbury Regional Prison that occurred on or about 16 March this year. On that day, on the 27th, Keating pleaded guilty to 10 counts of aggravated sexual penetration, two counts of indecent assault and threats to compel, three counts of threats to kill and one count each of deprivation of liberty and assault occasioning bodily harm. That matter has been adjourned for sentence by the District Court on 15 September this year and in that context it is important that in the public sittings of this inquiry the position is made very clear in relation to the nature of these proceedings and the purpose for which they are held. The matter of sentencing in relation to the offences for which Mr Keating pleaded guilty on the 27th of last month are entirely a matter for the courts and he will be sentenced for those offences in accordance with the usual sentencing principles. It is not the purpose of these proceedings to be involved or comment in any way upon that process. In particular, Keating is to be sentenced for those offences by the court and not for any offences or acts he has otherwise committed in the past and for which he has already received a sentence.

2/8/05 QUINLAN, MR 940

Spark & Cannon 2/1/slh OIC/05 As will be seen, Keating is already serving a life sentence for offences committed in 1979 and is the subject of an order for an indeterminate sentence which was made under the former section 662B of the Criminal Code. Those sentences applied to Keating before the current offences and they will continue to apply to him after he has been sentenced by the court in relation to the offences which he has recently pleaded guilty to. These proceedings are not concerned strictly speaking with Mr Keating as such, they are concerned with his management by the Department of Justice. For these reasons, and given that the matter is still before the courts for sentence, the details of the offences which occurred on 16 March 2005 are not the subject of the inquiry and the detail, other than to note that serious offences occurred on that day, will not be the subject of detailed examination by the inquiry. The inquiry has gone to some lengths to ensure that the administration of justice by the courts in relation to those offences is in no way affected or interfered with by these public sittings which must be held prior to the reporting date of the inquiry, which according to the terms of reference is 1 October this year. For the sake of completeness I will set out the lengths that have been gone to. Firstly, on 12 May 2005 - this is document 519 - a letter was written to Mr Cock QC the director of public prosecutions in relation to the public hearings generally. Indeed, a meeting was held between the inquirer and the director on that day. That letter of 12 May stated: Commencing on 9 June 2005 the inquiry into the management of offenders in custody under the Public Sector Management Act 1994 will hold public sittings to examine inter alia the management of the following offenders who are serving terms of imprisonment in West Australian prisons. The three prisoners who are then referred to were Paul David Cross, who was dealt with in the sittings in June, Brian William Edwards, who was dealt with in the sittings in July, and the third was Paul Stephen Keating. The letter continued: These offenders have been selected for examination by the inquiry because of offences alleged to have been committed by them while sentenced prisoners on the following dates. The third referred to Paul Stephen Keating on or about 16 March 2005. The letter continued:

2/8/05 QUINLAN, MR 941 10.34

Spark & Cannon 2/2/slh OIC/05 It may be that proceedings are pending or are intended to be brought which have a relationship to the actions of these persons. The inquiry is of course anxious to ensure that during its public sittings nothing will be done which will constitute an unacceptable interference with the course of justice or will otherwise be inconsistent with its obligations. As far as presently appears, nothing of such a nature appears likely to occur. However, in order to ensure that what is done by the inquiry does not interfere with any proceedings the matter is brought to your attention. If you wish to raise any matter in this regard you are invited to communicate as soon as possible with the executive director of the inquiry Mr Peter Byrne. Thank you for your consideration. Yours sincerely, Dennis Mahoney AO QC. On the same day a letter was sent to Mr Keating who is in the special handling unit at Casuarina Prison. That letter, document 521, from Mr Byrne the executive director stated: Dear Mr Keating, commencing on 9 June 2005 the inquiry into the management of offenders in custody under the Public Sector Management Act 1994 will hold public sittings to examine the management of a number of offenders serving terms of imprisonment in West Australian prisons. It is likely that you will be one of the prisoners whose management will be considered during the course of the public sittings. It may be that proceedings are pending or are intended to be brought which relate to your conduct while a sentenced prisoner. The inquiry is anxious to ensure that during its public sittings nothing will be done which will constitute an unacceptable interference with the course of justice or will be otherwise inconsistent with its obligations. As far as presently appears, nothing of such a nature appears likely to occur. However, in order to ensure that what is being done by the inquiry does not interfere with any proceedings the matter is brought to your attention. Keating responded to that correspondence by a letter dated 23 May 2005, which is document 520. That letter read: Dear sir, I today received your correspondence of 12 May 2005. My preliminary response is as follows. Firstly, prior to your correspondence I was completely unaware of the said inquiry. As such, without knowing the inquiry's terms of reference I think it unfair to ask me to raise any matter. Given 2/8/05 QUINLAN, MR 942

Spark & Cannon 2/3/slh OIC/05 the above and my current judicial proceedings I am concerned with several matters. However, I will seek legal advice on such matters before consulting with you. I do request, however, that you provide me with the terms of reference of the inquiry. I further request to attend the inquiry with counsel in any matter which involves me. Yours sincerely, Paul S. Keating.

2/8/05 QUINLAN, MR 943

Spark & Cannon 3/1/glj OIC/05 The executive director responded to the letter from Mr Keating on 30 May and enclosed a copy of the inquiry's terms of reference. As for whether Mr Keating attended the inquiry by counsel or in any other matter was not a matter within the control of the inquiry, and would be a matter to be the subject of application by counsel were that seen to be necessary. On 18 July 2005, correspondence specifically in relation to Mr Keating was written to the acting director of public prosecutions Mr Ken Bates. That document is document 523, and it read: As previously advised, the inquiry into the management of offenders in custody under the Public Sector Management Act has been holding public sittings to examine inter alia the management of a number of offenders who are serving terms of imprisonment in Western Australian prisons. Public sittings have already examined the cases of Paul David Cross and Brian William Edwards. As I advised the director on 10 May 2005, the inquiry also intends to examine the prison history and management of Paul Stephen Keating. I am aware that there are a number of outstanding charges against Mr Keating arising out of events on or about 16 March 2005. I am advised that Mr Keating has pleaded guilty to those charges in the Court of Petty Sessions and has been remanded to the District Court for sentence. I am also advised that Mr Keating is due to appear in the District Court on those charges on 27 July 2005. Given the limited time within which I am required to report to the minister, I propose to commence the public hearings in relation to the management of Paul Stephen Keating on 2 August 2005. I propose to do so whether or not the outstanding charges have been finally disposed of. As there is no prospect of a jury trial on these charges, Keating having pleaded guilty, and as the inquiry does not intend to call evidence as to the detail of the offences against the complainant, there does not appear to be any prospect that public sittings of the inquiry could interfere with the proceedings before the District Court. I would be grateful if you can confirm that this is the case as soon as possible. I am also concerned that the District Court be fully informed of my intention to proceed. Accordingly, could I also ask that you inform the court before whom Keating appears on 27 July 2005 of the inquiry's intention to proceed with the public hearing on 2 August 2005. To that end I am happy for you to provide the court with a copy of this letter. Of course, if the court indicates a preference that I 2/8/05 QUINLAN, MR 944 10.40

Spark & Cannon 3/2/glj OIC/05 not proceed with my public hearing prior to dealing with Mr Keating, I would appreciate you bringing this to my attention immediately so that other arrangements can be put in place. Thank you for your consideration. Yours sincerely, Dennis Mahoney AO QC, Inquirer. A copy of that letter was forwarded to Paul Stephen Keating at Casuarina Prison, although it would appear due to administrative difficulties it did not arrive immediately; nevertheless, a copy of the letter was provided by the director of public prosecutions to Mr Sutherland, Mr Keating's counsel in relation to the current offences. In that regard, as I indicated earlier, Keating pleaded guilty on 27 July 2005 to those offences and the matter was remanded for sentence. At the hearing before the District Court, I'm instructed that reference was not made to the fact of these proceedings, although the officer from the director of public prosecutions advised the investigators with the inquiry that a copy of the letter of 18 July had in fact been provided to the District Court. At any rate, on 27 July 2005 the inquirer wrote to her Honour the chief judge of the District Court and that is document 522, and wrote in these terms: I have been appointed under the Public Sector Management Act to hold an inquiry into the management of offenders in custody in Western Australian prisons. Commencing on 2 August 2005 the inquiry will commence public sittings to examine inter alia the prison history and management of Paul Stephen Keating. I am aware that Mr Keating pleaded guilty this morning to a number of offences arising out of events on or about 16 March 2005 and that he has been remanded for sentence on 15 September 2005. As I am required to report to government by 1 October 2005, I have previously advised the director of public prosecutions and Mr Keating that I propose to commence the public sittings on 2 August 2005 whether or not the outstanding charges have been finally disposed of. I did so on the basis that as there was no prospect of a jury trial on these charges, and as the inquiry does not intend to call evidence as to the detail of the offences against the complainant, there did not appear to be any prospect that public sittings of the inquiry could interfere with the proceedings before the District Court.

2/8/05 QUINLAN, MR 945

Spark & Cannon 4/1/nal OIC/05 I specifically requested that the court be fully informed of my intention to proceed with the public hearing on 2 August 2005 when Mr Keating appeared today. It would appear that this may not have occurred. To that end I enclose a copy of my letter to the director of public prosecutions and Mr Keating dated 18 July 2005. I have not received any objection from the director of public prosecutions or Mr Keating in response to my letter of 18 July 2005 nor has the director brought to my attention any concerns raised by the court in this regard. Accordingly, subject to any issue being taken before then, the public hearings will commence as scheduled. As I indicated to the director, while the fact of the recent offences will be referred to the inquiry does not intend to call evidence as to the detail of those offences. Of course if the court indicates a preference that I not proceed with my public hearings prior to it dealing with Mr Keating I shall abide by any direction in that regard. Yours sincerely, Dennis Mahoney AO QC, Inquirer. A copy of that letter was sent to Mr Keating at Casuarina Prison, his solicitors and to the director of public prosecutions and there has not been any further concern or objection raised. I set that material out in detail, again to provide the context in which this matter arises and to stress again that these proceedings are not intended to reflect in any way on the sentencing process but rather to look at the management of offenders such as Keating and the lessons that might be drawn from it. In that respect it is necessary to present a clear picture of Keating's offending behaviour so that those issues can be understood. It's not an occasion to descend into the detail of each such offence but rather to provide a proper understanding of the kind of individual that is needed to be managed. In that respect Keating provides a particular occasion to look at the management of prisoners who are serving indeterminate sentences. He is the subject, as I said, of a sentence imposed under the former section 662 of the Criminal Code, a provision which is now largely replaced by section 98 of the Sentencing Act 1995. Unlike Cross who was looked at in June and Edwards who was looked at in July, Keating is the subject of a specific order for indeterminate imprisonment and that raises different issues, in my submission, than the issues of management of either finite sentence prisoners or life prisoners.

2/8/05 QUINLAN, MR 946 10.46

Spark & Cannon 4/2/nal OIC/05 Those issues are different because of the reasons for which those indeterminate sentences are imposed. Unlike finite term sentences or indeed a life sentence imposed, for example, for murder an indeterminate sentence is imposed for particular - what might be called utilitarian purposes in addition to but, in a sense, separate from the purposes of punishment in relation to a particular offence. If I can illustrate that by reference to section 98 of the Sentencing Act, which provides the relevant statutory provision for such sentences. It provides - I referred to this in the last public sittings: If a superior court sentences an offender for an indictable offence to a term of imprisonment, does not suspend that imprisonment and does not make a parole eligibility order it may in addition to imposing the term of imprisonment for the offence order the offender to be imprisoned indefinitely. As is clear from that subsection the order for indefinite imprisonment is in addition to what would be the appropriate term of imprisonment for the offence in question and that relationship can be seen in subsection (2) where it continues: Indefinite imprisonment must not be ordered unless the court is satisfied on the balance of probabilities that when the offender would otherwise be released from custody in respect of the nominal sentence or any other term he or she would be a danger to society or a part of it because of one or more of these factors. Then the factors are listed: The exceptional seriousness of the offence, the risk that the offender will commit other indictable offences, the character of the offender and in particular any psychological, psychiatric or other medical condition affecting the offender, the number and seriousness of other offences of which the offender has been convicted and (d) any other exceptional circumstances. So such an order is explicitly an order in relation to protection from danger. It can only be made where a court has reached a conclusion that the offender would be a danger to society or a part of it after they would otherwise be discharged from the sentence for the offence in question, so that it is very much based on a predictive model as to their behaviour and raises the question as to the appropriate criteria for when such a sentence should be lifted or an indefinite imprisonment should cease.

2/8/05 QUINLAN, MR 947

Spark & Cannon 5/1/slh OIC/05 As we say in the last sittings, the mechanisms for the release of a person on indefinite imprisonment are in a sense - are in essence the same as the mechanisms for a person serving a life sentence; that is, there are statutory review dates set by the Parole Board in relation to the prisoners and the ultimate decision-making power rests with the executive government on advice to the governor and executive council, but the fact of the circumstances for these offences - these sentences being imposed, in my submission, raises clearly different criteria, although community protection will of course impact on all such decisions, but criteria which are over and above criteria that relate to the punishment of the offender for the particular offence. That issue is and should return to the question of danger in relation to the prisoner and an appropriate assessment by somebody - it is currently the Parole Board - and then on advice to the executive government as to whether those requirements in subsection (2) of section 98 still operate in relation to the offender. It's fair to say though that Paul Stephen Keating is unusual even amongst offenders who have been given an indefinite term of imprisonment. Prisoners who receive an indefinite term of imprisonment are very few in the prison system because of the extraordinary or exceptional nature of a term for indefinite imprisonment, but in terms of the management of them, Paul Stephen Keating is unusual amongst those prisoners. It is fair to say that he has had, particularly in the last 10 years, an astonishing amount of attention both clinically and administratively to the management of his case. He has had the capacity to draw a large number of people into the management of his case to the point that he has had ongoing regular one-on-one attention from clinical staff, he has been the subject of management by a committee formed in the first instance to deal with his case - a high level committee which we will hear referred to, the serious offenders management committee - which was a committee which dealt with a number of prisons but in its original inception dealt firstly and foremostly with Paul Stephen Keating. It's quite clear that the public hearings with which we deal now are into the management of a small number of particularly difficult to manage prisoners. There will not be many of them in the prison system but their capacity to cause harm is such, in my submission, that a different approach needs to be taken to their management, approach which is separate to although properly integrated with the approach that takes place in relation to prisoners generally. I will explicate that as I proceed through the opening but in terms of the issues which arise out of 2/8/05 QUINLAN, MR 948 10.52

Spark & Cannon 5/2/slh OIC/05 Keating's case and in relation to offenders of this kind generally, if I can just briefly summarise the kind of issues which arise. The first issue is a return to consideration of the AIPR system which was considered in detail in relation to Paul David Cross. It would appear that that system of classification doesn't necessarily fit with a prisoner such as Keating. As will be seen in relation to some of the instruments, there are extraordinary differences in the scoring that has been achieved in relation to the application of that system to Keating because it's difficult to determine what should be left on and what should be left off in relation to that system, and it may be that the nature of his offending pattern, both outside prison and within the prison environment, is such that it doesn't pick up the seriousness of risk which otherwise might be picked up by use of the scoring instruments in that system. The second general issue which arises is the need for a high level oversight of these seriously difficult to manage prisoners by what's described by some as a multiple disciplinary approach, so both management staff and clinical staff being involved in oversight at a high level for these prisoners. That was something which was attempted in relation to Keating with the serious offenders management committee. As with other matters that have been examined in the course of the public hearings of this inquiry, the establishment of that committee was prima facie a good idea and something which should occur in relation to prisoners of this type, but again with other matters which have been examined it was a good idea which does not appear to have been implemented with any great clarity as to the composition of the committee, what its purpose was, what its powers were in relation to prisoners, how a prisoner would get onto the committee, what criteria there were, how a prisoner would get off the committee, so there is a need for that kind of oversight but the operation of the serious offenders management committee perhaps indicates what can occur without a proper structure and formal planning in relation to that kind of oversight.

2/8/05 QUINLAN, MR 949

Spark & Cannon 6/1/slh OIC/05 The third general issue is the need for clarity of purpose in relation to planning in relation to such prisoners and consistency in relation to those matters. What in my submission can be drawn in relation to the management of Keating is that the plans for his management changed at times; changed in terms of their purpose and changed by way of entropy rather than any careful planning. At times intervention was established for a particular purpose and then that purpose seemed to be lost and by - as I said, by way of entropy a new purpose was taken up. I will come to the detail of that later. The fourth general issue is the nature and the impact of these statutory reviews that the Parole Board is required to do in relation to indefinite sentence prisoners. The Sentence Administration Act, as we saw on the last occasion, sets up what is by definition being in legislation a fixed and arbitrary time period for the review of such prisoners. In relation to indeterminate sentence the first review is a year after the sentence commences and then three years thereafter. What may be said to happen as a result of that, however, is a philosophy develops where the statutory review date is perceived and seen to be the earliest eligibility date for release, which in legal theory it is because a person could legally be released on that date, but it's seen as an earliest eligible date for release to which planning and prison management is worked towards. When examining Keating's case it might be seen that that date in the future tended to drive matters in relation to Keating's management such that his management or his progress through the system was pushed too fast and when he then didn't get anywhere they were left with a person whose expectations exceeded the reality of his situation. That in itself, a person whose expectations for their future exceed the reality of their situation, is itself a serious management problem and a problem which was identified in relation to Keating at a relatively early stage, so there's a pressure of the system to do something in relation to these dates. The impact of those reviews can be seen in the decisions that were made by the serious offenders management committee. As will be seen, once the expectations, if you like, of Mr Keating's progress were stalled by reason of the decisions for him not to proceed to a prerelease program, the serious offenders management committee as a result of that rather descended into confusion as to its role and it ultimately disbanded in early 2004. A fifth issue which arises which others have raised with the inquiry is: what is the best way to deal with the assessment of indeterminate sentence prisoners in terms of 2/8/05 QUINLAN, MR 950 10.59

Spark & Cannon 6/2/slh OIC/05 the decision-making process? There has already been evidence in relation to life sentence prisoners and whether or not that decision-making should be reposed in the political arm of government or whether it should be reposed elsewhere. Similar issues arise in relation to indeterminate sentence prisoners as arise in relation to life prisoners such as Brian Edwards, but as I said earlier, the decision-making process is somewhat different in relation to an indeterminate sentence prisoner and the question arises as to whether or not, given that an indeterminate sentence is imposed by the court on the basis of the evidence and a standard of proof and particular statutory criteria, that decision-making process as to whether those criteria continue to be met is better made by the court based on evidence according to a standard of proof and based on the same statutory criteria. Issues of accountability have been raised in relation to that question in the last hearings, but as was also raised, accountability takes a number of forms. Accountability in the political sphere obviously takes the form of the ultimate accountability to an electorate. Accountability in the form of judicial proceedings takes in a sense a three-fold form, that matters are determined on evidence in open hearing and that reasons for decision are necessary to be given. There is then of course the additional accountability of accountability to the law through the appellate process. Those are other issues which arise in relation to indeterminate sentence prisoners and for which lessons might be drawn from the way in which these matters are dealt with in other states of Australia.

2/8/05 QUINLAN, MR 951

Spark & Cannon 7/1/glj OIC/05 The final issue which arises in relation to seriously difficult to manage prisoners relates to the infrastructure that applies in relation to them: where they are best held; if they have particular management needs. In Mr Keating's case, it would appear that he has been held for significant periods of time in management structures and holding structures which are not ultimately conducive to a person's psychological wellbeing and for which it has always been necessary to try and move him on and it may be that that's because there's no alternative within the current prison system to those management options which are available. So in that context it's necessary to say something as to the kinds of infrastructure in terms of the units that he has been held in and the management practices that arise there. Those then, sir, are the broad issues that arise in relation to a prisoner such as Keating, and with that I will then turn to the history of Keating to deal with those issues in more detail. Keating was born in 1959 in New South Wales and had a juvenile criminal record in New South Wales. His first offences, serious offences, in Western Australia were in 1977 when he was 18 years of age. On 11 October 1977 he was convicted of deprivation of liberty and two counts of rape and sentenced to a five-year parole term with a minimum of one year, nine months' imprisonment. The circumstances of that case were that on 26 June 1977 at Osborne Park he abducted a nurse and subsequently raped her. The judge in the sentencing remarks on that occasion stated in the sentencing remarks - and this is in document 284 on page 7. His Honour Jones J refers in the next half of the page: You came here from New South Wales and arrived in this state in June, just about three weeks before you committed these crimes. The series of outrages which you have perpetrated on your unfortunate victim constituted an atrocious crime. To say that you behaved like an animal would not be true: no animal would behave in the way you did - and the sentence was then imposed; a finite sentence at that stage. In 1977, on October 12 1977, Keating requested to be transferred to minimum security at Wooroloo Training Centre or Karnet Prison Farm and indicated that was because - for his preference for working on farms and the statement that he felt that retention at Fremantle Prison would have an emotionally detrimental effect on him. On 27 October 1977 the prison assessment and orientation report written by an officer recommended that Keating remain at Fremantle Prison at maximum security as he presented as an irresponsible 2/8/05 QUINLAN, MR 952 11.05

Spark & Cannon 7/2/glj OIC/05 young man who appeared to be emotionally unstable and impulsive. The report indicated that Keating had been referred to a psychologist at his request and attended Alcoholics Anonymous meetings. On 17 November 1977 a psychologist completed a report concerning Keating. This would appear to be the first of many psychological reports in relation to Keating; it's document 287, which commences: This inmate's youth and immaturity cause me to be concerned at the effect which Fremantle Prison is having on him. He recognises that he has committed a serious offence and must be dealt with accordingly. However, he is a nervous, sometimes clearly frightened young man and it concerns me that maximum security may be detrimental to his present and future adjustment - and the recommendations towards the end of the page are: Immediate transfer to Pardelup. Keating has a country background and work experience and is keen to work on a farm. His lack of family and friends in the state negates concerns about visits; (2) if the committee feels this would be unwise for security reasons, an alternative would be to transfer to Bunbury with consideration of a transfer to Pardelup after a trial period; thirdly, if it's deemed necessary to maintain Keating in maximum security for a further period, I suggest that his present difficulties justify an early review. If he is to remain in Fremantle, I request that he be reviewed no later than two months from now. On 18 November 1977, the following day, the classification committee decision slip indicated the committee's recommendation for Keating to remain at Fremantle Prison in view of the likelihood of escape. This decision was approved by the director on 23 November 1977; however, it included the notation, "If at all possible, I would like to see this inmate out of Fremantle with a recommended review date of February 1978."

