Why internal reviews don't work and are a waste of tax payers money

Why internal reviews don’t work and are a waste of taxpayers’ money.

An opinion and review piece in response to an article in the Otago Daily Times, NZ in conjunction with the Inquiry into Tony Douglas Robertson’s management before and after his release from prison 2013.


On the 24th May 2014, Blessie Gotingco, was walking home when she was deliberately driven into by Tony Douglas Robertson. It wasn’t a fatal collision, but one that resulted in serious injuries which ensured that she could not fight back or sound an alarm. It gave Robertson the opportunity he had been prowling that same street and area for; to kidnap someone, place her in the boot of the car he was driving, and take her home where he sexually assaulted and murdered her before disposing of her body. The fact he was driving a car he wasn’t legally able to drive, one that Corrections had allowed him to drive, despite a report from a highly secret unit set up specifically for this purpose saying it should not be allowed; fell on deaf ears.

The public thought it a ‘bestial’ act. And after public pressure, and a personal meeting with Blessie’s family and their victim advocate Ruth Money, the Hon Amy Adams and Peseta Sam Lotu-Iiga, Ministers for Justice and Corrections respectively, agreed to an internal inquiry.

The family, and Ruth Money, wanted an independent one, and if it had not been for the intervention of Amy Adams, there might have been nothing. Both Ruth, and I knew, it was a weak second best, but it was at least something.

What has this case got to do with Duffy? Bear with me, it will be worth the wait.

January 2016, New Zealand, the inquiry report on Tony Douglas Robertson’s management by New Zealand Corrections was released. The family of Blessie Gotingco, their victim advocate Ruth Money, and other concerned parties eagerly read the report. I guess we were still hoping that a sense of duty and decency would prevail. The fact that Sam Lotu-Iiga had left his office and been replaced by ‘Crusher’ Collins just a month before, should have informed us of the prevailing winds. When you bat or play for the victim though, hope is a by-word for motivation. You must keep going. The Hon Judith Collins, new in, received the report and went with it.

Pat yourself on the back Corrections a very difficult job done well, said Judith Collins.

Blessie’s family were rightly devastated. They couldn’t quite believe that the bottom line was that Robertson, was simply too good for New Zealand, and although everybody had tried their best, nothing more could have been done. That the only person to blame was the offender.

But was this really the case? Well, it certainly followed the final Inquiry report, chaired and signed off by Mel Smith. The only way anybody would know any different was if you had intimate knowledge of the case and, or, been successful in obtaining the many thousands of relevant documents relating to it from the Courts Police, Corrections, other Govt departments, inquiry transcripts, all under Official Information Act disclosure. If one person had that material, understood it from a position of experience and knowledge, then was Mel Smith’s concluding report accurate? Did it really reflect the information and evidence surrounding the case? My summary at the time was;

I agree with Mel Smith, the chairman of the government inquiry, this is a story of tragic loss. However, having reviewed all the material provided to me, I do not, and cannot agree that Police and Corrections carried out a difficult task well. The matter of hindsight is mentioned many times by both the inquiry and staff giving evidence, and yet the key staff involved had several instruments at their disposal which would have afforded them foresight had they used them. The findings of the Corrections department are that this crime could not have been prevented, and that Blessie, in effect, was destined to die on that day, that Tony Robertson was too good and too determined for them, and it is not their fault. I do not agree that she had to die that day and this report sets out the reasons why. Following in the words of Antonio Gotingco; if you have a snake and you put it the chicken house, do not be surprised about the outcome. Here we know we have a snake; Robertson was an extra familial and stranger child sex offender who abducted to offend, who spent his many years in prison refusing all efforts of engagement, and in denial of his offences. Most of his prison time was spent in solitary or super max conditions; he had over 50 citations of abuse and violence recorded against him, he was violent when confronted over his offending, and in the words of the psychologist was, right up there when it came to high risk; so, you know you have a snake that is in the top 1% of worst snakes. When you take that snake and place in it the chicken house, or in this case the public arena, it is vital to use the foresight that knowledge of your snake affords you, and to use all proactive policing tools to protect potential victims and to neutralise the otherwise predictability of the outcome. It is done elsewhere, I have done it many times from 2006 onwards, there were other options, there was another way, and this case was no different. Blessie could have lived.

That Inquiry was closure for the Government. The family regarded it as a whitewash; and from all the facts, had the exact same thing happened in a country where corporate manslaughter existed, it would have at least been investigated for criminal liability. But there is no corporate manslaughter legislation in New Zealand.

But what has all this got to do with the case of Sam Samson Duffy!

If you can focus on Mel Smith’s Inquiry Report and its recommendations, it has a proverbial ‘shit load’ of things to do with it. The rub here is very simple; if the recommendations are not heeded then the report is a waste of time and money, if agencies just refuse to act on them, then it is still a waste of time and money.

Duffy, like Robertson, got a lengthy jail sentence for sexual abuse against children. Like Robertson, he got denied parole, in Duffy’s case seven times. Like Robertson, Duffy, was in denial and refused treatment and was considered as untreated by Corrections (if you have read my other posts you know what that really means). From the news report timeline, like Robertson, Duffy, was being released as a time served prisoner on licence conditions. In Duffy’s case his was to be standard conditions and he was being released with no plan. Like all parole board cases, conditions can only last for six months.

