Postal address
GPO Box 123

Purpose and Objectives

The Department of Justice and Community Safety’s (DJCS) Justice Assurance Review Office (JARO) reviews deaths and other serious incidents in Victorian adult prisons and youth justice facilities.

The purpose of JARO’s work is to understand what happened, and to identify whether any changes can be made to prevent similar incidents from occurring in the future. JARO assists the DJCS Secretary to ensure that adult prisons and youth justice facilities are safe, secure and humane.

JARO plays a critical role in enhancing the safety of prisons and youth justice facilities by ensuring DJCS is equipped to learn from deaths and other serious incidents, and it helps ensure accountability for such matters.

What JARO reviews

JARO undertakes the following work:

Review Type



Death in Custody reviews

Reviewing all deaths in adult prisons and youth justice facilities

Joint JARO and Justice Health (JH) review [1]

Death in the Community reviews

Reviewing select deaths in the community (detailed below)

JARO review assisted by JH where required

Serious and Significant Incident reviews

Assessing and reviewing serious and significant incidents [2]

JARO review assisted by JH where required

Thematic reviews

Conducting thematic reviews and targeted analysis of issues posing systemic risk

JARO review


JARO is part of DJCS’s Integrity, Regulation and Legal Services (IRLS) group. The Director, JARO, reports to the Executive Director, Integrity and Reviews, and the Deputy Secretary, IRLS.

Two internal committees contribute to the oversight of Death in Custody reviews:

  • the Review Oversight Committee
  • the Aboriginal Review Oversight Committee.

These committees have a shared objective of ensuring safer custodial facilities and a reduction in the number of serious incidents. The committees are co-chaired by the Deputy Secretary, IRLS, and the Deputy Secretary, Corrections and Justice Services (CJS). The Deputy Secretary, Aboriginal Justice, is a standing member of the Aboriginal Review Oversight Committee and the Deputy Secretary, Youth Justice, attends in the event that the death of a young person is being considered.

DJCS has established an independent Aboriginal Expert Panel to provide advice on reviews into specified Aboriginal deaths in custody. The role of the panel is to guide the reviews, test review findings and recommendations, and ensure the reviews are conducted with due regard to critical matters.

Limitations on JARO and JH’s work

As JARO, JH, Corrections Victoria (CV), and Youth Justice (YJ) are all part of DJCS, JARO and JH’s review work is not, and does not purport to be truly independent. However, Death in Custody reviews are undertaken independently of CV and YJ. That is, sitting outside CV and YJ, JARO and JH subject the performance of CV and YJ to scrutiny and review without influence or interference from either.

JARO and JH’s review work is not designed to answer all questions surrounding a death or serious incident. Instead, their work forms part of a broader process of inquiry that involves, among others, the Coroners Court of Victoria and Victoria Police. Nevertheless, when they are completed prior to the coronial inquest, DJCS often provides Death in Custody reports to the Coroners Court to assist with its investigations.

JARO and JH work diligently to prepare thorough, high-quality reports. However:

  • they do not have the powers of other bodies, such as the Coroners Court and Victoria Police, for example, to compel witnesses to give oral evidence, or produce documents and other information
  • given DJCS’s legal obligations, in particular the obligations it has in relation to staff, on occasion JARO and JH may decide it is undesirable to request a witness to participate in a review, for example where they have concerns about a person’s welfare
  • noting that private companies and healthcare providers operate and/or support the operation of some of Victoria’s prisons and youth justice facilities, there may be challenges in obtaining information in certain circumstances.

Accordingly, JARO and JH will not always be able to collect all relevant evidence and make findings on all issues. However, JARO and JH will generally produce a report, and the report will clearly highlight instances where the review was limited by the availability of information or access to staff.

Death in Custody reviews

JARO works collaboratively with JH to conduct a review when an adult or young person dies in custody. These joint Death in Custody reviews consider the circumstances surrounding a person’s death, including the intersection between the health and custodial systems.

The purpose of the review is not to apportion individual blame, but rather to identify any system failings or gaps that need to be addressed. Accordingly, individual’s names are generally not included in Death in Custody review reports.