2/8/05 QUINLAN, MR 953

Spark & Cannon 8/1/nal OIC/05 There was a further report in relation to Keating by the prison psychologist on 31 January 1978, which is document 289. It continues in the second paragraph: Mr Keating feels that the possible benefits of continuing this program; that is, a communication skills group program, outweigh at the moment the advantages of transfer to an outstation. To facilitate most effective use of these opportunities I would recommend a further period of detention in Fremantle. I wish to emphasise however that there is no assurance that Mr Keating's needs will continue to be adequately met in Fremantle. Ultimately, his best interests will be served by transfer to a less secure institution. In order to ensure that Mr Keating's progress be adequately assessed and the greatest advantages be taken of placement opportunities I request that his case be reviewed in three months time. According to the next prison assessment and orientation report it was recommended that he remain at Fremantle and that that decision was upheld. In 1978 on 26 May, according to a prison assessment and orientation report, Keating requested to be transferred to Bunbury rehabilitation centre. He acknowledged that his transfer would permit him time to settle down and prepare for prison based work release. That is reflected on document 291, which in the second page has as its recommendations: Transfer to Bunbury because of (a) lower security rating (b) improved maturity and self-confidence (c) has reached a stage in his sentence where the commencement of a release program would require him to be treated as a normal inmate and his transfer out of maximum security institutions. On 20 June 1978 the classification committee decision slip indicated the committee's recommendation for Keating to be transferred to Bunbury rehabilitation centre and for psychological counselling to continue. This decision was approved by the director on 26 June 1978 and indeed on 5 July that year Keating was transferred to the Bunbury rehabilitation centre. On 15 September 1978 Keating requested to be transferred to the Wooroloo training centre in order to receive practical training as a boiler maker before leaving prison. This application was not recommended by the prison assessment and orientation review report dated 18 September identifying that Keating was a sex offender and also appeared to have an alcohol problem. This was of particular concern due to the uncertainty of the attitude 2/8/05 QUINLAN, MR 954 11.11

Spark & Cannon 8/2/nal OIC/05 of Wooroloo towards sex offenders. That request from Keating was supported by the clinical psychologist by correspondence on 4 October. The review board however, on 13 October, concluded that he should remain at Bunbury rehabilitation centre due to the nature of the offenders and that decision was approved on 18 October 1978. On 4 December 1978 Keating applied for prison based work release. This request was supported by the prison assessment and orientation report of 5 December 1978, which identified Keating presented no management problems and was respectful to staff. It was noted in this report that Keating was rated as a minimum risk and had travelled outside the institution for work parties on several indications giving no indication of escaping. The writer of the report recommended that he be stationed at the most disciplined work release centre as he felt Keating was easily led. On 8 December 1978, as a result of case conference, normal prison based work release was recommended indicating metropolitan area was preferred. The director approved this decision on 20 December and ministerial was approved to commence on 8 February 1979, three months prior to his earliest eligible date for release on parole. He was transferred to Brunswick Junction Prison to commence work release on 23 February 1979 and commenced employment on 26 February 1979 as a labourer at the sleeper processing company in Picton Junction. Shortly after on 10 March 1979 Keating escaped from legal custody. The incident report in relation to that is document 299, which states: As instructed, at 8.45 am I left Brunswick Prison to take a cricket team to Bunbury rehabilitation centre and inmate Keating, P.S. a work releasee to Bunbury on shopping leave. I left Keating, P.S. at the Bunbury Railway Station at 9.15 am and told him, "Return to the Bunbury Railway Station between 11.30 am and 12 noon on Saturday morning, 10 March 1979." I returned to the railway station at 11.40 am. I then waited until 12.20 pm. Keating did not return. I did a tour of the Bunbury shopping area and did not find Keating.

2/8/05 QUINLAN, MR 955

Spark & Cannon 9/1/slh OIC/05 The further investigations showed that there were no reasons for Keating's actions and the officer felt his decision was instantaneous as he had handed in his weekly pay the night before. Two days later on 12 March 1979 whilst at large, Keating broke in and entered a residential property at Trigg where he stole a quantity of jewellery. The next day, 13 March 1979, so shortly after his escape from legal custody, whilst still at large, Keating answered a newspaper advertisement from a woman seeking a male flatmate. He was selected by the woman from a number of applicants. At approximately 10.20 pm that night the flatmate went to bed whilst Keating was watching television in another room. Sometime later he entered her bedroom. She asked him to leave. He threatened her with a knife and threatened to kill her if she made a noise. After an unsuccessful attempt to have oral sex with her, Keating raped her at knife point. He tied her up and stole $174 from her handbag. The judge's sentencing remarks when Keating was ultimately sentenced for those offences on 3 October 1979 - document 308 - and it's significant to refer to these because this was the offence for which Keating was given his life term which he is currently still serving. His Honour Sir Francis Burt CJ said in his sentencing: The details of the crime of rape of which you were convicted were fully revealed at your trial and they need not be repeated. It is enough to say that they reveal your crime to be one of the worst cases of rape. Force was used and more force was threatened. You were armed with a knife and you threatened to use it. In addition to intercourse you subjected the complainant to many indecencies of the grossest kind. It was an unprovoked violent sexual crime. Those acts having been done, you bound the complainant's hands and her feet and her hands to her feet and you left her so, immobilised on the floor of her bedroom. This was the offence of depriving her of her liberty. You then stole her money, which was the offence of robbery. You then drove off in her motor car, and this was the offence of unlawfully driving her motor car without her consent. Towards the end of the remarks on the third page of that document his Honour the chief justice imposed the sentence: For the crime of rape, Keating, I sentence you to life imprisonment.

2/8/05 QUINLAN, MR 956 11.17

Spark & Cannon 9/2/slh OIC/05 Keating was apprehended on 16 March 1979 and returned to maximum security at Fremantle Prison. On 17 March 1979 at East Perth Court of Petty Sessions he received a finite sentence of three months' cumulative imprisonment for escape legal custody. On 30 April 1979, according to the prison assessment and orientation report, it was recommended that he remain in maximum security at Fremantle due to the future court. On 5 June 1979, Keating escaped from maximum security at Fremantle Prison. Incident reports indicate that Keating escaped under the tray of the rubbish truck and was subsequently recaptured by an officer, the driver of the truck, while at the Fremantle Council rubbish tip on the same day. On 18 June 1979 at the East Perth Court of Petty Sessions Keating received a further finite sentence of three months' cumulative imprisonment for escaping legal custody. On 8 August 1979, Keating was sentenced to a finite term of two years cumulative imprisonment for break, enter with intent. This was the offence committed on 12 March 1979. After sentencing Keating was reportedly about to be placed into the van to return to prison whereby he ran away from court escorts on the spur of the moment. He was apprehended on site. The following day he was sentenced to a further finite term of one-month concurrent imprisonment for escape legal custody. On 5 September 1979, so the following month, two incidents were reported. One incident reported Keating had attempted to escape legal custody. He was later charged for that offence on 10 September 1979 at Fremantle Court of Petty Sessions where he received a further finite sentence of two months' cumulative imprisonment. On the same day of the attempted escape Keating reportedly committed an act of misconduct by being in possession of an article not issued to him, namely, a spanner and was confined to a punishment cell for four days. As I have already indicated, on 3 October 1979 he was convicted on his plea of guilty and sentenced in relation to the offences committed on 13 March 1979, which included the life sentence. The management of Keating then returned to review by psychologists and psychiatrists. There was a review by a consultant psychiatrist F.G. Farrelly on 24 November 1980, which is document MI309. The report is a short one and reads:

2/8/05 QUINLAN, MR 957

Spark & Cannon 10/1/nal OIC/05

This 21-year-old single man from Sydney is serving life imprisonment for rape. He had a deprived upbringing. He never knew his father and began an institutional life in the homes at about 11 years of age but even before that he had been taken in care and fostered out on a number of occasions from the age of 6 onwards. He has never been deemed to be psychiatrically ill, either in the Eastern States or here and I concur with that view. He has no mental symptoms of any sort. He does have bouts of indigestion, which are traceable to an ulcer which was detected when he was 15. Keating attends psychological counselling from Shirley Cook and attends the prison shop. He has asked me if it would be possible for him to continue this routine for a year or so without change. I told him it would be my recommendation as well. What's instructive about that is that it's a review by a consultant psychiatrist that says that Keating is not psychiatrically ill and that would appear to be the conclusion throughout his prison career. There does not appear to be any occasion on which a consultant psychiatrist has diagnosed a psychiatric illness in relation to Keating. There are certainly psychological reports which refer to his psychological condition but in terms of a treatable psychiatric illness none has ever been identified. On 22 January 1981 Keating received a prison charge for unlawfully assaulting another prisoner. As a result of that offence he was confined to punishment for five days. On 8 December 1981, according to a clinical psychologist, it was reported that Keating had been seen by the psychologist on a regular basis since June 1980: During this time I consider that significant progress has been made with respect to the personal issues contributing to Mr Keating's offending behaviour. Psychological treatment has now reached the point where Mr Keating is highly motivated to develop the positive potential he has discovered in himself with regard to interpersonal and vocational spheres, however in view of this - perceived necessary to remain in segregation whilst at Fremantle opportunities for such development to take place at this institution are extremely limited. I strongly recommend therefore that in order to consolidate the gains already made and to encourage future development Mr Keating be transferred to an institution where he would be able to interact more

2/8/05 QUINLAN, MR 958 11.23

Spark & Cannon 10/2/nal OIC/05 constructively with his environment. I would suggest Albany maximum as a first step to be followed up as soon as possible thereafter by transfer to Canning Vale medium. Again, what's interesting about that report is that it's a theme that then runs through much of Keating's placement in terms of where to put him and how he might be properly dealt with. On 16 December 1981, according to the prison assessment and orientation review, Keating remained in the segregation centre since the incident of 20 January 1981 and that is the assault. Within the confines of the segregation centre he was under constant surveillance and reportedly at no time gave concern. On 31 December 1981 he wrote to the case conference committee requesting he be transferred to Albany Regional Prison in view of his segregation status. On 28 January 1982 the review board decided that he was to remain maximum security at Fremantle Prison in view of the nature of his offences, escape record and as he had committed serious offences whilst at large. On 17 May 1982 he was removed from the segregation centre at Fremantle Prison to special yard at his own request and on 8 February 1983, as a result of case conference, the director approved for him to remain at Fremantle Prison at low maximum security due to his record and nature of offences. On 23 April 1983 he received a prison charge for assaulting another prisoner and as a result was confined to a punishment cell for four days. On 12 January 1984 he was the subject of a report by a clinical psychologist, which is document 317. That report commences: I have seen Keating on a fairly regular basis throughout 1983 for general counselling. He is now 24 years old, having spent almost all of his adolescence in boys' homes and prisons and having served more than four years in Fremantle since his most recent offence. Progress which has been made in counselling has been more towards avoiding deterioration and maintaining stability rather than active and intense psychotherapy. He remains subject to depressive mood swings but recently they tend to be less intense and express as aimless despondence. Towards the end of the report: In view of the sometimes fragile stability he has achieved at Fremantle and the present risk of conflict elsewhere I recommend continued placement at Fremantle. Consideration should be given to his 1985

2/8/05 QUINLAN, MR 959

Spark & Cannon 10/3/nal OIC/05 review to placement elsewhere. A reduction in security rating would give recognition to the improved good work and behaviour reports achieved in the last two years.

2/8/05 QUINLAN, MR 960

Spark & Cannon 11/1/glj OIC/05 On 25 January 1984 correspondence from Keating was received saying he wished to remain at Fremantle Prison, and on 23 October 2004 he was the subject of another psychiatric report, which is document 319 and again, this report confirms that there were no symptoms of mental illness and in the last paragraph: If in fact he qualifies for a reduction in security rating to medium, then I would support a trial at Bunbury or Canning Vale. Transfer would be a logical and constructive step to consolidate the limited progress he has made, in keeping with his eligibility for parole in October 1986, for your consideration. The next day on 24 October 1984, as a result of a case conference, it was recommended that Keating be reduced to medium security rating and recommended that he be transferred to Canning Vale Prison on an eight-week trial period and on 3 November 1984 Keating was transferred to Canning Vale Prison at medium security. 14 days later Keating again escaped legal custody. According to the advice of escape from legal custody, Keating had broken into the gymnasium roof and climbed the wall, using a steel frame. He was in the company of five other prisoners and during the time at large he broke into a house in Balcatta where he arranged for a woman to come to the house. Two females attended the house, at which time they were indecently assaulted and sexually assaulted. He was apprehended on 20 November 1984. What can be seen at this point is a pattern emerging in terms of Keating's incapacity at that age in his 20s to control his offending behaviour. He was placed in prison originally for sexual offences in 1977. He escaped in 1979 and within two days committed serious sexual offences for which he received a term of life imprisonment. When he next went to medium security, he escaped within 14 days and that day committed sexual offences against two women. He was apprehended on 20 November 1984 and returned to maximum security at Fremantle Prison. The next day on 21 November at East Perth Court of Petty Sessions, he was sentenced to a finite term of four months' cumulative imprisonment for escape legal custody. On 2 January 1985 he was transferred to Fremantle public hospital as a result of a drug overdose. Two officers were in attendance and leg irons were applied. He returned to Fremantle Prison on 3 January 1985 after receiving medical treatment. On 23 April 1985, Keating was sentenced at the Perth Supreme Court for break and enter, two counts of deprivation of liberty, three counts of unlawful indecent assault, and sodomy. 2/8/05 QUINLAN, MR 961 11.29

Spark & Cannon 11/2/glj OIC/05 He was sentenced to a 14-year minimum nonparole period and subject to detention at the governor's pleasure pursuant to section 662(b) of the Criminal Code. His earliest eligible date for release on parole was calculated as 2 June 1996. So this is the point at which Keating becomes an indeterminate-sentence prisoner. So by 1985 he is subject both to a life term and to a term of indeterminate imprisonment, both being due to offences committed whilst at large following escapes from legal custody. MAHONEY, MR: What, in the prison system, is the significant difference between the life sentence and the indeterminate sentence? QUINLAN, MR: I don't think, in terms of management of a prisoner, there's any significant difference in terms of the day-to-day management of the prisoner. The only difference may arise in terms of their statutory reviews, but indeed in the case of section 16 of the Sentence Administration Act now and the previous provisions that applied, those regimes are similar as well in terms of the occasions for statutory review. So depending upon each prisoner and what minimum periods are set, the statutory reviews will kick in at a different time, but otherwise in terms of their management they are largely similar. In 1985, on 26 April there was a memorandum to all staff, forwarded by the director - this is document 329. This was from Ian Hill, the then director, which said: The above-named prisoner was recently convicted and received a 12-year nonparole period, at the expiry of which he is to recommence serving his life sentence. Given his criminal history and the consistent nature of his offences, no consideration is to be given to transferring him out of maximum security until he has served the sentence he has just received. Before any further consideration to his movement within the system, my approval is required.

2/8/05 QUINLAN, MR 962

Spark & Cannon 12/1/slh OIC/05 There were orders for removal of treatment which occurred in relation to treatment received by Keating in 1986 in April. Then on 27 October 1986, Keating committed the first of his serious offences of a sexual nature within the prison environment. At approximately 3.45 pm an incident occurred during an interview with Keating by a female psychologist at Fremantle Prison. The interview had been conducted in a room within the prison hospital annexed buildings. Keating reportedly held a home-made knife, a scissor blade, to the psychologist's throat, putting some tissues in her mouth and made unspecified demands. After some time the psychologist was able to talk Keating into relinquishing the knife and leaving her alone. She took the knife and threw it out the window once Keating returned to prison routine. She then went to the assessment centre and advised her colleagues who contacted the superintendent. Following the incident the superintendent ordered the prisoner to be transferred immediately to the observation cells and an investigation into the situation was undertaken. It was later revealed that during the incident Keating had fondled the psychologist's breasts and put his hands down the front of her trousers. Immediately following the incident he armed himself with an industrial can opener in the infirmary kitchen and refused to come out when called upon. The superintendent intervened and they were able to place Keating in an observation cell. On 28 October 1986, the next day, upon unlocking the cell, Keating was found to be in a distressed state. He was transferred to Fremantle Public Hospital suffering from what appeared to be a drug overdose. In view of the risk he posed, Keating was ordered by the director Mr Hill to be placed in separate confinement for 30 days. This was confinement according to section 43 of the Prisons Act which is a provision which enables the chief executive officer for maintaining the good government order and security of the prison to order the separate confinement of a prisoner for 30 days. As will be seen, this is one of the mechanisms used to manage Keating in the course of his sentence, including a period when he was subject to rolling 30-day section 43 orders. Indeed, those orders continued in 1986. On 12 January 1987, Keating was sentenced in the Perth District Court for the aggravated indecent assault involving the prison psychologist and was subject to a further parole term of three years' concurrent imprisonment. On 21 January 1987 as a result of a case conference it was recommended that he remain at maximum security in Fremantle Prison in view of the length of sentence and the 2/8/05 QUINLAN, MR 963 11.35

Spark & Cannon 12/2/slh OIC/05 nature of the offender's offences. The decision was approved by the director that he should not be transferred out of maximum security until he had served his 14-year sentence. On 4 January 1988, Keating was involved in the Fremantle Prison riot whereby damage was done to division - number 3 division of the prison and five prison officers were taken hostage. Following his involvement, Keating was placed in the special handling unit Fremantle Prison until such placement was no longer necessary in order to maintain the good government and good order of the prison. This is a different regime to the section 43 regime to which Keating has been often subject. Keating was charged as a result of the Fremantle riot with two counts of assault and six counts of deprivation of liberty and remained in the special handling unit and continued to remain there until the end of the period that he was in Fremantle. Correspondence from Keating began to be written to the director of the department. An example of it appears as document 341. Page 4 of that document is the letter from Keating which is an early example of the kind of letters that Keating writes to prison authorities in relation to his concerns and feelings in relation to the management of his case. One of the issues that is raised in that correspondence is - one can see on the third page of that letter, the last page of this document, he says: This is my eleventh year in this prison system. The more time I do the more I realise what a waste of time it is to trust, believe or respect any person in the administration. Oh, yeah, what year will my application for interstate transfer be processed or why is it I don't meet the criteria to be a participant in the sex offenders program? Listen, I just want to do my time and sentence in peace and I've always wanted but lately the way the department carries on, to be frank, pisses me right off. All I can say is I hope you get your act together at Casuarina. Well, Mr Hill, after reading this you will either think I'm crazy or mad or bad but that meeting I had with you the day we ended our hunger strike I had respect for you and your word but your department's actions proved to you that I'm just a low-down scumbag. Thank you. Regards, Keating.