Duffy would have been allocated a prison case manager and typically before release, some time from after the last parole hearing, so plenty of time to plan, they would communicate with probation officers, probably the officer allocated to him on release, to form a ‘pre-release plan’. It considers things such as, is the case simple or complex, risk ratings, accommodation, family, community support, employment, health needs amongst other things.

As an untreated time served sex offender Duffy, in my opinion, can only have had a classification of high risk. Both the prison case officer and probation would know this, as the opening screen of the offenders file on Corrections Integrated Offender Management System, contains his assessed risk level, sometimes known as a ‘banner risk’. Here are some things that Mel Smith’s Inquiry said should happen after the Robertson Inquiry, all applicable here and highlighted in italics;

The increased likelihood of reoffending by long-term prisoners who have served their full sentence-frequently without attending rehabilitation programmes-makes it imperative planning for their release is carefully considered and starts early. This is doubly so with a high-risk offender.

Corrections would have had to consider accommodation, where he was going to reside on release. They cannot by any stretch of the imagination have carefully considered it, if they were going to place him back into the same location of his victims. Was the victim even spoken to or considered?

Considering proposals for release also must be early enough to help develop and seek approval for any special conditions on a prisoners release, including any proposed limits or obligations to be imposed on an offender, such as areas where the offender cannot go.

Did Corrections develop special conditions? No. Initial release was scheduled with standard conditions only. The fact they now consider them necessary should not have been contingent on the mother of one of the victims raising concerns.

In my opinion, with the similarities between Robertson and Duffy when it comes to pre-release planning the following applies;

With a release date set, Corrections had two options for his supervision: seek special release conditions lasting up to six months and or seek an extended supervision order for up to 10 years.

Did they do either? No. Have they done so now? Partly, yes.

Even though only standard conditions were applied for under the Parole Act 2002 the Parole Board does have discretion to impose special conditions for the same six months if they feel it appropriate. It must be questioned why they did so later and yet failed to do so in the first hearing.

The special conditions available for an extended supervision order are identical to those applicable to any offender released from prison except they last much longer and can require “intensive person-to-person monitoring” for up to a year. Such monitoring can involve a Corrections appointed person supervising the offender round the clock.

Why did Corrections not initially apply straight for an ESO? The offender fits the criteria and I am pretty sure they will be doing so before his conditions expire.

The penalty for any breach of any condition of an extended supervision order is up to two years’ imprisonment. Compared with one year maximum for breach of parole or release conditions

In my experience in managing sex offenders in the community it helps to have two things on the table front and centre. One, a victim strategy and two, a deterrent. None of that was present on the first hearing.

The following is a combined set of views from the Robertson Inquiry;

Corrections favoured extended supervision orders taking effect when release conditions end. In the inquiry’s view, this approach needlessly duplicates the process of obtaining assessments. It is also the inquiry’s view that high risk prisoners who serve their entire long-term sentence and who have not acknowledged their offending should be the focus of much earlier release planning and more coordinated efforts. In this case, applying solely for an extended supervision order would have better focused resources.

Was any of this undertaken in the first hearing?


From a pre-release planning aspect and management in the community, Robertson’s and Duffy’s cases are similar enough. Duffy refused to attend treatment, acknowledge his crimes, and was unwilling to attend a parole hearing. It can only be expected that upon release, Duffy will be a challenge to manage. Standard conditions in his victims’ back yard as a plan to manage those challenges, beggars belief.

Corrections have what is known as ‘high risk’ advisors. They lend assistance by way of advice. We don’t know if they were involved. I can only guess not, because if they were, then why did they not recommend an ESO from the outset, or at least special conditions, and imposition of psychological assessment upon release. Duffy fits all the criteria, the fact they are doing so now appears to me there were major operational failings and a failure to heed the Robertson Inquiry Report.

Again, bearing in mind the similarities;

It is the inquiry’s view that Corrections should have assessed Robertson for an extended supervision order and, if recommended, applied for one when it became clear he was unlikely to complete rehabilitation before the end of his sentence…..

Yes, this applies in Duffy’s case, I suspect they will do so in the future, and should have done so from the outset.

The efficient management of offenders, particularly high-risk, long-term offenders, demands a concerted effort by all of Corrections’ available expertise, whether case managers in prisons, probation officers, psychologists or officers from the high-risk team and intelligence group. A combined approach of this sort is necessary in the interests of both the offender and the safety of the public. It is also likely to be more efficient.

Any of this apparent in Duffy’s case? Zip.

Corrections had ample opportunity to assess and apply for an extended supervision order, so that, if made, it could have come into effect on the day of Robertson’s release.

This applies to the case of Duffy just as it did Robertson. How this case got to the stage it did without the mother’s intervention is mind boggling and shows that internal inquiries never have the clout to bring about real change.

