The purpose of this Review was not to attribute fault to particular individuals involved in the critical incident. Rather, the terms of reference required the Review to:
- examine the events and circumstances surrounding the incident;
- establish any factors that may have caused or contributed to the events;
- examine the adequacy of the emergency management response during the incident; and
- make recommendations for the management of offender cohorts, particularly women and other strategies to mitigate any identified system weaknesses.