2/8/05 QUINLAN, MR 964

Spark & Cannon 13/1/mjd OIC/05 Hill responded to that letter on 12 May 1998 which is the first page of this document and one interesting note about that is the reference to the sex offenders program which will appear later on in Keating's history, point C of that letter. Your comments in relation to not meeting the criteria to be a participant in the sex offenders program is a matter of professional judgment by the team leader. I have no doubt the decision was made on the basis that at this stage it is still a pilot program which is currently undergoing evaluation prior to it becoming a program which is integrated across the operational divisions. On 31 July Keating was charged with behaving in a disorderly manner by fighting with another prisoner at the special handling unit and as a result was cautioned for that charge. On 9 December 1988, Keating was sentenced to a finite term of six years two months cumulative for the offence which occurred during the prison riot, namely, two counts of unlawful common assault and six counts of unlawful detention. His earliest eligible date for release on parole was recalculated to 31 January 1998. MAHONEY, MR: You say release on parole. That really means for the special release programs for indefinite prisoners. QUINLAN, MR: That's right. At all of these times he is the subject of a life sentence and an indeterminent sentence. So that - what is identified as his earliest eligible date is in fact his statutory review date or the date upon which he would be reviewed under those particular sentences. But it suffices to note that even his finite terms at that point, in 1988, take him right into the late nineties. On 25 January 1989, it was recommended that he remain at maximum security at Fremantle Prison. He continued to remain in the special handling unit and was rated as a high-risk prisoner. In January 1991, according to prison incident reports, he destroyed two guitars and ripped his wall shelf off the wall in his cells. According to the officer he was noticeably shaking, recovering from a rage of emotions. He was reported to have stated that he had requested on numerous occasions to be removed from separate confinement to get his head together but to no avail. As a result of that incident on 1 February 1991, he was ordered to be placed in separate confinement for 30 days. On 1 March a second order for separate confinement was endorsed and the minister was notified of those decisions. A proposed management plan was put together for Keating in February 1991. This is 2/8/05 QUINLAN, MR 965 11.41

Spark & Cannon 13/2/mjd OIC/05 document 346. The letter is to the executive director from the superintendent of Fremantle Prison. The background which is set out there is that: Prisoner Keating P.S. is a long-term prisoner placed in the special handling unit at Fremantle Prison. He has been in the unit since January 12, 1988 following his involvement in the riot fire. What's significant to note about this is that by this stage he has been in the special handling unit at Fremantle Prison since the beginning of 1988, it is now the beginning of 1991. As we will hear evidence, the special handling unit is a unit of intense supervision of prisoners. The staff-to-prisoner ratio is much higher than in the general prison population. The movement of prisoners is restricted. The contact that prisoners will have with the general prison population is restricted. It's a particularly intense form of supervision that is obviously being applied to Keating for a significant period of time. As shown in the minutes of the special handling unit management meetings Keating has for some time expressed anxiety over his placement and his sentence. He is becoming increasingly solitary and he's showing indications of disruptive behaviour. The special handling unit staff are concerned for Keating's welfare. They fear that Keating may become suicidal and/or violent towards other prisoners and staff if he is unable to resolve his inner conflict and anxieties. Psychological counselling has not assisted him and his circumstances have been discussed with the ODP staff who agree that some kind of program time out would be beneficial. The proposal on the next page is: The special handling unit team recommend that Keating be provided with a short term individualised management program to assist him in boosting and maintaining his self-esteem. I concur with their recommendation. It is envisaged that not only will such a program provide the prisoner with time out and a positive outlook it will also avert further confrontations and ease existing tensions within the special handling unit.

2/8/05 QUINLAN, MR 966

Spark & Cannon 14/1/nal OIC/05 The management program that was proposed was that Keating be placed in division 2 and work in the boiling house during the day for a 12-week period to complete his practical training; he sit a four-hour exam at the end of the 12-week period and at the end of the 12-week period he be returned to the special handling unit. While residing in unit 2 Keating will remain under the general control and review of the officer in charge special handling unit. He will not enter the mainstream regime but will be supervised under special handling unit guidelines. Over the page in the summary: Prisoner Keating has been placed in the special handling unit for some three years. His increasing anxiety has been noticed by staff and they are concerned for his welfare. It is apparent that Keating's tension is related to his long-term placement in the special handling unit and it is expected he would gain extreme benefit from a time out period. That indeed occurred - correspondence however was also received from Keating to the executive direction on 4 March 1991 and this is document 347. Again, this will become evident - this document shows an increasing degree of contact that Keating makes with the authorities as his sentence continues. It begins: There are two reasons why I chose to open my letter to you with the above quotation - and there's a quotation at the beginning of the letter: The first and most important reason is that my letter is essentially to make a compassionate appeal to you which I hope you will have the change of heart towards me and provide me one last opportunity by releasing me from the negative and oppressive environment of the special handling unit. This would then allow me to have more responsibility for myself and more control over my future, both of which would strengthen my self esteem and sense of worthiness, which in turn would further enable me to utilise the final six and three quarter years I have left to serve until my EDR date doing the many constructive things I would like to do in preparation for my long-awaited return to society. MAHONEY, MR: He seems to have the language within his control at that stage, doesn't he? QUINLAN, MR: Well, he certainly does and at that stage he had - we can see from the second page, the last paragraph 2/8/05 QUINLAN, MR 967 11.47

Spark & Cannon 14/2/nal OIC/05 on that screen: The past three years since the riot has also seen me undertake and successfully complete five educational courses; these include creative writing, year 11 English, English communication and two mathematic courses. I am sending you photocopies of all completion certificates. And at the end of that sentence - end of that paragraph: In fact, I am and have been on the long-term prisoner's program since I was first introduced even though I am being denied the full rewards of the program by being in the SHU - that is the abbreviation for the special handling unit. The letter encloses letters to Keating's diary that he has written, poetry that he has written and the like in relation to his imprisonment. As a result, on 28 March 1991 the executive director ordered the removal of Keating from the special handling unit, the minister was advised that he would be returned to mainstream prison population and employed in the boiler house at Fremantle Prison. On 4 July 1991 a report by the superintendent Mr Peter Moore was forwarded to the director of prison operations. Mr Moore indicated in his report that since Keating had been removed from the special handling unit on 28 March 1991 he had been observed as steadily assimilating into mainstream prison life and had no presented as a management problem. Mr Moore revealed that Keating had passed his examination for certificate of competency for boiler attendant on 24 June 1991 and also suggested Keating was being considered for placement in a self-care unit at Casuarina Prison. What's useful to note about this - as I indicated, I think I may have said he was in the special handling unit for the entire time for the rest of Fremantle but he was moved out of the special handling unit and shortly thereafter, from March to July, it was then suggested that he was being considered for placement in a self-care unit. We will see that that was a relatively short period of time. In October 1991 he was transferred to Casuarina Prison at maximum security when Casuarina Prison opened and was in the self-care unit. Shortly after October 1991, on 29 January 1992, he committed his second offence against a female person in prison and a more serious offence than the one that he had committed against the prison psychologist in 1986.

2/8/05 QUINLAN, MR 968

Spark & Cannon 15/1/mjd OIC/05 At 11.20 am on 29 January 1992, a female senior prison officer was alone in the self-care unit where Keating resided. At this time Keating was the only prisoner in the unit undertaking his cleaning duties. He punched her to the right side of the head with his fist and dragged her into the staff toilet block. Armed with a knife he punched her and threatened to kill her. He then sexually assaulted her. When another officer returned to the self-care unit during his meal break he discovered that the female officer was missing. The officer managed to talk Keating out of the toilet at which time Keating requested to speak with the superintendent. The superintendent arrived at the unit with officers from the recovery team to secure Keating. As a result of the assault the female officer was referred to the Sexual Assault Referral Centre and received medical treatment. Keating was immediately, pursuant to section 43 of the Prisons Act, ordered to be placed in separate confinement for a period of 30 days. That order was endorsed by the acting executive director of the Department of Corrections and the minister was advised of that decision. On 28 February, a month later, Keating was ordered to remain in separate confinement for 30 days and that continued on a monthly basis until 2 March 1993. The minister was advised of the decisions and informed that in view of the gravity of the allegations relating to the sexual assault of a female prison officer, his separation from the prison mainstream was considered essential in maintaining the good order of the prison. On 6 August 1992, a pre-sentence report by a clinical psychologist with the sex offender treatment program identified that Keating had little control over his offending behaviour and presented as an extremely high risk of violence towards others around him when stressed. He recommended that should treatment be attempted the most appropriate venue would be within the confines of a secure psychiatric facility. On 20 August 1992 at the Perth Supreme Court, Keating was sentenced to a finite term of five years' cumulative imprisonment for four counts of aggravated sexual assault, deprivation of liberty and two counts of assault with intent. His statutory review date then was calculated as 2 June 2001. On 23 October 2002, in response to a request by the director of prison operations, a management plan was developed for Keating. If we can go to that it's document 355. The significance of course here is that now Keating has committed a serious sexual offence, which got him in prison in 1977, two serious sexual offences in 1979 and 1985 which were committed at large while he had escaped 2/8/05 QUINLAN, MR 969 11.53

Spark & Cannon 15/2/mjd OIC/05 custody and offences of aggravated indecent assault in 1986 within the prison environment, an aggravated sexual assault in 1992 within the environment. The management plan which was prepared at that time, prepared by a psychologist within - the manager of prison programs describes the behaviour cycle, this should be on page 4 of the - that it was felt that Keating has a behavioural cycle that enables his likely response to certain events to be predicted. This cycle can be illustrated as follows. It begins with engagement, proceeds to idealisation - this is of relationships with other people - then a rejection stressor, disengagement with the person, reaction, assault and then withdrawal, isolation and guilt. What the management plan which was prepared, there should be document page 6, states: The following recommendations are made. Placement, to remain section 43 until March 1993. So at this stage he is in separate confinement within Casuarina Prison under section 43. To be placed in the special handling unit in April 1993. Any subsequent placements or work assignments outside of the special handling unit must have the prior approval of the director prison operations. Staff safety. Keating must be viewed as posing a risk to female officers, therefore, he should not be allowed to have one-on-one contact with any female staff for the duration of his sentence. The significance of that is that his sentence at this stage, his finite sentence, will go to at least 2001. The management plan is that for the duration of his sentence he should not be allowed to have one to one contact with any female staff for the duration of that sentence. It continues: Supervisory staff should be briefed on the behavioural cycle contained in the first part of this report. Specific indicators to be aware of include idealisation of individuals, attachment to individual female staff, the gathering of information of a personal nature about particular staff members, increases in Keating's stress levels particularly in circumstances involving perceived rejection. It is recommended that at least initially Keating will be managed by prisoner program staff who are not Casuarina-based.

2/8/05 QUINLAN, MR 970

Spark & Cannon 16/1/slh OIC/05 Then in relation to counselling: An initial goal of counselling will be to teach Keating better use of meditation stress reduction techniques and problem solving. It's hoped that this will enable him to better manage stress without letting it overwhelm him. Longer term counselling with a view to attempting to address the offending behaviour and provide a safety vent will be undertaken by the manager prison programs. As has earlier been referred to, Keating had applied for application for a prison transfer to New South Wales. There's correspondence on the file in relation to the matter that there was a cautious recommendation to support that transfer. For example, on document 357 on 21 December 1992 correspondence was sent by the coordinator of the special needs team which suggested that although he identified Keating had a dysfunction childhood, was highly institutionalised, had severe psychological problems in relation to women, was extremely dangerous, he also identified that since his mother's death his only family contact was with his brother Martin and that it was his desire to maintain and strengthen his bond that motivated his application for interstate transfer: In this respect I do feel Keating's argument warrants serious consideration in that his chances of ever achieving a successful rehabilitation would be much enhanced by having at least a modicum of social supports available to him. As an example of the kinds of stressors that are evident - or the effect that they have on Keating's condition, an incident report of 27 January 1993, which is document 358, records: On Wednesday, 27 January 1993, I was rostered sentence planning. At approximately 1400 hours Mr Williams from Rockingham CBC and myself interviewed Keating regarding his application for interstate transfer. During the interview Keating became quite agitated and aggressive to questioning and stated on a number of occasions Mr Northcott had all the answers. Towards the completion of the interview Keating made a number of threatening comments including, "If I don't get approval I'll go completely off my brain. You can come and shoot me," and, "If you think I've been a problem in the past you've seen nothing yet." The interview was then terminated and the writer spoke to Keating and calmed him down. IOU staff - that's where he was living in segregation - 2/8/05 QUINLAN, MR 971 11.59

Spark & Cannon 16/2/slh OIC/05 were notified of the incident and threats and advised to use caution with Keating. On 8 February 1993, Keating's sentence of five years for the aggravated sexual assault on the prison officer was increased by the Court of Criminal Appeal to a nine-year cumulative sentence. That resulted in Keating's earliest date for consideration by the - statutory review date of 1 February 2004. That is the date to which all matters were directed which followed thereafter. On 18 February 1993 as a result of case conference it was recommended that Keating remain maximum security at Casuarina Prison. His application for transfer to New South Wales was also recommended. That correspondence continued in relation to his application for interstate transfer. Ultimately on 13 August 1993 correspondence from the deputy superintendent of Casuarina Prison requested that he be removed from special confinement to the special handling unit regardless of the progress of his interstate transfer applications. On 17 August 1993 a prisoner management plan was formulated. That's document 364. If we can go to page 3 of that document, some points to note in relation to that - further down that page: It has been assessed that Keating presents and will continue to present as a very high risk of violence towards others around him, particularly when under stress. While this is particularly so in relation to sexual violence to women, it is also true in relation to violence per se. Keating's pattern of offending behaviour poses particular problems given his length of sentence, history of previous assaults on prison staff and his ability to lull staff into a false sense of security.

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Spark & Cannon 17/1/glj OIC/05 Keating has been in section 43 since February 1992. The aim of the program was to reduce the risk of staff being assaulted and the management placement was that Keating be transferred to the special handling unit on 23 August 1993 and subject to the special handling unit regime. Significantly - and in bold: point 3, point 4 of that management plan was that Keating poses an extreme risk to females and must never have one-on-one contact with any female for the duration of his sentence. Again, at the time that that statement was made the duration of sentence would have gone to February 2004, and over the page we can see that that decision was endorsed and approved by the superintendent on 19 August 1993. So on 23 August 2003 (sic) he was removed from separate confinement to the special handling unit. Prior to his removal he was briefed on the regime which was required to be followed. On 27 September 1993 correspondence was ultimately received from New South Wales, indicating that they did not approve his interstate transfer and he would remain in custody in Western Australia. At this point then he's moved from the strict regime of confinement within a punishment cell into a strict regime within the special handling unit which, again, has a high staff to prisoner ratio; does not mix with the mainstream of the prison, and has significant movement restrictions. His further management was then the subject of consideration by the department and a particularly important point of that was a letter written on 4 November 1993 to the executive director, document 366. On this document in the second full paragraph: Keating is subject to weekly performance reports and a weekly behavioural observation report to the superintendent by the coordinator SPU. Monthly review meetings are held in the special handling unit as per director's rule 3N, the most recent being October 8 1993. Keating has been interviewed on an irregular basis by Mr D. Northcott, the most recent being October 14 1993. Keating's general conduct since placement in the special handling unit has been above average. His cell is always clean and tidy. He is always punctual; maintains a limited fitness program, and is an excellent worker in the industries area. Over the page, second full paragraph: Keating has indicated a desire to address his offending behaviour in more than one area. He has 2/8/05 QUINLAN, MR 973 12.05

Spark & Cannon 17/2/glj OIC/05 spoken in some depth to the coordinator SPU on the Fremantle hostage riot situation. Keating has also spent some time with Senior Officer Walker and spoken at some length on the - and I won't mention the name of the victim, but the incident involving the prison officer in 1992. Keating has to date maintained his commitment to discuss in a rational manner any issues that may upset him that need addressing. Regarding Keating's desire to address his offending behaviour, participation in the sex offender's treatment program has been discussed. At this stage his placement in the SHU and the length of sentence prohibits the involvement in the current residential program. However, alternative personalised programs may need to be explored. Skipping the next paragraph: Due to the complex nature of Keating's offending behaviour, underlying reason for his behaviour, propensity for calculated violence towards staff, his ability to manipulate staff and his dangerousness, the recommendation for an outside consultant is supported by Casuarina management and the assistant director, operational management. The above recommendation is no reflection on the capabilities of the current special needs team; however, Keating's offending history represents that he is a special case and requires the need of a specialist forensic psychiatrist. To this end, Dr Brian Thomas-Peter, forensic psychiatrist of Edith Cowan University, has been approached to assess and attend to Keating's counselling and, if applicable, treatment needs. Liaison could then be established with the appropriate members of the special needs team. Dr Thomas-Peter has registered his interest and formal contact is currently been initiated - and over the page, in relation to comment: The review of Keating's placement in the SHU has highlighted the need for a comprehensive review of the management regimes of the SHU - and then that review deals with a number of matters. The significance of that plan is that Dr Thomas-Peter was indeed engaged to write a report in relation to Keating and that report was received on 13 December 1993. It was a report which became for a time the template in relation to Keating's management. 2/8/05 QUINLAN, MR 974

Spark & Cannon 18-19/1/cl OIC/05 I'll take your Honour to the report now which is document 368. Can I note in relation to this that Dr Thomas-Peter who currently resides in the United Kingdom and is attached to the University of Birmingham is in fact in the state at present and will be giving evidence to the inquiry tomorrow in relation to the matter, but turning to that report, seeing on the introduction firstly, Dr Thomas-Peter commences: I have been asked to review the case of Paul Keating in respect of his treatability, dangerousness and management. I have had the opportunity to consider his prison files and speak with staff who are or have been responsible for his management. In addition I have interviewed Mr Keating at Casuarina Prison for a period of just less than two hours on 20 December 1993. In relation to presentation the introductory comments are: Mr Keating presented as a rather tense and fragile man who oscillated between tearful expressions of helplessness and anger. It was my impression that the time of my interview coincided with other events which had upset him. He had an urgent need to reveal to me the injustice of his situation in high security which he could not tolerate and that he could see no hope for the future. Mr Keating offered examples of how he had been handled unfairly, the most recent of which was his removal from a job of trust in the school. He described how he had worked hard and reliably but was removed from the position following female staff expressing some concern about his presence. This led to him feeling betrayed and angry. Two paragraphs down: He indicated that the circumstances of being in the special handling unit were such that he could readily be provoked into an explosive outburst during which he would lash out at others, forcing the authorities to kill him. It was difficult to ascertain the seriousness of these threats in view of his emotional state and history of manipulation. Dr Thomas-Peter then goes on in relation to treatability with these introductory remarks: Every therapist will consider slightly different factors when trying to determine someone's suitability for treatment. Broadly we should consider general characteristics of motivation for 2/8/05 QUINLAN, MR 975 11.46

Spark & Cannon 18-19/2/cl OIC/05 change, commitment to the therapeutic process and openness to alternative explanations of events. With sexual offenders we are concerned specifically with sexual interest, attitudes and beliefs, social functioning and patterns of emotions, thoughts and behaviours. Over the page there's a discussion of the general considerations in relation to Keating and at the end of that discussion on that page, the conclusion is: On the basis of his brief appraisal Mr Keating presents a daunting therapeutic prospect. There is always a possibility that things will change but it is my impression that his fragility, poor insight, pathological investment in control and his ingrained pattern of sexual interest which is associated with this is simply too pervasive to respond to treatment. Over the page: In relation to assessment of risk, there were several factors significant in the consideration of his dangerousness. That he has committed a number of offences of a similar kind over a very long period is a very negative prognostic factor. He is clearly fixated in his sexual interest and has been for much of his life. (b) Mr Keating views his offending behaviour as being entirely outside of his control and the causal agents of his offending behaviour being outside of him, embodied in institutions or people. He attributes to himself no responsibility for his conduct. In this sense he continues to perceive his offending behaviour as a legitimate response to adverse circumstances. (c) Mr Keating perceives the experience of his victim as being of little consequence. In other words, he displays few internal or moral constraints on future offending behaviour; (d) cognitive rehearsal of sexual assaults remains a technique by which he repairs negative moods of disappoint, frustration and anger; (e) he has demonstrated he can cultivate opportunities for sexual assault and can conceal these plans effectively; (f) finally, he appears to have no difficulty in subduing and controlling his victims to effect his intentions. In sum: there is little evidence that he has changed significantly in many years. Despite the therapeutic efforts he has received and there being long periods between offences there is no reason to think that he

2/8/05 QUINLAN, MR 976

Spark & Cannon 18-19/3/cl OIC/05 is any less likely to offend again now than at any time in the past. Then Dr Thomas-Peter comes to management and concluded: It is my view that the emphasis on treatment of Mr Keating's underlying psychopathology and offending should be replaced by the management of his immediate distress and avoiding conflict. Engaging him in treatment carries with it the prospect of him being released into the community and this creates what would appear to be an unrealistic expectation in Mr Keating which only exacerbates the problem of his management. Then he continues: (a) of central importance in this strategy is the sensitive and honest representation of his prospects for discharge to Mr Keating and the stated objective of helping him adjust to his situation. (b) he should be returned to the general population within the high security prison as soon as is practical. His psychological distress may be alleviated by being allowed to find his place within a group of his peers and establishing a routine into which he can settle. It is my impression that the intensity of the special handling unit was causing him great distress, increasing the risk of him acting out. (c) he should not be subjected to further clinical interviews implying treatment, change and discharge but should have access to the periodic, sympathetic attention of correctional staff who have established good relationships with him. The attention he demands will be more or less frequent and the members of staff will be more or less popular with him. The important point is that he is strongly motivated to have contacts among the staff and will make these contacts at his own pace. There is no need to pursue him. (d) Mr Keating is skilled in involving numerous people in his problems, causing them to feel obliged or responsible to offer help or do things for him. Ultimately this results in him being disappointed and angry, leading to confrontation. The only way to avoid this is to resist the temptation of becoming enmeshed in his concerns. The point here is that it is the process of gaining influence and control which