A prison case manager would have had knowledge of the facts surrounding Duffy’s offending, as would the probation officer that was going to be responsible for his management in the community. Accommodation is a real issue for Corrections and so it would have come up very early in their planning with Duffy. How they concluded that putting him back into the area of his victims displays that they have learnt nothing from the Robertson Inquiry, and fails to take into account their own guidelines of which there are many but include; other matters to weigh up include proximity to victims….Corrections staff also need to check with appropriate organisations such as Police, Child, Youth and Family and mental health teams to find out if they approve of the proposed address.

Did Corrections work to their own guidelines and that of the Inquiry?

Did they inform Police? If they did, was it the Police who alerted the mother of the victims? What was their view on Duffy being released back into the same location? I would like to think that they objected strenuously.

Robertson Inquiry absolute recommendations pre-release;

13. Corrections should seek the advice of its own psychologists before recommending any special condition to the Parole Board that involves a psychological assessment or treatment

Was that done on the first hearing?

No. Can’t have done as there were no special conditions in the first hearing. They cannot go back in time and say that standards conditions were sufficent, because they have since applied for special conditions.

14. Corrections should advise the Parole Board of any special condition suggested by the centre for impact on sexual offending, but declined by Corrections, and the reasons for declining it.

There is no mention about this in the article, and I wouldn’t expect there to be. CISO is that small secret unit I talked about earlier. In part, the seed of thought for this unit was formed following the visit by Hon Anne Tolley to CEOP, in the UK, as part of her evidence gathering for the introduction of the Sex Offenders Register in New Zealand. The two-line recommendation says very little to the untrained eye.

To someone who has knowledge of every single document, every single transcript released under OIA relating to the Robertson inquiry, and how joint sexual offending intelligence gathering and dissemination groups work; then it is simply at the very heart of what would have given rise to the rebuttal of the ‘mantra’ from Corrections and the Inquiry, ‘that it is with only hindsight, that they can be held accountable’.

It was CISO that sent them intelligence documents that afforded them the foresight of what was about to happen. Documents from one government department, set up and financed jointly by Police, Corrections and others for exactly this type of case, and then ignored by one of them.

So, this recommendation partly deals with that, but also tells us that CISO was probably not involved where they should have been in the Duffy case. I am sure had they, they would not have endorsed the initial no plan, no victim strategy approach.

15. Corrections should manage offenders who are released on conditions and who are also the subject of an extended supervision order application at the highest management level.

Agreed, Duffy is not yet subject of an application, Corrections though have since stated that he will now be considered for it. He must be, as he now has the same conditions as an ESO, this set though only lasts for six months. The issue here is that Duffy was applicable for one before release and was initially set for standard conditions only and being accommodated in the same location as his victims. Highest standard of management? Not a chance.

17. Corrections should offer to probation staff more frequent refresher training in managing high-risk sex offenders, including the use of risk assessment tools.

To be balanced here, it isn’t that clear whether the prison case manager, or the probation officer had the lead on the initial application, but either way, it is staggering they came to the decision they did and shows a complete lack of victim awareness and the risk assessment of sex offenders. This is true by simple fact they are now treating Duffy in accordance with the Inquiry recommendations, on the same level as if he were on an ESO.

19. Corrections should consider expanding the role of high-risk advisors to include providing day-to-day advice and support to probation officers.

This expansion may well have taken place, but were they involved in providing advice? If so, what? Duffy can only be described as high risk, no matter who or what risk assessment is used. He failed to engage in prison for his entire period, he was time served, he refused to admit his guilt or show any remorse, he is in denial and untreated, (as if that would make any difference in his case). On the face of it, I would have to guess they weren’t involved when they should have been. A word of warning about risk assessments. They cannot predict what an offender will do. At best they are general possibility indicators.

As an observer who knows a thing or two about managing high risk sex offenders in the community; monitoring and surveilling them; managing the intelligence capture, gathering, analytical process and dissemination of an equivalent CISO team; working with, to, and from, a sex offenders register;  I am amazed that the standard conditions even got as far as the parole board let alone past them in the first hearing. The fact they have admitted issues were not adequately addressed is evident that the application before them initially was not fit for purpose. The Robertson inquiry also fully supported risk assessment training for parole boards and courts. My guess is that hasn’t been done, because if it had the parole board would have bounced the application back.

If the mother had not sounded the alarm loud enough the possible consequences don’t bear thinking about.

This where my amazement though, turns to disbelief and dismay. Taken in context with the Robertson Inquiry, lessons have not been learnt. The reasons for it are many and varied, but most will eventually wind its way back to arrogance. Victims are continually not placed at the heart of the decision-making process. It is one thing to be educated, another thing to act on that education. Not my words, but applicable here.

Internal reviews are not independent, far from it, and this case proves that Corrections cannot or will not learn from their past mistakes. Simply, Corrections didn’t think they were at fault in the first place and when the Inquiry agreed, on came the green light.

Fast forward and here we are today.

Andy Milne’s statement that they will now be considering applying for an ESO is all about optics. The truth of the matter is very different and inextricably linked to the Robertson Inquiry.

After a time, I considered that my paper copy of the Inquiry report was only good for lighting my fire on a cold winter’s morning.

Maybe, it will be of some use after all.