The principal objectives of Death in Custody reviews are:

  • to establish the circumstances and events surrounding the death
  • to identify whether any changes in operational methods, policy, practice or management arrangements could help prevent a similar death in the future.

Among other things, Death in Custody reviews consider:

  • the direct cause of the death, where known, as well as systemic factors that may have contributed to the event
  • the custodial and health care management of the individual in the lead up to their death, including whether the custodial management and services provided (health, wellbeing, rehabilitative, cultural and any other) were appropriate
  • whether the social and emotional wellbeing, and cultural safety of the person was properly supported during the individual’s time in custody
  • failures of process or performance
  • system gaps that need to be addressed, including whether any broader, systemic issues caused or contributed to the death, or impacted the individual’s custodial experience
  • the extent to which the individual’s human rights were protected
  • instances of good performance or innovative practice
  • opportunities to reduce the likelihood of such deaths occurring in the future
  • any other issues relevant to the review, including the implementation of recommendations from previous reviews.

Death in Community reviews

Adult Community Corrections

JARO conducts Death in the Community reviews where the death is from unnatural or unexpected circumstances and:

  • the offender dies within three months of release and was being supervised by Community Correctional Services (CCS) at the time
  • select cases where a straight release offender [3] dies proximate to their release from custody
  • where a supervision order offender [4] dies while residing in a residential facility.

These short-sharp reviews are designed to provide targeted and concise advice about the circumstances of the death, and any immediate and systemic risks identified.

Death in the Community reviews consider the custodial and CCS case management of an offender, including their transition from custody to the community. JARO works with JH on select cases to ensure appropriate consideration is given to the individual’s health care management.

Youth Justice

JARO reviews the death of young people in the community where the death is from unnatural or unexpected circumstances and the young person is on a community based order at the time of their death. These reviews occur irrespective of whether the young person has spent time in custody.

These short-sharp reviews are focused on providing targeted and concise advice about the circumstances of the death, and any identified immediate and systemic risks.

In reviewing the death of a young person, JARO’s objective is to identify any improvements that can be made in the community case management of young people.

Bi-annual community case analysis

JARO undertakes a bi-annual analysis of the preceding six months’ cases to comprehensively explore themes and issues identified across community deaths in the adult and youth justice spaces. The bi-annual review provides an opportunity to proactively deliver assurance on new and emerging or, in some cases, enduring risks by examining the root cause of an issue and making recommendations where there are opportunities for systemic improvement.

Serious and Significant Incident reviews

JARO conducts reviews of Serious and Significant Incidents within adult and youth custody settings. These reviews consider the incident itself, as well as the circumstances in the lead-up to, and management of, the incident. The purpose of these reviews is to identify systemic risks and then assess the adequacy of existing policies, systems, practices and other controls.

JARO uses an incident assessment model to provide a structured framework to consistently identify and assess risk. Although JARO only reviews the highest-risk incidents, it monitors all incident categories to identify emerging themes and system risks. Examples of serious and significant incidents include; escapes, major fires, riots and certain assaults and sexual assaults. These reviews consider the impact and controllability of an incident and will make recommendations where there are opportunities for improvement.

Thematic reviews

JARO also conducts Thematic reviews focusing on emerging themes or issues across the adult and youth justice systems. Thematic reviews provide an opportunity to proactively deliver assurance on new and emerging or, in some cases, enduring risks by understanding the root cause of an issue and making recommendations where there are opportunities for systemic improvement.


[1] JH is a business unit of DJCS. Its role is to monitor and review the performance of health service providers in Victoria’s prisons.

[2] Examples of serious and significant incidents may include, but are not limited to, escapes, major fires, riots, certain assaults and sexual assaults.

[3] Prisoners who are straight released to the community have completed their custodial sentence and return to the community without any supervision.

[4] Supervision Orders provide for the post-sentence supervision of serious sex offenders and serious violent offenders who pose an unacceptable risk of committing a relevant offence if a supervision order is not made and the offender is in the community.