2/8/05 QUINLAN, MR 977

Spark & Cannon 18-19/4/cl OIC/05 is significant to him. The actual problems which he presents may well be unimportant or unresolvable. Staff should be advised that he may be disturbed by almost imperceptible or imaginary transgressions. Feeling useless and humiliated arises from a sense of being ignored, being treated unjustly or not being taken seriously and he is hypervigilant to such transgression. This is a central problem in his management, taking him sufficiently seriously to prevent him being disturbed but avoiding becoming so entangled that conflict is generated. In view of his history and what has been said in this report, it is my view that Mr Keating should not be allowed in circumstances where he could isolate a woman for the foreseeable future. Regardless of the apparent quality of the relationship he may develop with a particular female, it is insufficient to inhibit a sexual assault in the right circumstances. 6. In conclusion, Mr Keating represents a significant risk to others, particularly females and the probability of him responding to treatment of the underlying psychopathology is very low. Accordingly, the emphasis on treatment should be reduced while at the same time the importance of palliative care in reducing his distress and immediate risk of acting out should be acknowledged. I have offered some suggestions on how this might be done, including managing Keating within a general prison population and removing from him the opportunity to isolate females. That's the end of the report. The report then, the opinion offered by Dr Thomas-Peter, was that the emphasis on treatment was itself leading to unreasonable expectations on Keating's part which posed a management problem if those expectations were not met. Indeed, the likelihood of productive treatment was identified as being so low that what Dr Thomas-Peter recommends was, quote, "palliative care in reducing his distress and immediate risk of acting out." That is a management philosophy which would appear to have been adopted for some time in relation to Keating. It's an unusual management philosophy inasmuch as it would only apply to a very small number of prisoners in relation to those issues of rehabilitation and treatment. Indeed, Dr Thomas-Peter has indicated to the inquiry and will be giving evidence he had not made such a recommendation in relation to a prisoner prior to this recommendation in relation to Keating and had not made one since, so that this was a particularly unusual management problem and was quite out of the ordinary in relation to the management of a prisoner. 2/8/05 QUINLAN, MR 978

Spark & Cannon 18-19/5/cl OIC/05 As will be seen, however, Dr Thomas-Peter did recommend that Keating come out of the special handling unit and there be attempts to integrate him into the general prison population. The first response to that report from Dr Thomas-Peter is contained in a management plan for Keating, document 369, from the clinical psychologist and coordinator of the special needs team. It summarises the points in Dr Thomas-Peter's report and continues at the bottom of the first page: I also note that Dr Thomas-Peter makes the recommendation that Keating should be returned to the mainstream prison population in order to alleviate Keating's psychological distress engendered by the existing special handling unit management regime. This last observation and recommendation were unexpected because during the numerous contacts I have had with Keating in the past two years, he has made it plain to me that he feels that he could not cope with the constant petty pressures and politicking to which he would be exposed in the mainstream population. In fact he was initially most reluctant to end his prolonged solitary confinement in section 43. Over the page: In any event, Keating has now settled in the special handling unit and has expressed a clear preference to remain there. Moreover, he continues to be a danger to women and he cannot readily be kept separate from female staff in the general prison. Therefore, it is my view that any attempt to return Mr Keating to the mainstream prison population within the foreseeable future would be unwarranted and possibly precipitous. Thus, with the exception of the suggestion that Keating be returned to the general population it is here recommended that the advice provided by Dr Thomas-Peter be adopted and incorporated into the management plan previously prepared by Mr Northcott. The central aim should be to assist Keating to serve his sentence in the least unsettling manner possible whilst maintaining frank and unambiguous communications with him.

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Spark & Cannon 20/1/slh OIC/05 So that at that stage the clear philosophy in relation to his treatment was managing his immediate needs, avoiding conflict and avoiding distress without holding out the prospect of therapeutic change leading towards release. He continued to stay within the special handling unit throughout 1995 and into 1996. There are various reports - incident reports in relation to his behaviour in the special handling unit, some of which clearly suggested a deterioration in his condition; document 370, for example, a report on 18 September 1996. One of the officers reported - and it starts on page 2 of the document: On Wednesday, 18 September 1996, in my capacity as senior officer special handling unit, at approximately 1330 I was confronted by prisoner Keating who appeared in an aggressive and agitated state. He repeated his usual verbal repertoire re his placement in the SHU and his possible transfer to Albany Prison. He continued, "You people talk about change but nothing ever happens. If you people want war you will get war. If it's against khaki so be it." He went for long pauses just staring at me, his face ashen in frustration. I told him that I hear what he's saying and walked away. A few minutes later he requested to see me. I told the control officer to tell Keating to come to my office. The control officer - going to page 1 of the document - observed Keating rush down to the rear workshop and grab something and put it in his pocket. He hesitantly came back into the day room and came to my office. He asked me what was going on. I asked him what he meant. He replied, "I know recovery is outside. If you're going to pluck me and put me over this side I have McCole's letter in my pocket and I'll be getting in touch with him straightaway if you do." I told him that this was not going to happen at the present time and he eventually calmed down. During the confrontation in the day room I had concerns that Keating would strike me. I also have concerns that Keating is deteriorating. The unit staff have been advised of the incident and threats made and have been advised to use caution with Keating. About a week later there was a report made by an officer, which is page 3 of this document, on 26 September 1996:

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Spark & Cannon 20/2/slh OIC/05 Keating is displaying signs of a recluse. Staff of the SHU note he rarely leaves his cell before the other inmates whereas he was always first to rise, breakfast and move into the leather workshop. Keating sits apart from the rest and would appear not to invite company. Prisons Schulz and Napier both claim to staff that Keating has "lost it" and they are very wary of him. Keating has stated in the past and present to both staff and prisoners he will end it all if the opportunity arises and relates how he will kill a hostage and expects the MSU to shoot him as he himself will not suicide. Obviously something had to be done in relation to his management within the special handling unit. A further report was commissioned - an independent report was commissioned and received by Dr Kevin Howells, an assessment report in relation to Keating, which is document 371. This report on the second page under Information Sources for Present Assessment says: I was able to read a large number of previous reports and other documents contained in Ministry of Justice files. I interviewed Keating for a total of four to five hours over late August and early September 1996 at the special handling unit. I interviewed staff about their observations of his behaviour within the SHU. I also interviewed Mr David Wiener from the sex offender treatment unit about previous assessments at the unit. In addition Mr Keating completed the following psychometric tests - and those tests are all there to be identified: Presentation at Interview: Mr Keating cooperated fully with the interviews and psychometric assessments. His affect was variable within and between sessions. He was sometimes distressed and tearful about being at the end of his tether. At other times he was angry and resentful about his bad treatment by the "system." His thought processes, mood and general presentation did not suggest major mental disorder. The conclusions that were reached by Dr Howells appear on page 10 of the report. A number of the conclusions are consistent with the conclusions which have been reached in the past. The first is: The information collected for this report is not consistent with the presence of clinically significant psychiatric disorder. Mr Keating's

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Spark & Cannon 20/3/slh OIC/05 problems are better understood as being the result of a specific form of sexual deviation rather than of a mental illness.

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Spark & Cannon 21/1/nal OIC/05 (2) he shows a range of longstanding personality problems. (3) he appears to achieve a period of stability during his time in the SHU and to have formed good relationships with the staff. He has also maintained and developed his leather work as a way of coping with the SHU environment. He currently reports high levels of stress, tension and despondency at the prospect of an indefinite stay in the same environment. (4) Mr Keating's previous behaviour clearly puts him in the category of high risk for sexual assault. The frequency of previous sexual assaults, the occurrence of assaults within a restricted prison environment, the rapidity with which he offended during escapes and his use of a weapon during offences all confirm his risk status. (5) a previous report by Dr Brian Thomas-Peter suggested that Mr Keating be returned to the mainstream of the prison in order to prevent acting out and deterioration as a result of his failure to deal with the intensity of the SHU environment in the long term. I support the principle of this recommendation. To minimise the risks in transfer to the mainstream however, certain safeguards should be applied. Any transfer would need to be graduated and progressive, a principle endorsed by the new ministry guidelines for the SHU. A series of steps would need to be specified with progression along the steps depending on Mr Keating making adequate progress and coping with problems that might arise. Any plan would need to allow for return to the SHU should major problems arise. (6) Dr Thomas-Peter also recommended that Mr Keating not be offered treatment for his sexual deviance on the grounds of his poor insight, need for control and his ingrained pattern of sexual deviance. He added that treatment might suggest an unrealistic prospect of being released into the community. Many of this points are valid and I would agree with the conclusion offered by Dr Thomas-Peter that sensitive and honest representation of his prospects for discharge should be part of his management plan. On the other hand, the current assessment does show some areas in which treatment gains could be made, for example, the offending cycle, anger management, cognitive distortions, poor sexual knowledge. If he were to be considered for return to mainstream then it would be sensible for him to undergo any treatment which might reduce his risk. I recommend that the 2/8/05 QUINLAN, MR 983 12.29

Spark & Cannon 21/2/nal OIC/05 sex offender treatment unit be requested to assess the feasibility of including Mr Keating in a future program. And this is of significance: The purpose of the program would be to provide him with the assistance necessary to reduce his risk of reoffending within the prison environment. Satisfactory progress on the program would be a precondition for reintegration back into the mainstream. As is clear from that report it reaches a similar conclusion in relation to Dr Thomas-Peter as to the prospects of long-term change to Keating's offending behaviour and the fact that treatment might suggest an unrealistic prospect of being released into the community. It's clear, in my submission, from the content of that report that the purpose for the recommendation of the sex offender treatment program is for the purpose of facilitating Keating's return into the mainstream. As recommended by Dr Howells, an assessment was done by the sex offender treatment unit on 6 November 1996, document 372. Towards the bottom of that page in the middle of the second - in the middle of the last paragraph it's stated: There is no doubt that Mr Keating represents an extremely high risk of reoffending; the basis of this risk assessment being his history to date. However, an opportunity to engage in sex offender treatment may reduce his risk as opposed to no treatment at all, which places the community in danger upon Keating's eventual release. The issue of Mr Keating's risk of further attacks upon female prison staff should he leave the special handling unit must be considered a priority. Strict conditions must be set in place to ensure that Mr Keating does not find himself alone with any female staff. In recommending Mr Keating for inclusion in the intensive sex offender treatment program I am of the opinion that his behaviour can be more closely monitored by his participation in the residential program at Casuarina Prison. Strict limits must be imposed with regard to his ability to move about the prison freely and further, any female co-facilitator must be vigilant about not allowing a situation to develop where she finds herself alone with Mr Keating. And the last paragraph: As such, I recommend Mr Keating's inclusion in the next intensive residential sex offender treatment program at Casuarina. Despite this being 2/8/05 QUINLAN, MR 984

Spark & Cannon 21/3/nal OIC/05 significantly earlier than his eventual release date his offending behaviour within the prison warrants his early admittance, however it is imperative that Mr Keating be closely monitored throughout the treatment program and his release from the special handling unit into either mainstream or protection. A period of time in protection at another prison, such as Albany, may be an option considered to monitor Mr Keating's behaviour prior to his inclusion in the sex offender treatment program. There was a management meeting in relation to Keating on 12 March 1997 and document 373, a report given from the assistant superintendent operations to the superintendent of the prison on 8 April 1997.

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Spark & Cannon 22/1/mjd OIC/05 That report states: As you will recall on 11 March 1997, we met with Mr Peter Upton-Davis, manager SOP, Ms Jackie Tang assistant director prisoner management and Ms Cinzia Zuin SOP to discuss Keating's ongoing management. Keating had an expectation after meeting with and correspondence from former director general Mike McCall that he would soon be mainstreamed and this, we agreed, was quite unacceptable until steps had been taken towards counselling and a graduated return to mainstream. Mr Upton-Davis agreed that the reintegration was necessary and Ms Zuin offered to commence regular therapeutic counselling and prepare Keating for possible inclusion on the SOP scheduled for December 1997. Down the paragraph the next paragraph - I won't mention the name of the counsellor who is there referred to because of what occurs later on in the evidence, suffice it to say - a counsellor of the SOP agreed to take over Ms Zuin's role in counselling and recently commenced seeing Keating on a weekly basis. So again, preparation was occurring in relation to Keating being reintegrated back into mainstream. He commenced individual therapy with a psychologist on 26 March 1997 and from his assessment a treatment and management plan was formulated in conjunction with prison management and health services and endorsed by the director general. The focus of the sessions was to explore his offending behaviour with a view to him acquiring awareness of his high risk situations and from there to develop appropriate relapse prevention strategies to avoid reoffending. There was then on 28 April 1997 correspondence for the superintendent forwarded to the director of prison management regarding his placement in the special handling unit. The superintendent Mr Connolly stated: The long term placement in the special handling unit was having a detrimental effect on Keating's state of mind. It was recommended that Keating have access to recreational mainstream activities in a controlled area outside the confines of the special handling unit as detailed in recommendation 6 of the policy and practices review of the special handling unit. 2/8/05 QUINLAN, MR 986 12.35

Spark & Cannon 22/2/mjd OIC/05 It was thought this may assist in his long-term management and may in some ways address his offending behaviour. It was also noted that the prison psychologist was now counselling Keating on a weekly basis and there was a placement available in December 1997 to the residential sex offenders treatment program. There was a memorandum from the counsellor to the assistant superintendent prisoner management dated 1 May 1997 which is document 376 and it states: During a therapy session with Mr Keating on Wednesday, 30 April 1997 it became apparent that he is becoming increasingly resentful and agitated in his current environment. This emotional state is linked with what he sees to be a lack of progress and commitment to have him removed from the SHU. While these issues are an ongoing focus of therapy it is important that he see a demonstrated commitment from the prison system. It would appear Mr Keating is experiencing similar emotions and perceptions that have preceded his assaultive behaviour in the past. Hence, I am concerned about the possible risk of Mr Keating acting out. To his credit Mr Keating has committed himself to the therapeutic process and has undertaken all tasks assigned as well as completed a great deal of work of his own volition. Notwithstanding his commitment, he is becoming increasingly disillusioned with the prospect of ever being returned to mainstream and he is therefore somewhat reticent to continue with therapy as he is under the impression that at some point therapeutic services will be ceased without warning. It is my belief that treatment gains can be made with Keating, however, it is imperative that he be given some concrete signs that efforts are made to reintegrate him into the mainstream. So again, the focus which is apparent at that time is the reintegration of Keating into mainstream. On 12 May that year he received the approval to participate in recreational activities outside of the special handling unit in accordance with the recommendation that had been made. On 12 June 1997, as a result of case conference it was recommended that he remain maximum security and to facilitate his special handling unit placement it was recommended that he remain in Casuarina Prison. On 29 June 1997, a report by a senior consultant forensic psychiatrist recommended that he be involved in a rehabilitative management plan and in view of his stable

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Spark & Cannon 22/3/mjd OIC/05 mental state should be subjected to escorted outings on the oval on a regular basis with a view to expose him once again on a graduated basis to mainstream eventually. From a psychiatric point of view, his mental state was identified as stable.

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Spark & Cannon 23/1/glj OIC/05 A management plan was prepared for him on 3 July 1997 - which is document 380. That management plan identifies immediate measures, medium measures and long-term measures. The immediate measures were to continue the regular sessions twice weekly with the psychologist from the sex offender treatment unit. In the medium term, that was September 1997 to June 1998, that he participate in pretreatment interview to confirm eligibility and willingness to participate in the sex offenders treatment program and the transfer from the SHU to the residential program, and from June 1998 and beyond to ensure that he sustains progress in the gains. When it was agreed that he would be put in the sex offender treatment program, a management plan was identified in relation to him and forwarded by Mr Peter Upton Davis. the manager of the sex offender treatment unit. This is document 381 and it's dated 3 August 1997. Preamble: Mr Keating has been listed to participate in a nine-month treatment program commencing September 1997 - and then significantly under the Basis for Program Participation: The case manager for this process is the superintendent or nominated delegate of Casuarina Prison. Sex offender treatment program will provide a program aimed at reducing the risk of reoffending. There are no absolutes, guarantees or cures. Any reduction in the propensity to offend will in all probability be marginal. The purpose of participating in a treatment program is to reduce the risk of reoffending in order to maximise his chances of being released back into mainstream prison. Progress into prison mainstream would be subject to ongoing assessment that he does not pose a high risk to the safety to himself or to prison staff. Staff safety will be a key issue in determining both the initial and ongoing program participation. Program integrity will not be compromised. There's a note, "The program is designed to be a prerelease program which provides skills and strategies relevant to life outside prison," and a caution noted, "These skills and strategies used inside a prison setting 2/8/05 QUINLAN, MR 989 12.41

Spark & Cannon 23/2/glj OIC/05 may in fact be counterproductive," so that attention needed to be given to that given the purpose of the program in relation to Keating. The final part of that letter, on the second page, stated: The issues in this case highlight the need for an accepted policy on program participation to be determined as soon as possible. Currently no policy, only locally-developed practices, exist with regard to program participation. While Mr Keating is an exceptional and dangerous case, there are other sexual and violent offenders who are approaching his notoriety in terms of levels of dangerousness. So again, at that point the purpose for the attendance in the sex offenders treatment program was that which had been identified by Dr Howells, which was the reintegration into mainstream. Following extensive individual counselling with the prison psychologist referred to earlier, Keating joined the residential sex offenders treatment program at Casuarina Prison on 9 September 1997. Keating did not successfully complete the program at that time due to an incident which occurred on 14 January 1998. According to an incident report made by the psychologist with whom Keating had done the individual counselling prior to the sex offender treatment program, there was an incident involving a verbal interaction between that facilitator and Keating. If we can go to document 383, and I should say, sir, in relation to this particular incident, albeit that it did not result in a prison charge, I would seek that there be an order that the name of the psychologist involved not be the subject of publication; an order under section 13 of the Public Sector Management Act, due to the sensitivity of the information which arises in relation to it. MAHONEY, MR: I have power to make that order, do I? QUINLAN, MR: Yes. Well, the power under section 13 of the Public Sector Management Act is to make any directions in relation to the conduct of the inquiry, not specifically provided for in the act, and given that there's no requirement to sit in public sittings in any event it would seem to be broad enough, in my submission, to prohibit such an order - such a disclosure. MAHONEY, MR: What precisely would be the order? QUINLAN, MR: The order would be that the name of the prison psychologist involved in the incident of 14 January 1998 not be identified, or information in relation to that that would enable the identification of that person not be identified.

2/8/05 QUINLAN, MR 990

Spark & Cannon 24/1/nal OIC/05 MAHONEY, MR: Yes, all right. I will make that order then. QUINLAN, MR: Please you, sir. The incident report - - - MAHONEY, MR: I have in mind what I have seen myself in relation to the documentation and I think it is appropriate that the order be made. QUINLAN, MR: If it please you, sir. Page 3 of the document is the incident report itself from Wednesday, 14 January 1998 concerning an incident with regard to prisoner Keating, Paul: Background. Following conclusion of the morning session of the sex offender program group Keating approached myself as I was leaving the group room and asked if he could see me before I went to lunch. I asked him if it was possible to wait until after lunch because it was quite late. I walked towards the office door leading to the outside of the unit. Keating seemed to indicate that it would be appropriate to wait, however before I could get to the door Keating decided to tell me why it was he wanted to see me. From here he went on to say that following a disclosure in group this morning that at approximately 10.30 pm last evening, 13 January, that the reason he had become so angry was because he had thought about and for some time had targeted myself as a victim for his offending. He revealed that he had long been thinking about taking me hostage, kidnapping me and subjecting me and subjecting me to endless periods of torture, mutilation and degradation. He went on to say that if I knew him as well as he thinks I did that I would have known that I was the target of his behaviours because he did not feel anything towards - there's reference to other psychologists - who run the other programs. He impressed upon me that I would be his sole target and that I knew this. He further impressed upon me and stated that I also knew that should he act out again that he would kill that person and he reiterated that I would know that he would kill me. Keating was challenged by me and told that they were indeed an offending fantasy and offending thoughts and he seemed surprised and unwilling to acknowledge that. I also raised with him the need for this to brought up in group, which he was extremely resistant to do and became angry about, however I impressed that this needed to be dealt with immediately. 2/8/05 QUINLAN, MR 991 12.47

Spark & Cannon 24/2/nal OIC/05 Further, he went on to say that he was unsure what would have happened if these thoughts in their intensity had not occurred when he was locked up in his cell at night and that I would be vulnerable - they were not his words; he used another term - if they occurred during the course of the day or when I was present and he expressed concern that he would act on these and carry out his fantasy. While Keating was telling me this he was looking directly at me and was saying it seemingly without feeling or any thought for the consequences of how I would feel for his revealing this to me. Following this I approached the other psychologist, who is the facilitator, and I said we would need to go now and we returned to our room. I felt threatened and intimidated by Keating and I also felt and had felt for some time that he was building to an offence and following a brief discussion we approached Mr Bob Jennings, who was assistant superintendent of operations at Casuarina. Action was then taken to remove Keating from SOTP. The letter to the executive director, which is page 1 of that document from the superintendent of Casuarina Prison from the following day confirms that: At approximately 1330 hours SOTP staff requested to see Mr Jennings. It was evident on their arrival at his office that the psychologist was in an extremely distressed state. The psychologist's trauma emanated from a verbal interaction that had just taken place between herself with Keating. The attached preliminary report from Ms X outlines the basics of the conversation. A verbatim report will be provided by Ms X at an appropriate time. Both facilitators are extremely professional staff who have handled the highly complex task of engaging in treatment with disturbed individuals such as Keating in an objective and judicious manner giving appropriate consideration to their own and others safety. For Keating's conversation to have intimidated the psychologist to such a degree illustrates the seriousness of the situation. While no physical act took place it is clear that Keating crossed the boundary of what may be acceptable when professionally managed in treatment to a situation where a victim was in danger. The staff involved did not consider his actions were disclosure as part of a treatment but clearly a threat to her personal safety and a statement of intent. Keating was immediately removed from the area without incident. It is of note that prior to leaving he requested of Mr Hide, assistant 2/8/05 QUINLAN, MR 992

Spark & Cannon 24/3/nal OIC/05 superintendent incident management, that he be allowed to address the group. Mr Hide gave permission and Keating informed his peers that his removal was a result of his own inappropriate actions and that the two psychologists were in no way responsible. Keating has been interviewed by the forensic case management team. He is currently located in the IOU area under section 36 of the Prisons Act. Staff from the sex offender treatment program were debriefed following this incident and the psychologist has been seen by a trauma counsellor from Prime. That incident which occurred in January 1998 is of some significance in relation to the follow-up management of Keating because other than those two documents and an incident report, which appears in the intelligence section there does not appear to be any other documentation available in relation to the follow-up concerning - from a management point of view concerning those offences.

2/8/05 QUINLAN, MR 993

Spark & Cannon 25/1/slh OIC/05 No prison charge was ever raised in relation to the matter and other than references in the later psychological reports, to which I will turn after lunch, there is no other action taken in relation to that particular matter, nor, subject to one exception, does it appear in relation to the classification reviews that occurred in relation to Keating. In this regard it is not clear whether there are other documents in relation to the matter which might have been available, as has occurred in the case of Cross, it is apparent, and there will be evidence that there are files in relation to Keating that the inquiry has not been able to access and they have not been found by the Department of Justice, including an assessment file and his unit files which might have shed more light in relation to the matter. MAHONEY, MR: Why have these not been available? QUINLAN, MR: They have not been found. In blunt terms they are missing and have not been located. There have been inquiries by the Department of Justice to try and find the files and in addition there have been internal investigation unit investigations into the fact that they cannot be located. Detective Sergeant Saunders who will be giving evidence can provide the correspondence with the department to find that material. Further inquiries may be continuing in relation to that but suffice it to say that that incident in January 1998 which precipitated his removed from the sex offender treatment program does not appear to have precipitated any other matter in - any other result in terms of prison charges or matters of that kind. That is perhaps a convenient point for me to leave it for the luncheon break and then I can turn to what occurred after that in 1998 up until the recent time following lunch. MAHONEY, MR: Perhaps you might be able to let me know in due course what is the present position in relation to the missing files because those files will obviously be of significance in relation to a matter as important as this. QUINLAN, MR: Yes, well, in that regard we have arranged for an officer who is attached to the inquiry coordination unit within the department to be available to give evidence as to what steps have been taken. As we have said in relation to Cross, it is not possible to say whether there would be material on those files which would be of assistance. All that is possible to say is that there are files which were in existence which cannot now be located. MAHONEY, MR: This is the position then obtaining both in relation to Cross and in relation to Keating. QUINLAN, MR: Yes.

2/8/05 QUINLAN, MR 994 12.53

Spark & Cannon 25/2/slh OIC/05 MAHONEY, MR: Yes, all right. It's nearly 1 o'clock. We will resume at 2 o'clock. QUINLAN, MR: Yes, if it please. (Luncheon adjournment)

2/8/05 QUINLAN, MR 995

Spark & Cannon 26/1/cl OIC/05 MAHONEY, MR: Yes, Mr Quinlan? QUINLAN, MR: Yes, if it please you, sir. I have reached the point in the chronology when Mr Keating was taken off the sex offenders treatment program in January 1998. MAHONEY, MR: Yes. QUINLAN, MR: What then occurred was that he as returned initially I think to the induction and orientation unit or what's sometimes called the multipurpose unit. His first contacts were with persons attached to the forensic case management team. Just to put that in context, the sex offenders treatment program is being operated by the program's division of the department. It in a sense is autonomous and comes into prisons to do the programs and isn't fully integrated at the site level with the prison. The forensic case management team which was formerly referred to as the special needs team and is now referred to as the prison counselling service consists of the on-site counsellors within a prison to provide counselling, particularly at risk counselling in relation to individual prisoners and consists both of psychologists and social workers as part of its team, and it happens from time to time that staff might move from one division to the other. Indeed, the psychologist in relation to whom the incident on 14 January 1998 occurred, later on in her working career with the Department of Justice moved into that forensic case management team and, if you like, developed a different perspective on the integration of that team with the prison management, but the immediate response after Keating was taken off the sex offenders treatment program was that he had intervention commenced with the forensic case management team as opposed to the program's branch and the sex offenders treatment unit. So there was a case management meeting at which various people attended and a new plan devised in relation to Keating. The first indications of that, at least that are available in writing, are a memorandum document 385 of 18 May 1998: The following are recommendations of the case management meeting held at Casuarina to discuss prisoner Keating. In attendance at this meeting were Dr Hodgkinson, Dr Pullela, Tim Connelly, Dave Hide, Sunny Gianatti and Glenn Ross. They are variously medical practitioners. Dr Pullela is a consultant psychiatrist. Mr Connelly was the superintendent at Casuarina. Mr Hide was assistant superintendent or a manager at any rate at Casuarina. Mr Gianatti was a psychologist with the forensic case 2/8/05 QUINLAN, MR 996 1.57

Spark & Cannon 26/2/cl OIC/05 management team and Mr Ross was the manager of the forensic case management team: The meeting was held to develop a management plan for Keating, made necessary by his being withdrawn from the sex offenders treatment program. The outcome of this meeting is the following management plan. One can see in the short term the management was to be moved to the ordinary side of the IOU. That requires some explanation. The IOU which is induction and orientation unit at Casuarina Prison is also, as I said, referred to as the multipurpose units. It was originally intended to be an induction and orientation unit and it is housed close to reception at Casuarina Prison. In fact the uses that it is for - there are a number of them. One side of the unit is a very close supervision strict regime unit that is used for punishment and for section 43 prisoners. So that a prisoner, such as Mr Keating was, on section 43 confinement, segregation was moved to one side of the induction orientation unit. The other side is used in a sense as an intense protection unit, so a protection unit of greater security than the other unit at Casuarina which I think from memory is unit 6 which is a protection unit for disturbed and/or vulnerable prisoners. So the intention there was to move Keating to the ordinary side which I take to mean the side of the induction and orientation unit which was not the punishment segregation side but the high level protection side, and he was to continue work with Ms Gianatti, who was the psychologist from the forensic case management team, with a view to completing the elements of the sex offender treatment program, and then the medium-term plan was the transfer out of Casuarina to Albany for a fresh start and a longer-term plan was transfer to Bunbury as per a sentence plan. That refers to an earlier sentence plan in 1997.

2/8/05 QUINLAN, MR 997

Spark & Cannon 27/1/slh OIC/05 It's at this point that Keating's - from 1998 onwards that his management becomes particularly intense in the sense that it continues to build and bring more and more people into it and gives rise to more and more correspondence in relation to his progression through the system. It began with Ms Gianatti beginning one-on-one counselling with Keating in March of 1997. That was originally on a weekly basis for half a day a week. After that meeting with the forensic case management team in May a management plan was developed by Ms Gianatti. This is document 497. This is to those other attendees at the meeting referred to: As recommended at the case management meeting a treatment plan for Mr Keating has been formulated. I would appreciate comment on the overall plan plus some recommendations will require approval and feedback from prison management. The plan which - then continues: The therapeutic environment: to maximise treatment gains, the individual needs and environment that promotes physical and emotional safety - et cetera. Under Assessment it says - this is, you will recall, in May: I have been unable to locate a report from SOTU - sex offender treatment unit - commenting on the reasons for Mr Keating's removal, what facets of the treatment program he had completed and a general comment on his progress to the point of his removal. The administration from SOTU said a report may be available in a few weeks. It is correct to say that there was not a final treatment report in relation to the sex offender treatment unit until the following month, but certainly in terms of the reasons for Keating's removal would appear fairly clear from that incident report of the psychologist. It's not clear whether Ms Gianatti had that available to her but the therapeutic issues which continue later on that page - it says: (1) as noted in the draft treatment plan, mixed messages as to being accommodated in the special handling unit and the negative aspects associated with the unit; (2) Mr Keating's concerns that the proposed individual counselling will not be recognised by the Parole Board.

2/8/05 QUINLAN, MR 998 2.03

Spark & Cannon 27/2/slh OIC/05 What is notable about that is that the reference to the Parole Board can obviously only be a reference to prerelease planning of some form and it shows - as I said in opening earlier today, things tended to happy by entropy rather than direct decision but this is the first sign of a shift towards the philosophy behind his management preceding 1998; that is, palliative care and integration back into mainstream, towards Mr Keating again moving on the road towards release and the Parole Board and matters of that kind. It's notable because one has to keep in mind in relation to those types of movement on his part the management concerns raised by Dr Thomas-Peter in his report of late 1993 in terms of the potential for that kind of movement to increase expectations and exacerbate the management problems at a later point in time. Then there was a discussion of sex offender - general sex offender treatment goals. This is over the page. The goals are identified and Ms Gianatti refers to, since her involvement with Mr Keating in one-on-one counselling, the gains that she perceived had been made: (3) to recognise when risk is imminent and be able to deviate himself away from potential offence by implementing a plan strategy of appropriate and socially acceptable behaviour. The comment there is: It would seem that Mr Keating implemented one of his coping strategies by disclosing his fantasies in an attempt to take away the potency of his thoughts and thus minimise the risk of acting out. That at least on the face of it appears to be a reference to the incident of 14 January 1998, although - and perhaps with hindsight it's easy to see these movements but it appears to represent a shift away from what was stated at the time by the superintendent, that the events involving the psychologist - I will make sure I've got the quote right: The staff did not consider his actions were disclosure as part of treatment but clearly a threat to her personal safety and a statement of intent.

2/8/05 QUINLAN, MR 999

Spark & Cannon 28/1/mjd OIC/05 If that is a reference to the same incident it represents a shift in the approach to what had occurred on that occasion. There's other references in that report to the kids of actions which were being undertaken. On the second-last page of that report under Ongoing Relationships, the last paragraph there: It has been my experience that staff in the IOU demonstrate professional and supportive behaviour toward Mr Keating and other inmates. As SOTU officers provide an essential and valuable role in the treatment process it is proposed that with prison management support that identified officers may also play a similar role. Under Time Frame: Mr Keating is highly motivated to undertake treatment. I have undertaken to commit at least one half day a week to his treatment needs. This will mean that much of Mr Keating's work will be self-motivated and will take the form of journal writing and personal work. This time frame will be reviewed. MAHONEY, MR: Just pausing there. I notice a little higher up in that memorandum reference is made to the Outreach ministries. Do I understand that be a reference to the Outreach organisation which goes into prisons ahead of release and talks to prisoners about the provision on their release of things such as work, housing and family assistance. QUINLAN, MR: I think that that certainly may be one of the functions of Outreach Services. I don't know that it's necessarily confined to that and it may simply be - and I think it is the case for example with Mr Larner who is referred to there, that it is a ministry, as it's suggested, which is outside the prison which has people making contact with prisoners just for human interaction in terms of providing visits to prisoners who otherwise would not have visits. MAHONEY, MR: I was wondering whether the fact that he was contacted by the Outreach organisation indicated the purpose of preparing him for release. QUINLAN, MR: It may do. We may have to ask Ms Gianatti about the particular role performed by Outreach on that occasion. At least in - at this stage this memorandum the move towards release, at least in the prisoner's perception, is still somewhat ambiguous. It's - I might describe it as it's inchoate expectation at this time and hasn't yet to fully materialise but it's part of the move in that direction. 2/8/05 QUINLAN, MR 1000 2.09

Spark & Cannon 28/2/mjd OIC/05 What is interesting in relation to compare in terms of those comments in the time frame: Mr Keating is highly motivated to undertake treatment. I have undertaken to commit at least one half day a week to his treatment needs. This will mean that much of Mr Keating's work will be self-motivated. Compare that to the statement made by Dr Thomas-Peter earlier that: Engaging him in treatment carries with it the prospect of him being released into the community and this creates what would appear to be an unrealistic expectation in Mr Keating which only exacerbates the problem of his management. The other comment that: Mr Keating is skilled in involving numerous people in his problems causing them to feel obliged or responsible to offer help or do things for him. Now, by drawing those distinctions I don't mean by that any criticism of the practitioner who is undergoing the treatment at this but simply flag the caution with which issues of treatment had been identified in relation to Keating before and what might need to be the approach that's taken in terms of his ongoing plans.

2/8/05 QUINLAN, MR 1001

Spark & Cannon 29/1/cl OIC/05 There was then correspondence to the superintendent in relation to the proposed management plan which is document 387, which shows that in relation to Keating a commitment was made by the executive director offender management to the Ombudsman, that the management and placement of a select number of high risk prisoners would be the subject of decision at the highest levels of the offender management division: I have discussed this matter with the executive director offender management. We will consider a recommendation of a committee comprising the superintendent, director prison operations, assistant director prison management, senior forensic psychiatrist, health services representative and the director of policy, programs and requests. So we can see here coming into gear the high level committee which is proposed which ultimately, as can be seen from the next document, 388, at that time was referred to, if we look at the second page, "manager meeting, high profile prisoner, Prisoner Keating," and we can see the range of people attending that. It's not the same committee but it's this kind of committee which ultimately is reflected in the serious offenders management committee which is formed at a later time. As a result of their meetings it was proposed: Keating remain security, is placed in a standard cell in the induction and orientation unit, and that the counselling with Ms Gianatti continued to be assessed by the sex offender treatment unit in regard to programs. At around that time I should say to fill in the picture the treatment report from the sex offenders treatment unit was received, which is document 384, which is cosigned by the psychologist involved in the incident on 14 January and with Ms Shires, the senior programs officer. In terms of parts of the report if we look at page 4 - or page 3, sorry: On 5 December 1997 - I will refer to the psychologist as Ms X when I'm reading from it - Ms X had a conversation with Mr Keating at his request. During this conversation he revealed that he was upset that he no longer had one-to-one counselling. He felt it was unfair and that he was being treated differently to other group members. Several other men were having individual counselling with program facilitators. It was explained to Mr Keating that if he needed one-to-one counselling, 2/8/05 QUINLAN, MR 1002 2.14

Spark & Cannon 29/2/cl OIC/05 appropriate security arrangements could be made to facilitate. The next paragraph: During the course of this conversation Mr Keating became aggressive in his demeanour, threatening to Ms X. The conversation was terminated and Mr Davies, Mr Vaughan, Mr Hide and Mr Brennand were informed of the incident. Mr Hide provided the facilitators with an intel file on Mr Keating which contained a detailed offence cycle that documents six phases or stages of Mr Keating's assaultative behaviour. That's the document that I referred to earlier with the circular offence cycle in it: With this information, it was apparent that Mr Keating was moving through the stages of his offence cycle. The next paragraph: Mr Hide agreed that what was being described was indicative of Mr Keating's past behaviours and further informed us that in a single day Mr Keating has been known to pass through many phases of his cycle. Over the page: Mr Keating again asked to have one-to-one counselling. He claimed he was having problems disclosing in group. Then towards the end of that paragraph: Mr Keating was advised that Ms Shires would commence individual work with him once he returned to the group. Mr Keating was clearly unhappy with the situation, preferring to work with Ms X. It was explained to Mr Keating that Ms Shires had worked for SARC in Geraldton for many years and was, therefore, more experienced in his area of need. Less than a week after the above incidents Mr Keating approached Ms X and asked to see her. He was advised that she would see him immediately after lunch. Mr Keating became agitated and impressed a need to speak immediately. A conversation was then had with Mr Keating in front of the office in the residential area of the SOP. Mr Keating disclosed that he had been planning to take Ms X hostage and subject her to hours of brutality and assault. He further claimed that he wanted to inflict maximum 2/8/05 QUINLAN, MR 1003

Spark & Cannon 29/3/cl OIC/05 pain by cutting her up slowly with a view to killing her. He claimed that he wanted to do with because he was angry. He also stated that had she been in the unit the previous day, he would have carried out his plan. Mr Keating stated that he wanted to work through his fantasy. In spite of being shocked and horrified, Mr Keating was confronted by Ms X over his fantasy, planning and targeting of a victim. Mr Keating, however, was not able to see that this was part of his offending cycle. Next paragraph: It was fortunate that on this occasion Mr Keating chose to inform his intended victim of what he had been fantasising and planning. In the past he has been able to conceal his plans and act out seemingly without warning. Whilst he has been able to conceal his plans previously, it has been obvious after the event that he has been building to an offence. On this occasion the communication sharing between administration and facilitators of the SOTU were vital in ensuring the incident did not eventuate into something far more serious than threats and statements of intent.

2/8/05 QUINLAN, MR 1004

Spark & Cannon 30/1/nal OIC/05 It was fortunate that the facilitators and administration were aware that Mr Keating appeared to be entrenched in his assault cycle and hence the necessary precautions of not placing oneself in vulnerable positions were followed. MAHONEY, MR: This was the second occasion in which he had indulged this fantasy, was it? QUINLAN, MR: No, this is the report of the first occasion, which ultimately was produced in June. Of concern is the fact that even though it was apparent Mr Keating was engaging in pre-assaultive behaviour he denied having been fantasising, planning or targeting a victim. He had been asked these questions repeatedly throughout the four months he was in group treatment. Mr Keating's deliberate omission of important information is not seen as a good indicator of future openness and honesty. Had he been prepared to disclose earlier and in a more appropriate manner a different outcome may have been possible. And over the page under the heading Recommendations: Due to his early removal from treatment and the reasons for his removal Mr Keating is not considered to have successfully completed the treatment. He is therefore not considered to have addressed his offending behaviour. It is the opinion of the sex offender treatment unit that he continues to present and extreme risk of reoffending in a like manner in the future. It is suggested that in future Mr Keating be exposed to a range of psychologists or allied health professionals. His lack of relationships with others and limited contact with people on a large scale throughout his life has resulted in him developing a faulty attachment style that is maintained through cognitive distortion. Engaging with a range of people in developing appropriate relationships with many individuals may help lessen his inclination to attach to and idealise single individuals. This may in turn ensure that people who work with Mr Keating are at less risk. Now, the one-on-one counselling with Ms Gianatti continued through 1998 and an interim report was given on 29 November 1998 - this is document 389. This begins: Reasons for Removal. After his removal from SOTU Mr Keating did not receive any form of debriefing, closure or supportive counselling from professionals 2/8/05 QUINLAN, MR 1005 2.20

Spark & Cannon 30/2/nal OIC/05 within the Ministry of Justice. Prison management provided a supportive role. Mr Keating was referred to myself after an unsuccessful attempt had been made to provide him with a male therapist from outside the ministry. Issues re Management Plan - and number 2, again I would note - number 1 firstly: Mr Keating continues to engage in treatment and maintain his treatment gains, however recognition of change needs to be considered by putting in place procedures where Mr Keating can be afforded the same consideration as other prisoners. Sex offender treatment that is being provided currently to be clarified and recognised in some formal notation by SOTU, prison management and the Parole Board. Again, this is representing that gradual shift, although not an explicit decision being made, away from the approach recommended by Dr Thomas-Peter towards an approached directed at change, the Parole Board et cetera. At the bottom of that page: After his removal from SOTU Mr Keating did not receive follow-up or closure that in the past is afforded to all individuals who are removed from a treatment program to ensure they are stabilised and psychologically intact. Over the page: After his removal from the program Mr Keating made an extremely serious suicide attempt. I believe that it was only because of the interventions made by prison management, David Hide, officers in IOU, that he did not make further attempts. Can I say in this regard, sir, that the inquiry has endeavoured to identify the circumstances of that what's described as extremely serious suicide attempt and can find no record in the prison files or management files of any such suicide attempt, so the nature of it hasn't been identified. Whether or not it's referred to in any of the missing files is unknown. The document then continues by addressing what are described as treatment gains in relation to Mr Keating and indeed when one looks at the sex offender treatment goals on almost all of them there are reports given - this is on the bottom of that page to the first one - which suggest positive gains in his treatment. So, for example, the first is in relation to take responsibility fully for his deviant behaviour: Since my involvement with Keating I have found at no time has he attempted to minimise of justify any of his sexual offending.

2/8/05 QUINLAN, MR 1006

Spark & Cannon 30/3/nal OIC/05 Over the page: At no time has there been any deviation from this stance. (2) develop an understanding of the antecedents of the assaultive behaviour. Mr Keating has a sophisticated understanding of high risk situations and good insight into his past offending cycle to recognise when risk is imminent and be able to deviate himself.

2/8/05 QUINLAN, MR 1007

Spark & Cannon 31/1/glj OIC/05 This is, again, where it would seem Mr Keating implemented one of his coping strategies by disclosing his fantasies in an attempt to take away the potency of his thoughts and thus minimise acting out. There's an addition in this one: Mr Keating maintains that at no time was his therapist or anyone else at risk of physical or sexual assault. He states that his work on changing his cognitions prior to and in one-on-one therapy with Ms X was firmly in place. He commented that it was only in the initial stages of one-on-one counselling that Ms X was potentially at risk; however, due to meditation and the conscious ongoing fighting of the fantasies, Mr Keating was able to replace the negative and abusive fantasies with positive thoughts. Mr Keating stated that is why he was so upset that his fantasies had spontaneously returned after months of abstinence. He also stated that his fantasies involved Ms X in the future, not at that point in time. An exploration of the group dynamics and negative internal and external factors at the time of Mr Keating's removal indicate high levels of stress, anxiety and fear on many levels. That would appear to explicitly link that asserted gain to the incident involving the psychologist on 14 January 1998 and it remains to be seen the extent to which that was explored with the psychologist herself in relation to her perception of the matter. Again, when one continues: Develop an understanding of internalising how his behaviour has impacted. He's been encourage to grieve and acknowledge the losses - et cetera et cetera. (6) to change his attitudes and beliefs towards women. The formal module has not been addressed, although many issues have been discussed in the course of therapy. Mr Keating has continued to demonstrate a deep respect for females and at this point of time is looking at his fears associated with some females; (6) to understand how the mismanagement of his anger and irrationality played in committing the offences. Mr Keating is developing a sophisticated understanding of the above and his work is progressing well. Covert sensitisation - it would seem he had formulated a style of covert thought stopping. "Promotion of self-worth," number 8; the conclusion there is: 2/8/05 QUINLAN, MR 1008 2.26

Spark & Cannon 31/2/glj OIC/05 Interaction with unit staff, other staff, continues to enhance a self-worth and intimacy. The therapeutic relationship and other relationships with peers and staff indicates that Mr Keating is capable of high levels of trust and intimacy with others. And over the page, in summary: Mr Keating has made significant gains over the past months. He continues to remain highly motivated to learning and changing behaviours which are negative. And the future recommendation is: As noted in the report it's suggested that a comprehensive management plan be formulated in consultation with the appropriate parties. Now, that is clearly showing an optimism in relation to his future which is moving towards a management plan further into the future than his integration into mainstream. Similar issues were identified in June 1990 in a report from Ms Gianatti to the management review committee - this is document 390. On page 3 of that document under Therapeutic Intervention: It is to be noted that while some of the stressors are still present, Mr Keating has coped appropriately. Sorry, I will go back. If we go to the page before under some of the stressors, those stressors are identified: The removal from the therapeutic environment and placement in high security area; feelings of abandonment, grief and loss, helplessness and hopelessness; difficulties coping with memories of traumatic events retrieved just prior to his removal from the program; difficulties understanding why he was removed from the program, given that he had spoken out about his fantasies pertaining to his therapist whilst engaged in individual treatment. That would seem to be a further characterisation of the events of 14 January 1998. MAHONEY, MR: How much do we need of the detail of all of this? QUINLAN, MR: Not a great deal more. If I can just go through in relation to the issues to be addressed. On the fourth page:

2/8/05 QUINLAN, MR 1009

Spark & Cannon 31/3/glj OIC/05 Mr Keating continues to be fearful of his future. He states that whilst there are people who know him and this may provide some protection should others overreact, feel fear for him or react negatively, this is of major concern - and the principal issues which are identified relate to developing a management plan and the reduction of his security.

2/8/05 QUINLAN, MR 1010

Spark & Cannon 32/1/slh OIC/05 If we look at number 5: Mr Keating has passed on documentation to me and asked me to present it to the management committee. In November 98 I suggested a comprehensive management plan be formulated as a parallel process to the therapeutic intervention and the significant gains; (a) a formalisation of process dealing with any situation should he or anyone working with him feel they're at risk. Over the page: Security rating: Mr Keating is currently under ESG status. What is the requirement and time frame for medium security and a removal of the ESG status? A management plan to be formalised. The reason for going through that report in some detail is that in June 1998 not only - 1999, Mr Keating began to also engage others in relation to his management. In particular he complained to the ombudsman in relation to what he saw as the failure of the ministry to adequately manage him. The result of that complaint - we don't have a copy of the complaint but at least the outcome of it is reflected in correspondence from the - to the ministry. This is document - I don't think it's a document at all but a response to the ministry - from the ombudsman to the director-general of 20 August 1999 was: Thank you for your letter of 22 July 1999 about Mr Keating's management. The opportunity has since been taken to discuss Mr Keating's situation and his psychological plan with Mr Harrison. For your information I enclose a copy of my letter today to Mr Keating. The plan which is referred to is a management plan developed in response to the ombudsman becoming involved of July 1999. That's document 391 which is headed Management Plan for Mr Paul Keating as of July 1999. One can see a descending time frame from August 1999 down to November 2002 and a descending order of security status, if one looks again, from higher to lower at the bottom of the page with a gradual mainstream integration and then as one moves through: Firstly, continue with individual therapy. Continuing down: Need for special group. Intensive sex offender treatment program. Moving to: 2/8/05 QUINLAN, MR 1011 2.32

Spark & Cannon 32/2/slh OIC/05 Query favourable Parole Board decision. Yes. Prerelease program. At the very bottom: EED - which is earliest eligibility date - 1 February 2004. This plan quite explicitly puts the management of Mr Keating towards that path of achieving the earliest eligibility date of 1 February 2004. It of course doesn't and cannot guarantee it but in terms of the planning and the nature of the treatment which is proposed it is directed to the Parole Board decision being favourable and the introduction into a prerelease program. That would appear to be an about-face when compared to the management system - or management approach which was advocated for by Dr Thomas-Peter in his report of 13 December 1993. MAHONEY, MR: Is this schematic document something prepared by the ombudsman or by the Department of Prisons? QUINLAN, MR: Mr Harrison prepared this document - who is the principal clinical consultant - prepared in the context of the ombudsman approaching the department for clarity in relation to what the proposed management for Mr Keating was. MAHONEY, MR: He seems to have had an extraordinary amount of attention from an extraordinary number of people. I assume this is not typical of what individual prisoners get but is there a sign of any other prisoner who has received this amount of attention? QUINLAN, MR: The short answer to that is no. The inquiry has not come across any other prisoner with this level of commitment - or this level of input in relation to him. A comment made in an interview - and he could perhaps be asked in relation to this when he gives his evidence - that was made by Prof Thomas-Peter in relation to the matter was: You would be hard put in the criminal justice systems around the world to find someone who's had better, more carefully documented input. He's had tremendous input because he's a man who's capable of enmeshing people in his business because his needs are so important to him.

2/8/05 QUINLAN, MR 1012

Spark & Cannon 33/1/slh OIC/05 MAHONEY, MR: So one has somebody with this amount of attention and ultimately the decision that was made in relation to him turned out to be wrong. QUINLAN, MR: It's a matter of locating which decisions they were which turned out to be wrong in terms of whether they were treatment decisions, assessment decisions or management decisions, but certainly given the recent events there was an enormous amount of input into him which turned out to be unsuccessful. The point that I make about this plan of July 1999 is not simply whether it is the preferable approach to Dr Thomas-Peter's approach of December 1993 but whether or not the alternative approaches were specifically addressed and a choice made between them. That's what appears to be lacking, is some kind of clear point at which the decision was made that the approach reflected in December 1993 was the wrong approach for whatever reason and that this would be the approach which is adopted. Rather, what appears to have occurred is that it has simply occurred with the passage of time. The involvement in Keating increases as it happens because in a moment I will come to the creation of a committee which was set up to deal with these serious offenders. Can I just take one example of the way he - the demanding nature in terms of therapy that he has? In 1999 there was a proposal to - that Ms Gianatti who had been working at the forensic case management team in Casuarina had been conducting counselling with Mr Keating - it was proposed that she move to work in Canning Vale Prison. Mr Keating wrote to the director-general on 15 September 1999 - this is document 511 - recalling that this is within two months of these complaints to the ombudsman and the management plans - here we are, "Concerns regarding my management," and then he goes through various histories. At the bottom of the page: Unfortunately on Monday, 13 September, less than four weeks since receiving the ombudsman's correspondence, much to my total surprise, distress and disbelief I am informed that the forensic case management team therapist which I have been doing exclusive weekly therapy for the past 18 months and who not only has been instrumental in significantly helping me in addressing my offending behaviour but whose ongoing expertise is crucial in the early development of my newly acquired management plan has now been suddenly seconded to Canning Vale Prison for a three-month period. The decision to second Ms Sunny Gianatti my FCMT therapist to Canning Vale Prison does seem quite incredulous considering the recent comments made by the ombudsman. Skip the next sentence: 2/8/05 QUINLAN, MR 1013 2.38

Spark & Cannon 33/2/slh OIC/05 Therefore I now voice my concern regarding the ramification this decision has and will have on my wellbeing and the ongoing development of my management plan and personal growth. Considering all of the above, could you please confirm if the decision to second Ms Gianatti was made in view of my circumstances and in consultation with the offender management committee and with the principal clinical psychologist Les Harrison? The response to that - - - MAHONEY, MR: Do we know whether he composed that letter himself or whether it was composed for him? QUINLAN, MR: Other than to say there's nothing to indicate it wasn't composed by him. MAHONEY, MR: It seems an extraordinarily well-drawn letter with reference to all the touch points that one might expect if one were running a psychological assessment of him and aiming at all the - as I say, the touch points in relation to it. It makes one wonder whether it was prepared by him or by somebody else. QUINLAN, MR: It's fairly apparent from the correspondence as a whole that Mr Keating is extraordinarily well informed as to the way in which these processes operate. He writes voluminous correspondence dealing with the finest detail in relation to the management of his case. Interestingly the response to that letter - firstly, it was referred to the general manager public prisons for his attention and direct response and then the response - document 513 - was this:

2/8/05 QUINLAN, MR 1014

Spark & Cannon 34/1/cl OIC/05 I refer to your letter of 15 September 1999 in which you raise concern about your case management, given that Ms Gianatti of FCMT has been seconded to Canning Vale Prison for three months. Mr Glenn Ross, manager FCMT has advised me that the continuity of your case management will be maintained during this period as Ms Gianatti will continue to see you a weekly basis. Although these arrangements have been made in this instance, it needs to be recognised that they are not made in perpetuity and that circumstances may arise in the future where it might not be possible for Ms Gianatti to continue in this role. Were this to occur, it would necessitate some other qualified practitioner to be assigned to your case. So it's a matter where the prisoner himself is active in wanting to define who it is that treats him and the terms on which it is done, and to an extent the response of the department is a positive one in fulfilling the expectations that he has. The development of the treatment in relation to him I can say - and to provide another example of the way in which he writes, document 510 which is a letter to the general manager of prison services, Mr Terry Simpson, dated 12 January 2000. This is a seven-page letter, "Clarification regarding my management and treatment" which raises the Ombudsman's correspondence. It then discusses his treatment. It discusses the situation in relation to other prisoners and what decisions have been taken in relation to them, and one finds at the very end of the letter, and in fact some of these observations are apt: In summary, I doubt very much there is any other prisoner within the Western Australian prison system which has ever been required to do so much in terms of therapy in addition to the numerous other requirements which I have had to fulfil and still find myself continually being expected to fulfil in order to have my security rating reduced, thereby allowing me to progress through the system. All I am seeking is for my case to receive a fair and just hearing and for me to be allowed to move on and away from the shackles of my past. To this aim, I ask you as general manager of the Ministry of Justice to please ensure that I receive a fair hearing and the duty of care which I am entitled to receive. I also hope that you will give serious consideration to answering the numerous questions which I have raised. Please forgive me if I have said anything which has offended you throughout my letter as this was not my intention. I look forward to receiving your response. 2/8/05 QUINLAN, MR 1015 2.44

Spark & Cannon 34/2/cl OIC/05 It's a detailed seven-page letter and at the bottom of it one can see after the signature, "enclosing 14 articles," so it's correspondence which has set out in exhaustive detail what Mr Keating expects to be done for him, and shortly after that there was the creation of the serious offenders management committee. This appears to have occurred around 1 February 2000, document 392: I refer to your correspondence of 12 January 2000 in which you raise issues in respect of your management plan and provide further arguments to support your case. Rather than provide a lengthy response, I believe it's more productive to look forward towards the future. To this end I am pleased to advise you that a serious offenders management committee has been formed to take over the development and ongoing monitoring of your management plan. The membership is as follows. The membership includes: the director of metropolitan prisons, the director operational services, the director health services, the senior consultant forensic psychiatrist, the director sentence management, the superintendent Casuarina Prison and the manager of the forensic case management team. As I indicated at the outset, the formation of such a committee is a positive step, although, as will be seen in relation to the committee, whether it was implemented in the way that might have been hoped is a different question but to provide some indication of the way in which that was set up - document 515. Mr Ross who was the manager of the FCMT provided - this is a copy of an email where he refers: The ombudsman has previously been given guarantees that a committee of high-ranking staff members would be convened to ensure the coordination of the management of Prisoner Paul Keating. This assurance followed occasions where the ombudsman had received differing and inconsistent advice on the management of this serious offender. Terry Simpson has given approval for the convening of a "serious offenders management committee" to replace the former ad hoc committee which looked after the management of Paul Keating. It is believed that in addition to Paul Keating there are other prisoners within the system who are of serious concern to prison management and who would benefit from receiving the attentions of this committee. The first meeting was scheduled for 16 February. Down the bottom there is a statement of purpose which is:

2/8/05 QUINLAN, MR 1016

Spark & Cannon 34/3/cl OIC/05 The serious offenders management committee exists to assist superintendents to develop and monitor management plans for those small number of serious offenders whose behaviour whilst in custody has been extremely problematic and over whom significant concerns are held for their satisfactory progress within the prison system.

2/8/05 QUINLAN, MR 1017

Spark & Cannon 35/1/glj OIC/05 What's not made clear in the original setting-up of the serious offenders management committee is whether it was a decision-making body or a recommending body or a consultative body or an advising body and, as will become apparent, those roles over the course of time became somewhat blurred. Before that committee met there was another incident involving Keating, who by this time was continuing in his progress. Again, this is an incident involving a psychologist within the prison system, whose name may need to be kept confidential, but it was an incident which occurred in the ICU on the morning of 7 February, and on 4 February 2000 there was a memorandum sent to Mr Upton-Davis, describing an incident which occurred on 4 February 2000 and I will read it for the purposes of the transcript: On Friday morning, 4 February 2000, I went to Casuarina Prison with Deb Shires to support her whilst she interviewed a prisoner in the ICU. Dave Hide met Ms Shires and myself at the administration reception within the prison and escorted us to the ICU where he told the prison guards on duty what we had come for. After delivering this information, he left us with the prison guards in this area. There appeared to be four prison guards in the area on entering, with one guard departing on or just after our arrival. Both Deb Shires and Dave Hide had mentioned to be careful of Paul Keating prior to entering the unit and, upon entering, Deb Shires pointed out to me which one he was. He was busy making bread rolls as we entered. Deb inquired if I could stay with the guards at the security desk while she conducted the interview in the glass-panelled interview room, which would be in full view of all of us. This was accepted. After Mr Hide left, two of the prison guards went towards the SCU area to ask the prisoner to attend an interview. While they went to get the prisoner, the other psychologist moved to the glassed interview room to get ready for the interview. I stayed at the security desk with my back towards the remaining security guard so that I could watch what was happening behind me in the main room. For some reason the remaining guard, who was sitting behind the security desk, got up and went into the same area as the other two guards. Immediately after he left the room, Paul Keating quickly strided around the bread roll trolleys and moved directly towards me. He held a steel bread and butter knife in his hands. The knife was slightly serrated. He would have come 2/8/05 QUINLAN, MR 1018 2.50

Spark & Cannon 35/2/glj OIC/05 to approximately three to four of his paces from me when the phone rang behind the security desk. He immediately changed his direction mid-stride and turned to break open the bread rolls on the trolley with his knife. The guard returned to answer the phone. The other two prison officers returned to advise us that the prisoner rejected the interview. They also inquired why Keating had become so agitated. We then proceeded to the SCU area for another interview. I inquired with the prison guards as to why Keating would have a steel knife and was advised that in their area all knives are chained up or left in the control area. I briefly report the incident on the way back to the office, but as Ms Shires was suffering from a bad headache and was clearly stressed, I did not proceed to expand on the event. It was not until I tried to sleep that night that it hit home how easily the situation could have had a different ending. It was simply a matter of seconds. I became very concerned at the danger that existed for others who were in contact with Keating and knew I needed to report this incident in an effort to avert a negative consequence in the future. Again, what conclusions ultimately might be drawn in relation to that report provided by the person may be difficult to determine because there does not appear to have been any particular action taken in relation to that incident other than it being the subject of debriefing et cetera in the course of Keating's psychological reviews. There was a report prepared for the serious offenders management committee by Ms Gianatti, dated 13 February 2000 which recommended that he be seen both in the IOU and outpatients for counselling sessions; that he be waitlisted to participate in the intensive sex offender treatment program as the next stage of his treatment plan; that he continues to engage in engage in weekly counselling sessions in preparation for group treatment; that he continues individual therapy with Ms Gianatti whilst participating in sex offender treatment; that he continues ongoing assessment with Mr Harrison and that a formalisation of process dealing with adverse situations should anyone feel at risk, and a procedure be formalised should he be seen to be at acute risk of self-harm or suicide.

2/8/05 QUINLAN, MR 1019

Spark & Cannon 36/1/slh OIC/05 The serious offenders management committee met for the first time on 16 February 2000. Document 396 is the minutes. This inaugural opening of the meeting was attended by Mr Simpson who was the general manager public prisons. There was a general discussion. It was felt that the composition of SOMC was such that it should concentrate its efforts on only that small number of prisoners posing a significant risk of danger to others who had generally exhausted the capacity of individual prisons to manage them. As such these prisoners should be viewed as a problem for the system rather than for a particular location. In relation to Keating it was proposed that - in relation to Keating Ms Gianatti tabled the report together with documentation for Keating that he wished to be considered. Shortly after that Mr Harrison provided a comprehensive psychological risk and treatment needs assessment as part of the management plan. That is document 283. This is a significant document which is some 64 pages long, so it's not at all possible to go through all of the detail of it. It details a good deal of material in relation to Keating. Perhaps it's appropriate only to refer to some of the conclusions in relation to the document. In relation to diagnostic assessment - page 20 of the document - under the heading DSM-IV it's stated: Mr Keating meets the DSM-IV criteria for borderline personality disorder; criteria 1 to 6, 9 and possibly 8. Then there are various discussions of psychometric testing in relation to him. On page 31 of the report there's a heading Progress and Therapy where Ms Gianatti identified progress in the following areas: reduction in propensity to sexualise relationships with females; a reduction in dependency and a converse increase in ability to make his own decisions; increased ability to respond to a multitude of stresses; the development of a more self-adaptive self-image; increased ability to view negative reaction of others toward him as understandable, and development of strong internal locus of control. In relation to his risk of recidivism - page 34 - Mr Harrison concluded: Given the change in Mr Keating documented above I have concluded that currently the chances of Mr Keating recidivating are significantly lower than the SORAG finding of 58 per cent over a seven-year period. MAHONEY, MR: Just pausing there, what's that, a general finding that 58 per cent of people reoffend within a seven-year period?

2/8/05 QUINLAN, MR 1020 2.56

Spark & Cannon 36/2/slh OIC/05 QUINLAN, MR: SORAG is a reference to the sex offender risk appraisal guide which I think is an assessment based on risk category. If one looks at the top of that page: Recidivism base rates are an average rate of reoffence for offenders falling within a broad offence category. Individual offenders may have a significantly higher or lower chance of reoffending than might be suggested by the base rate. Actuarial approaches to recidivism prediction recalculate offence risk for specific individuals. On the sex offender risk appraisal guide, SORAG, Mr Keating was found to have a 58 per cent chance of sex offence recidivism within a seven-year period and an 80 per cent chance of sex offence recidivism over a 10-year period. Mr Keating's score is higher than that obtained by 89 per cent of Canadian violent sex offenders. Given Mr Keating's offence history it's not surprising that his risk as measured by the SORAG is significantly higher than the base rate for rapists. Mr Harrison's conclusion is that it's - his conclusion was that the chances of recidivating are significantly lower than that base rate of 58 per cent over a seven-year period: However, given Mr Keating's very serious offence history the extent of therapeutic work still needs to be completed and my inability to rule out his culpability in relation to recent allegations against him - and that relates to the incidents involving the psychologist in 1998 and the recent incident on 4 February 2000: I estimate his current risk to be significantly above the base rate for rapists of approximately 20 per cent. There is, nevertheless, considerable potential for the estimate of risk to be reduced in the future, particularly if his borderline personality disorder continues to be amenable to therapy and if he successfully completes an SOTP.

2/8/05 QUINLAN, MR 1021

Spark & Cannon 37/1/glj OIC/05 So that the recommendations were that individual therapy continue and he should be encouraged to progressively re-enter the mainstream prison environment and be considered for inclusion within the SOTP, with supplementary support, and indeed on 15 March 2005 that was the recommendation made by the SOMC committee that he be recommended for inclusion in an SOTP with consideration to be given to creating circumstances that would enable his participation. This, however, didn't stop communications by Mr Keating in relation to the ombudsman, and indeed in April 2000 there was further correspondence from the ombudsman in relation to further complaints by Keating - document 399 - so that one finds: On 9 March 2000 I received a further complaint from Mr Keating, specifically about the role of Ministry's Mr Glenn Ross in Mr Keating's management, and there are other complaints which are referred to. And on the third page: It is therefore of potential concern to me that Mr Keating is again not receiving clear, consistent and comprehensive information about his management regime and future objectives for him, including the potential for a reduction in his security rating which is obviously dependent on his risk assessment. For that reason I am inclined to the view that Mr Keating has a valid complaint which should be investigated. Consequently, I would appreciate receiving a background report from you which addresses but is not limited to the above two issues - and then a request for further reports to be provided in relation to his assessment. So notwithstanding the fact that Keating has since March 1998 had a single counsellor devoting a half a day a week to his counselling, has a management plan negotiated via the ombudsman, has had a committee formed to oversee his management, he has continued to write and involve external agencies in his case in order to progress his management through the system, and in that regard a response was provided to the ombudsman by Mr Simpson, the general manager of public prisons, on 2 June which said: Irrespective of difference in opinions on the intent and inappropriateness of Mr Keating's disclosure to Ms X, there has been no difference of opinion in relation to his management plan. Mr Keating has been provided with clear information on the outcomes of the SOMC meetings and is in full knowledge of the 2/8/05 QUINLAN, MR 1022 3.02

Spark & Cannon 37/2/glj OIC/05 requirements and expectations of him. He again came to the attention of the management at Casuarina Prison in July 2000 when he generated an elaborate computer greeting card and gave it to a female nurse within the prison system. Again, I won't name the name of the nurse, but the superintendent of the prison wrote to the general manager of public prisons on 3 July 2000 - document 401: A recent incident involving Keating creating an elaborate computer-generated greeting card and giving it to a female nurse has given rise to some concern. Keating has been the subject of various assessments in relation to his dangerousness. Several significant factors have been identified in consideration of his dangerousness, and a behavioural cycle enables some predictability to his likely responses to certain events has also been identified. He then extracts portions from Dr Thomas-Peter's report and the earlier assessment as to his cycle, and on the third page he notes: The content of Keating's greeting card has some disturbing hallmarks. He basically confirms point (b) of Thomas-Peter's assessment of risk by referring to himself continuing to grow as a person in a dysfunctional system. He also fits into the idealisation phase of Northcott's behavioural cycle with his comment about the nurse: "Truly beautiful, wholesome, genuine and intriguing young woman who I've ever encountered" - "sincere gratitude, respect and trust, goodness which radiates from you." There are also other references that could be viewed as idealisation.

2/8/05 QUINLAN, MR 1023

Spark & Cannon 38/1/slh OIC/05 At the end the comment is made: In view of past assessments of dangerous and taking into account the content of the recent greeting card episode, Keating's future management should proceed with extreme caution and it's recommended that this aspect of his behaviour be referred to principal clinical psychologist Les Harrison for assessment. In August 2000 the SOMC meeting - there was another meeting of the serious offenders management committee when the weekly meetings - counselling sessions with Ms Gianatti were confirmed. The incident where the card was made was raised at the meeting the serious offenders management committee noting that Keating remained at high risk. On 3 October 2000, Keating commenced an intensive sex offenders treatment program at Casuarina Prison. This was obviously a second attempt at going to that sex offender treatment program. It does not appear, however, that the purpose for which that program was being undertaken was recognised as the same purpose which was identified at the time that Mr Howells - Dr Howells recommended a program in 1996, namely for his reintegration into mainstream. It appears rather that Keating simply commenced the program as any other participant in the sex offenders treatment program. On 8 November 2000, minutes of the SOMC meeting revealed that Keating was progressing well in the SOTP and had become more relaxed and accepting. He was reportedly supportive of other participants and interacted with them. The deputy superintendent Mr Hide advised that Keating resided at the SOTP unit without incident. All the staff in the unit were advised of his offending behaviour and Ms Gianatti continued to see him on a weekly basis in a supportive role. On 8 January 2001 - document 404 - there was an incident report by an officer noting: During the morning of 8 January 2001, prisoner Keating asked me to find out when education officer - and I won't mention the name - was coming to the SOTP to see him. Upon questioning the prisoner it was established that the education officer sees the prisoner on a regular basis in the courtyard of SOTP out of view of the officers' office. Due to the prisoner's past history this situation seems highly dangerous. Submitted for your information. It's not clear that that particular incident report has any other reference in the material. There was a further progress report by Ms Gianatti on 6 February 2001 2/8/05 QUINLAN, MR 1024 3.08

Spark & Cannon 38/2/slh OIC/05 indicating his participation in the SOTP had allowed him to interact and build a trusting and appropriate relationship with another female, experienced a positive male role model and coped with the positive and negative experiences of the SOTP. On 7 February 2001, the minutes of the serious offenders management committee noted Keating's continued participation in the SOTP and his weekly counselling. It was also noted that Keating would complete the program requirements and a further review by Mr Harrison would be required to assess dangerousness. It was also noted that Keating was progressing well in his studies. In May 2001, the serious offenders management committee met again. This is document 407. This was a meeting in anticipation of Keating's completion of the sex offenders treatment program. An awful lot seems to happen in the months following May. It was reported: His participation in the SOTP is proceeding well and he's expected to successfully complete the program in June. A request from the facilitators of the program for Mr Keating to remain there after completion of the program to assist in the orientation of new participants was made by Ms Gianatti on their behalf. Prison management did not support this request. It was felt preferable for him to be accommodated in unit 1 for a period of four weeks. During the four-week period whilst Mr Keating is in unit 1, the necessary reports would be completed including a reassessment by Mr Harrison as to dangerousness. There being no reasons to the contrary Mr Keating would then be available for transfer to Albany Prison. MAHONEY, MR: Albany was a secure prison? QUINLAN, MR: Was and is a maximum security prison. What appears to be contemplated is this, and this is - at least this part of the decision-making would appear to be a sensible one. By this time in 2001, Keating had spent virtually the last 10 years in intense security environments.

2/8/05 QUINLAN, MR 1025

Spark & Cannon 39/1/rds OIC/05 He had either been in the special handling unit, the induction orientation unit or the multipurpose unit, both of which have a high staff-to-prisoner ratio, restricted movements and a high security regime or he had been in the residential program of the sex offenders treatment unit. He hadn't spent any time in a mainstream prison environment and the proposal to move him to Albany was a proposal to have him in a maximum security environment which was nevertheless a mainstream environment which was considered could not be achieved in Casuarina, he having a previous offence of attacking an officer at Casuarina and the difficulties that that would pose in terms of staff were he moved into mainstream at Casuarina. That would appear to be what was behind the proposals to move him to Albany, because it was the next best alternative in terms of a maximum security environment, although it's noted there that there was a proposal for him to be in unit 1 at Casuarina for a short period of time, a four-week period, prior to moving to Albany Regional Prison. Notwithstanding those proposals, Mr Keating again contacted the ombudsman - document 507 - on 10 May 2001. This is a letter four pages long, headed Ongoing Issue of Being Mismanaged: I am writing to you yet again to lodge a complaint against the Ministry of Justice for the way it is continuing to mismanage me. Then it goes in detail, what has occurred, and then we get to the last page: In any event, in light of this ongoing and quite appalling way that I remain being mismanaged, I again call upon your office to take urgent, affirmative and definite action in order to have my management resolved in a fair and just manner once and for all. Due to the seriousness - error of judgment that SOMC has made - this is the decision to go to Albany - I would ask you immediately raise this matter in person with Mr Simpson or even Mr Piper. Surely you must see that the decision flies in the face of all fairness and commonsense and seems to be a deliberate ploy of some description aimed at avoiding treating me like any other prisoner who has successfully completed the sex offender treatment program. In essence, this decision needs to be immediately overturned and the SOMC must make its decision after 2/8/05 QUINLAN, MR 1026 3.14

Spark & Cannon 39/2/rds OIC/05 I have completed the program and at a time when all assessments of the clinicians involved have been finalised and the recommendations have been fully considered. I should also be allowed input into any decisions which are made. On 22 June 2001 Keating completed the sex offenders treatment program. According to the treatment completion report dated 1 October 2001, he met all the objectives and was able to discuss his offending behaviour openly with no indications or justifications or minimisation. His participation reportedly remained at an extremely high level throughout demonstrating a high understanding of the content and it wasn't considered any further treatment issues remained for him relating to his sexual offending. There's then a flurry of reports. On 25 June 2001 there's a report by Ms Gianatti, a lengthy report which is document 409, recommendations including - this is the second-last page. This is an 11-page report: Recommendations: Mr Keating to be viewed as not requiring any further treatment programs or intensive therapy unless is assessed as necessary by Mr Les Harrison, principal clinical consultant, Ministry of Justice. On 27 June 2001 an interim psychological assessment report was prepared by Mr Harrison for the purposes of the serious offenders management committee. Mr Harrison noted two major initiatives that had occurred with respect to Keating's rehabilitation; namely, that he had embarked on study towards a university degree and that he had completed the sex offenders treatment program. In relation to the conclusions at that time on the sixth page of that report - document 410 - under the heading Reoffence Risk Estimate, he concluded: I am now confident that Mr Keating has very significantly reduced his reoffence risk. There is ample evidence of amelioration of dynamic risk factors.

2/8/05 QUINLAN, MR 1027

Spark & Cannon 40/1/glj OIC/05 Significant reduction in risk was noted in my previous assessment 15 months ago, and it is clear that Mr Keating has continued to strive towards rehabilitation. The change in attitude and behaviour are now becoming established as part of his personality. Given the above, I estimate his reoffence risk is now at least as low as the recidivism base rate of 20 per cent for rapists. If, as expected, Mr Keating maintains his commitment to rehabilitation and his ongoing change continues to become firmly established, his level of risk will concomitantly reduce further. Interim recommendations: I recommend Mr Keating be transferred to a mainstream prison environment. A direct transfer from his current location to Albany Prison would be congruent with psychological principles. A management plan for Mr Keating is developed following the receipt of the SOTP completion report. The focus of future intervention should be primarily on resocialisation. Mr Keating has achieved the major therapy goals and it's anticipated that psychological adjustment will continue without the need for intensive individual therapy. Similarly, there is nothing to be gained by further involvement in treatment programs. Support and encouragement of Mr Keating's education should be integral to his resocialisation and management. So the decision was taken by the serious offenders management committee that he would go to Albany, and planning had to be done in relation to that. The assistant superintendent of Albany Regional Prison had to prepare a plan, particularly in relation to Keating's management whilst at the prison, which was developed in July 2001 in anticipation of his arriving at the prison - document 411. The background information is identified, and then the management in relation to him. It's: A restricted management, even though it's a management in mainstream, so that he's to remain in unit 1, restricted to A yard, for a period of time; to have the same access to facilities within that area as all other prisons, taking into account his management plan; to be under one male officer escort when required to leave the yard for any purpose; recreation to be within the yard. The psychological assessment report of Mr Harrison of 21 August 2001 confirmed the interim conclusions that he had expressed in June. In anticipation of this, an individual management plan had to be prepared for Keating in accordance with the ordinary requirements of director-general's rule 2B, or 13 and 14 as they were at 2/8/05 QUINLAN, MR 1028 3.20

Spark & Cannon 40/2/glj OIC/05 the time, given the transition that was occurring in 2001. MAHONEY, MR: Just pausing there for a moment. What was the university qualification which he had obtained? QUINLAN, MR: He hadn't obtained it yet, but I think he had enrolled, as it happens - a bachelor of psychology degree at Edith Cowan University. I will confirm the precise nature of those university studies, but certainly he had undertaken, up to this year, psychology units as part of his university studies. As I said, in relation to the preparation of a management plan, it was necessary in accordance with the various systems that were then in place that the classification review be carried out in relation to Keating. A number of such documents were prepared by a Mr Glassborow, who was a sentence planner at Casuarina Prison. He carried out a classification review on 3 October 2001 - this is document 463. You will recall this document from the hearings in relation to Cross, or this template, and the scoring instrument that produced the various ratings. Going firstly to the end of the document in terms of the outcome, on page 3, it has a score of 18 which is a score which reflects maximum security in relation to a prisoner and that was indeed the recommendation which appears to remain maximum security in line with the CRS score. What is noteworthy about it is when one looks at the classification review questions on the first page, under the heading History of Institutional Violence the question, "Is there any history of institutional violence?"

2/8/05 QUINLAN, MR 1029

Spark & Cannon 41/1/slh OIC/05 The answer which is given is: Yes, assault involving the use of weapon and/or serious injury. Comments: Keating brutally raped, sodomised and penetrated a female staff member in 1992. That would have obviously scored - produced a higher score in relation to the matter, although it's to be noted that the question says, "State the most serious incident against staff, visitors or other offenders for the previous five years," so that strictly speaking the answer to that question in relation to the attack in 1992 would not produce an affirmative answer, although it may be that if the incident in 1998 involving the psychologist was regarded as institutional violence it very well would fall within the previous five years. An individual management plan was also prepared by Mr Glassborow and a copy of it has been retrieved off the TOMS system - it's document 460 - which recommends maximum security in relation to the prisoner. Interestingly, it's a document which is - this one is headed First Parole Review Exco Approval Report, although there are a variety of copies of this document on the TOMS system which have different headings, but at any rate, it is in the form that applied prior to the new AIPR system so this is in fact an individual management plan type of report which is one that is appropriate to the old 2B system rather than the individual management plans under director-general's rule 14, but in terms of the detail of that report, it's a detailed report, on page 6 of the report it details the assessments by the sex offenders treatment unit, the circumstances of the removal from the sex offender treatment program involving a psychologist were referred to and referred to in detail in terms of what occurred on that day. There was a reference to the incident involving the other person on 4 February at the unit which was referred to as well, can be seen in the paragraph headed There is Also a Further Report on File Which has been Discussed. The writer notes the similarity of the above report by one of the complainants in Keating's assault against another victim at Fremantle Prison in 1988 when the intervention of the telephone ringing prevented the incident from escalating into something far more serious. No prison charges were preferred against Keating. Nevertheless, it's an extensive report in relation to those issues which whilst not giving rise to any particular prison charge were incidents that the writer took into account in forming the management plan and the recommendations for the individual management plan. The decision in relation to the serious offenders management 2/8/05 QUINLAN, MR 1030 3.26

Spark & Cannon 41/2/slh OIC/05 committee to transfer the prisoner to Albany Regional Prison was one which would ordinarily be a decision which was made by the manager of sentence management. In Keating's case the manager of sentence management Ms Doyle who has previously given evidence was asked to prepare a decision slip in relation to Keating that he be transferred to Albany Regional Prison. Ms Doyle's evidence is that she inquired when she was asked to do this on what basis this was to be done and was told it was a decision of the serious offenders management committee, a committee which at that time she had never heard of, and indicated that she wouldn't do so unless and until she had located minutes where that had occurred and indeed ultimately found minutes of the serious offenders management committee and as a result thereof prepared the decision slip in relation to Albany Regional Prison, which is document 414. We can see there: Remain maximum security in line with CSR score. Transfer to Albany Regional Prison in view of (1) above. At that point - shortly after - three days after, he was transferred to Albany Regional prison at maximum security rating. Other than the short period of time that he had had in unit 1, Keating had not been in a mainstream environment since 1992 when he committed the offences against the prison officer at Casuarina Prison.

2/8/05 QUINLAN, MR 1031

Spark & Cannon 42/1/glj OIC/05 Indeed, at the time of those offences he had only been in the mainstream prison for a relatively short period of time having been in a segregated cell or the special handling unit since 1988 until 1991. So this was a prisoner who had spent an awfully long period of time in a particularly high security environment and was moving - other than those few weeks before in Casuarina - for the first time to a mainstream environment in Albany Regional Prison at a maximum security rating. So that would appear to have been significant progress in relation to moving Keating along within the system. As it happens, there was yet further complaint in relation to Keating not being progressed; this time complaint appears to have been made to the inspector of custodial services in 2001, and the complaint related to the preparation of the individual management plan in relation to Keating that was prepared by Mr Glassborow - document 498. This had followed earlier correspondence as a result of Keating's complaints throughout 2001 to the inspector of custodial services, and in this letter of 17 December 2001 the inspector of custodial services wrote to the executive director of prison services and states: Mr Keating has now shown me the individual management plan which has been determined for him since he has been at Albany Prison. Frankly, it's little more than a mish-mash of previous reports and comments and there appears to have been very little if any value added to it by the process of assessment which preceded the development of the plan. I must say it is in great contrast to some of the much better focused and meaningful IMPs that we saw in our inspection of Casuarina Prison in October. The issue of the management plan was discussed at a meeting of the serious offenders management committee on 28 November 2001, which is document 417, and in that report under the heading Paul Keating: The IMP - this is the second paragraph, The IMP for Mr Keating was discussed, with Mr Harrison raising objections to the inclusion of selective quotations from an earlier report of his. Ms Tang undertook to arrange a meeting with Mr Denis Bandy, manager assessment centre, and the author of the report to discuss the matter further. It was discussed that Mr Keating will experience difficulty in progressing to minimum security in the ordinary course of events due to the high classification 2/8/05 QUINLAN, MR 1032 3.32

Spark & Cannon 42/2/glj OIC/05 rating he receives and it will be necessary for an override to be exercised. It could, however, be expected that he would be reviewed for medium security in a relatively short period of time, possibly as early as next June. Now, that would seem a short period of time to be reviewing him, having only just got out of a secure environment within maximum to mainstream maximum, to be reviewing him in seven months' time. There is a view that Mr Keating is developing an expectation that he will commence on a prerelease program some 15 months prior to his eligibility date. This may not be the case as the eligibility date is a date for consideration only. It was noted that Mr Keating has advised that he has sought legal advice in regards to his management and placement. Significantly, the statement there - "there is a view that Mr Keating is developing an expectation that he will commence on a prerelease program some 15 months prior to his eligibility date" - is not surprising given what had gone on before; given what management plans and explicit plans seemed to have been put in place in relation to Keating's management and the degree to which he had become involved in pressing for his management and for his progress to be continuously updated. As that report indicated, a further review was to be done of Keating and no sooner he had arrived in Albany than a Mr Henderson went to Albany for the purposes of carrying out reviews of the individual management plan and the classification review in relation to Keating. If we go to document 479, this is a review carried out on 17 December 2001. Going to the end, one can see - recalling that the use of this instrument in October by Mr Glassborow produced an 18. The custody rating score according to the application of the same instrument on 17 December 2001 produced a custody rating score of 10 and a recommended rating of medium security.

2/8/05 QUINLAN, MR 1033

Spark & Cannon 43/1/slh OIC/05 The individual management plan that was prepared in relation to Keating - document 480 - on the third page at the bottom - or at the top had recommendations, "Security rating: medium. Facility: Bunbury Regional Prison," with a review date of 12 July 2002. That occurred in December 2001. Keating had barely been in Albany for two and a half months in a maximum environment. At that point the recommendation being proposed is a recommendation of reduction to medium and movement to Bunbury Regional Prison which is not a maximum facility prison but a medium facility prison. The SOMC committee met again on 20 February 2002; document 419. This is the point at which it would appear that SOMC appears to be taking over particularly a decision-making role in relation to placement and security in relation to a prisoner. The second full paragraph there in relation to Keating says: The committee entered into a lengthy discussion concerning the recommendation for a transfer to Bunbury Prison. There were varying views as to merits or otherwise of Keating going to Bunbury. The issues raised were related to previous offending history of Mr Keating, safety, associated risk should he be moved to Bunbury and his current stable status at Albany. Over the page: Keating's support comes from prison Outreach. Further, the committee had discussion around the fact that all medium-term prisoners were to transfer to Acacia. To remain in Bunbury was not an option for them. This raised further discussion on the merit of Keating being placed at Acacia. The staff at Acacia were unfamiliar with Mr Keating and had not as yet developed experience in preparing a prerelease program. Consideration was now also given to the fact that the crucial time for Mr Keating was between now and November when the Parole Board will sit to decide his suitability or otherwise for parole. The SOMC could not predict what the Parole Board's thinking on this matter would be. The committee agreed that a decision on Mr Keating's placement would require further information and liaison with Bunbury Prison in particular. The committee in agreement with Mr McAllister as the superintendent decided that Mr Keating's security rating would be reduced to medium and he would come off high-security escorts. It would appear quite clear here that the committee decided that Keating's security rating would be medium, 2/8/05 QUINLAN, MR 1034 3.38

Spark & Cannon 43/2/slh OIC/05 notwithstanding that the decision-making power in accordance with director-general's rule 14 would be with the manager of sentence management Ms Doyle. Just prior to Mr Keating being called into the video-link, the chairperson called for an extraordinary meeting of SOMC to be held on 13 March 2002. The committee agreed that the IMP was not accepted in full at this time. Then in the next paragraph: Mr Keating entered into the video-link and the chairperson explained to him the committee's decisions and the rationale for these and asked for Mr Keating's comments. His comments were as follows: as to the decision to be reduced to medium and remain in Albany, Mr Keating pointed that it showed him little hope of progress, "Am I to stay in Albany forever?" He also pointed out that since being sent to Albany it had cost him approximately $400 in phone calls. Then down the bottom Mr Leach told Mr Keating that SOMC would meet again on 13 March to discuss the issue of his placement and would arrive at a decision. Again, that would appear to be moving with particular haste in relation to the prisoner. Having been in not only a maximum environment but a close security environment for so long and having been in Albany Regional Prison for that time for only a period of five months the decision is taken to reduce him to medium. In an extraordinary way Mr Keating's response was, "Am I to stay in Albany forever?" What inference one might draw from that is that it's saying, "Medium is not much good to me. When am I to be moved to Bunbury Regional Prison?" In fact, at the next meeting that was to be addressed. As a result of that meeting of the serious offenders management committee his security rating was indeed reduced to medium, which is document 482.

2/8/05 QUINLAN, MR 1035

Spark & Cannon 44/1/nal OIC/05 This is the same day as the decision of the serious offenders management committee made by Ms Doyle and this perhaps reflects the tension which is developing between what the director-general's rule requires and what the SOMC committee was doing in terms of decision-making: Reduce to medium security in line with the classification review score and SOMC recommendation of 20 February 2002. SOMC met again on 13 March 2002 and it was revealed - this is document 420 - it was revealed after much discussion Keating was to be transferred to Bunbury. On the second page under Transfer: It was agreed he should be transferred to Bunbury and given the chance to prove himself prior to being considered for prerelease. This will be another opportunity for him to demonstrate his ability to cope with change and for prison administration to get to know him more. Delaying transfer was not regarded as an option, however it was considered that his education should not be interrupted so an appropriate time to move him may be during a semester break so that he does not spend time without access to his computer. It was asked if a transfer was possible without being required to spend undue time as Casuarina. The transfer process from Albany is that prisoners are transferred from Albany to Casuarina on Tuesday and then proceed to Bunbury on Thursday. Keating joined the teleconference. Then the second full paragraph: Paul asked about the psychologist's reports and the role of these within SOMC and the assessment process for a prerelease program. So essentially what's occurred is no sooner is he in mainstream in Albany Regional Prison in maximum that within a couple of months he's recommended and then ultimately reclassified to medium and then a month later, six months after his first reintroduction into mainstream maximum environment, he is sent to medium and at that very meeting the issue of prerelease programs is raised because that statutory review date is looming in terms of what needs to occur to try and progress him further. As a result of that decision document 476 - we can see down the bottom: Remain at medium. Transfer to Bunbury as per SOMC recommendation. There Keating remained within the Bunbury Regional Prison following his transfer via Casuarina Prison with a one-day transit. Thereafter, preparations began for 2/8/05 QUINLAN, MR 1036 3.44

Spark & Cannon 44/2/nal OIC/05 considering his inclusion in a prerelease program. On 3 July 2002 correspondence was forwarded to the department from a lecturer at Edith Cowan University commending Keating for his participation in his studies. The person described Keating as having the ability to do extremely well in his degree and that he had the ability to go further to complete a post-graduate qualification. On 22 July correspondence was forwarded from Outreach Services confirming their intention to accommodate Keating upon his eventual release and advised that they would provide sponsorship during his resocialisation program and home leaves. On 15 August 2002 a psychological assessment was prepared by Mr Harrison in relation to the suitability for a prerelease program. In relation to the risk of reoffending, this is document 424, page 9: I am confident that Mr Keating has maintained his commitment to rehabilitation. His progress and therapy is also consolidated and he has demonstrated an ability to deal with change in his environment, a factor that was of concern not only to SOMC but also to Mr Keating himself. Given the above estimate I estimate Mr Keating's sex reoffence risk is low and significantly below the base rate for treated rapists, ie, significantly below 20 per cent. Apart from continuing with his current endeavours and maintaining his treatment gains there is little, if anything, that can be asked of Mr Keating to reduce his recidivism risk further. Recommendations; I recommend that Mr Keating progress to a prerelease program at the most suitable juncture in order to prepare him for release to parole at his earliest eligibility date. I recommend that in addition to the usual components his prerelease plan incorporates appropriate opportunities for him to become familiarised with an on campus university environment. MAHONEY, MR: So you had a person who was recommended by a special committee at high level in the department by the principal clinical consultant, a psychologist; the university person with whom he had been working and the Outreach people who had been concerned with him, all of whom recommended that he be prepared for progress to a prerelease program which would have meant, had he satisfied that, that his sentence would have been brought to an end on parole.

2/8/05 QUINLAN, MR 1037

Spark & Cannon 45/1/rds OIC/05 QUINLAN, MR: If he was given parole at the end of that prerelease program, certainly. MAHONEY, MR: Yes. QUINLAN, MR: All of that, it might be added, within a year of his reintroduction into mainstream. So that report, for example, in August 2002 - it has not yet been a year since he returned to a maximum mainstream environment. MAHONEY, MR: My point at mentioning all of those is that notwithstanding all of those people giving consideration to him and recommending as they did, it turned out to be wrong. QUINLAN, MR: Yes. As it turns out, those recommendations didn't come to fruition in any way because ultimately on 25 September SOMC recommended his suitability for prerelease assessment. Correspondence was forwarded to the Parole Board. The Parole Board reviewed his case in October and requested that the Department of Justice prepare a prerelease program of two years' duration. You will recall, sir, that in the course of the prerelease program preparation one of the steps is that the manager of prerelease, after being asked to prepare a prerelease program, forwards the draft program to the executive director of prisons. That's one of the stages in that process and that in fact occurred in the case of Keating. So once the point had been reached when a program had been drafted and a prerelease program was prepared, it was sent to Mr Simpson and on that occasion Mr Simpson took the very unusual step, having discovered that the matter had already been to the Parole Board, and wrote to the chairman of the Parole Board expressing concern in relation to the speed with which effectively Keating was being moved through the system. This is document 433. The letter from Mr Simpson is: In reference to the above-named prisoner, I wish to bring the board's attention to some concerns I hold regarding his progress towards a prerelease program. Those concerns are expressed within the context of his serious offending history and his fairly recent progress from special purpose accommodation to mainstream maximum security and then medium security accommodation. Mr Keating has spent a relatively short period of time in medium security accommodation, having been placed at Bunbury Regional Prison only since 1 May 2002. Therefore I do have some reservations about progressing him to a minimum security facility at 2/8/05 QUINLAN, MR 1038 3.50

Spark & Cannon 45/2/rds OIC/05 this stage without a longer period in a medium security environment in order to test his ability to make necessary adjustments. For this reason you will note that I have not recommended approval on the attached grant of leave of absence form. So quite unusually in a sense the department is speaking with two voices on this occasion, given that steps have been taken within parole release to prepare the report on the plan on the request of the Parole Board and the executive director coming in over the top of that and expressing concerns in relation to it. The result of that was that at the Parole Board meeting of 19 December, taking into account that consideration, it requested that the department revise stage 1 of the prerelease program to include a period at medium security. You will recall that Ms Rabbitt on the last occasion referred to a small number of prerelease programs where the first stage may be in medium security. That was then forwarded to the Parole Board and the board reviewed the case on 30 January 2003 and resolved to report to the attorney-general recommending a revised prerelease program of two years' duration with the first stage being at medium. That is where the progress, in effect, hit a brick wall because the attorney-general rejected the proposal for a prerelease program on the basis that Keating represented too great a risk to be considered for a program at that time. The board then - document 437 - considered the case on 27 March, made the following decision: Attorney-general notation rejecting recommendation of prerelease program noted. Review 25 March 2004 on receipt of updated reports.

2/8/05 QUINLAN, MR 1039

Spark & Cannon 46/1/glj OIC/05 This is, of course, a function of the way in which this system is structured, that it doesn't matter what particular recommendation is made by the department or the Parole Board, that the ultimate decision-making authority rests with the government via the attorney-general and, this matter having been rejected, there was no further step that could be taken in relation to the matter, and in a sense any expectation which had been developed by that time in relation to the lengthy period of treatment, movement, progress and planning in relation to Keating had to effectively come to a stop, that it wasn't possible to progress the matter further. Keating, nevertheless, remained at Bunbury Regional Prison and, in fact, at Bunbury Regional Prison there was an effort to - because your Honour will recall Bunbury Regional Prison has a minimum and a medium security component. There was an effort to or a proposal that Keating's classification be reduced to minimum so that he could prove himself in relation to his position for the next time that a prerelease program came up, and there were a couple of classification reviews carried out in relation to him in October and then November 2003 and this is perhaps illustrative of the way in which the classification system can produce different results depending upon the inputs which have been put in it. You will recall that in October 2001 Mr Glassborow produced a classification review with the score of 18. In December 2001 - - - MAHONEY, MR: That would have meant - - - QUINLAN, MR: Maximum. MAHONEY, MR: - - - high maximum. QUINLAN, MR: In December 2001 Mr Henderson performed a classification review which resulted in a 10, which results in medium. On 10 October 2003 a further review was done - this is document 472 and if we go to the last page of that, on this occasion he scored an eight and the comments were: Recommend override to minimum security to participate in a prerelease program. Since his arrival at Bunbury Prison, Keating has produced an exemplary prison performance which has enabled the writer to arrive at the recommendations reduce to minimum security, outside the guidelines of his current classification review score. Remain Bunbury Prison to participate in early stages of prerelease program. There was a later classification review done the following month, which is document 474. This time the score is a five, which is the score for minimum security, 2/8/05 QUINLAN, MR 1040 3.56

Spark & Cannon 46/2/glj OIC/05 so that the score produced on 12 November 2003 produces a minimum security rating for Keating in line with the guidelines of his current classification review score, and one can see how that occurs, going to the questions that are asked and, again, this isn't to say that these scoring instruments or the use of scoring instruments of this kind are not a useful tool and an appropriate part of the management of prisoners generally, but this does perhaps highlight that for a certain number of prisoners the tool fails to capture what might be properly regarded as the relevant information. If we look, for example, "What history is there of escape?" - attempted escapes. As we have heard, Keating has a significant history of escape inasmuch as he escaped in 1979; he had a number of attempted escapes following that, and he had the escape in 1984 I think it was, but it scores the same as none because they are more than five years ago and the comment is made, "He does have an escape history; however, it's greater than five years ago, his last escape being 15 years ago." The next question, "What offences were committed at large?" The answer must necessarily be, "Not applicable." In fact, in relation to the escapes that had occurred more than five years ago, the offences which were committed at large were of a particularly serious nature that occurred very soon after the escapes: I think on the first occasion, two days after, and on the second occasion, the day of the escape itself.

2/8/05 QUINLAN, MR 1041

Spark & Cannon 47/1/slh OIC/05 Again, history of institutional violence. There would be few prisoners who would have a history of institutional violence which would include the kind of attack which occurred in 1992, but again as a result of the five-year cut-off it doesn't produce any score even though the history of institutional violence on Keating's part has a consistency to it. There's an offence against - there's offences committed at large in 1979 and 1984; there's an offence against the psychologist in the mid-80s in Fremantle Prison; there's an offence in 1992; there's arguably unlawful threats in 1998, so that there are spacings between these offences but what this kind of instrument doesn't capture is that kind of repetitive offending with reasonable gaps between the particularly serious incidents, but at any rate those plans were prepared and an individual management plan was prepared in relation to Keating - this is document 475 - the recommendation being: Minimum security classification. Placement: reduce to minimum security in line with CRS. Remain Bunbury Regional Prison in line with current approval and at prisoner's request. It should be noted that Keating's original proposal for a two-year prerelease program was rejected. As a consequence Keating has spent a further eight months at medium security. In preparation for this report it was considered appropriate to seek some other form of progression. An opportunity at minimum security at this time with or without a prerelease recommendation would provide him with enhanced development and the ability to achieve a staged community reintegration. Initially it's recommended his movement to and from minimum areas at Bunbury Regional Prison be done under the escort of a prison officer. This would also apply if a section 94 was approved. Given the proximity of his IMP review and his scheduled SOMC meeting it was deemed appropriate that this report be forwarded to SOMC members prior to the meeting so that they may preread and consider the proposal. The proposal then is notwithstanding that a prerelease program has been rejected something must be done to try and progress this prisoner's case because by this stage the case will of course have gained a certain momentum, at least in Keating's - from Keating's point of view, that it's constantly progressing. Once the decision is made not to go to a prerelease program unless some new avenue is taken it can't progress any further. This particular management proposal went to a meeting of the serious offenders management committee on 19 2/8/05 QUINLAN, MR 1042 4.02

Spark & Cannon 47/2/slh OIC/05 November 2003 where the - if I can find it - document 518. At this meeting the confusion, to put it that way, as to the role of the serious offenders management committee came to a head. Was it a decision-making body? Could it make a decision like this in relation to Keating? Could anybody make a decision for Keating to go to minimum notwithstanding a prerelease program had not been approved? Could the kind of proposal be put in place which had been recommended by Bunbury? Ms Doyle attended that meeting as the manager of sentence management, not as a member of the committee but at the request of Bunbury Regional Prison which is reflected in that - those minutes of the meeting because according to the director-general's rules under rule 14 the decision-making in relation to the reduction in security rating of a prisoner in Keating's position would ultimately be with Ms Doyle as manager of sentence management, albeit that the policy was in place, referred to on the last occasion, that life sentence prisoners or indeterminate prisoners could only be reduced to minimum in the context of a prerelease program. Essentially what occurred at this meeting was vexation, if you like, as to whether or not SOMC was making the decisions or Ms Doyle was making the decisions. That's reflected in the terms of reference that the role of the SOMC with the executive director of prisons has been discussed, relayed to members of SOMC, that SOMC had arisen from correspondence between the ombudsman's office. Under Paul Keating: There was considerable discussion about whether or not Mr Keating's security rating could be reduced outside the construction of a prerelease program. The committee was also unclear if it had the authority to do so without authorisation in policy directive 14.

2/8/05 QUINLAN, MR 1043

Spark & Cannon 48/1/nal OIC/05 While Bunbury individual management plan was of a high standard it was not progressed at this time because as it stands it does not fit with the policy. It was agreed that the terms of reference, once defined, as well as any changes would allow clarity as to the way forward, particularly in reference to any possible departure from the current policy. It was agreed to defer the IMP while these matters were attended to. So effectively nothing happened in relation to the progress of the matter until ultimately the matter was referred back to Mr Simpson as the executive director of prisons. On 17 December 2003, document 441, under the terms of reference it's discussed and then fairly bluntly on the second page under Paul Keating: Reduction to minimum security unless it is part of an approved prerelease program is not approved. Mr Keating's PRP is to be resubmitted in accordance with his yearly review which is due in March 2004. So having gone back to the executive director of prisons Mr Simpson clarified that that decision-making could not be taken by SOMC in relation to the reduction to minimum security. Further reports were provided to SOMC in relation to Keating on, for example, 8 February 2004 by Ms Gianatti. On 9 February 2004 the minutes of SOMC reveal that it was agreed the consideration of SOMC would not be required again until the development of actual prerelease program and it would be dependent on the Parole Board's consideration of Keating. That would appear to be the final occasion on which SOMC ever met. If we go to document 444: As prisons division is about to commence a process of review of assessment and case management it has been decided to also review the function and purpose of SOMC as part of the wider review. Whether or not SOMC continues in its current format or is replaced by some other mechanism which may better fit into the case management process will be decided after the completion of the review. Consequently, in the interim it has been decided to defer the next meeting of SOMC until the outcome of the review is known and further direction is determined. That is effectively where it has been left. SOMC has not met again since 9 February 2004 and there is no, as I am instructed, comparable committee. The process review of assessment and case management would appear to be the review carried out by Ms Leske, which was the subject of evidence in June, although - and we can check this - I don't think it's the case that SOMC itself was considered as part of that report. 2/8/05 QUINLAN, MR 1044 4.08

Spark & Cannon 48/2/nal OIC/05 There were then various other reports provided by the principal clinical consultant in relation to Keating and prerelease suitability was again reviewed by the board and the board again on 27 May 2004 reviewed Keating's case and resolved to report to the attorney-general recommending a prerelease program of two years duration conditional upon the board reviewing his case thoroughly at the completion of each stage. On 15 July 2004 the board noted the attorney-general's decision not supporting Mr Keating's inclusion in a prerelease program in addition to the minister for justice's decision not approving Keating's inclusion in a prerelease program. So again, the decision-making process continued until the decision reached the attorney-general and the minister for justice and the decision was not supported again. The final report in relation to Keating that is available from earlier this year was a report of 30 January 2005 and that's document 453. Page 5, conclusions and recommendations: Mr Keating's earliest eligibility review for parole was considered in February 2004 and was rejected by the attorney-general. His prerelease program also continues to be rejected by the attorney-general. Sensational and inaccurate statements via the media are incongruent with Mr Keating's treatment gains and commitment to rehabilitation as reported within the psychological reports, risk assessments, behavioural observation and comments by clinicians, education management and uniform staff, all who are involved with Mr Keating. There remains extensive evidence that Mr Keating continues to be a low risk of sexually offending. Recommendations, over the page: Mr Keating to be viewed as not requiring further treatment programs or intensive therapy unless assessed as necessary by Mr Harrison. Ongoing support as regards to Mr Keating's university studies, phone calls to be continued for the purpose of observation and support, progression to a prerelease program. That report by the counselling psychologist of 30 January this year and over to the next page Mr Harrison confirmed on 8 February this year: In my view Mr Keating has maintained a strong commitment to rehabilitation. The blockages to his progress towards eventual release and his continued stability despite his disappointments regarding this have provided further evidence that his treatment gains are firmly established and resistant to

2/8/05 QUINLAN, MR 1045

Spark & Cannon 48/3/nal OIC/05 relapse. As stated in my previous review, apart from successfully completing a prerelease program there is nothing more that could be asked of him with regard to his rehabilitation. My recommendations remain the same as from my previous review. I recommend that Mr Keating progress to a prerelease program. I also recommend that in addition to the usual components his prerelease plan incorporate appropriate opportunities for him to become familiarised with an on campus university environment. The correspondence was forwarded to the Parole Board by the manager of parole release on 1 March 2005. Again, the recommendation for inclusion into the prerelease program was proposed. It was proposed that Keating be reviewed by the Parole Board for inclusion on a prerelease program on 17 March 2005; that was prevented by the events which occurred on 16 March 2005 when Keating was involved in the series of offences in relation to an education officer with Bunbury Regional Prison for which he has now pleaded guilty and which will be the subject of sentencing by the District Court in due course. Following that incident Keating was, by virtue of section 43, separately confined in a cell as Casuarina due to the incident and is now placed within the special handling unit at Casuarina Prison to maintain control and security of the prison. That is essentially the outline of the history in relation to Keating and obviously identifies some of the matters which will now fall to be determined in the course of the evidence. If it please you, sir. MAHONEY, MR: Yes, thank you, Mr Quinlan. I notice it's just on 20 past 4. We will adjourn until 10.30 tomorrow? QUINLAN, MR: Yes, if it please you, sir. MAHONEY, MR: Yes. AT 4.16 PM THE MATTER WAS ADJOURNED UNTIL WEDNESDAY, 3 AUGUST 2005

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Spark & Cannon