Leading For Change: Barriers to Implementing Evidence Based Reform in Youth Justice, and the Critical Role of Leadership

Highlights

• This paper examines the relative strength of reform recommendations made by inspectorates and commissions of inquiry in youth justice services, assessed by their type, effectiveness, and sustainability.
• The strongest recommendations were related to tangible involvement by leadership to establish stronger clinical governance processes.
• Ways to develop leadership capacity, and system coherency are discussed. 

Abstract

A series of reviews and inquiries into the quality of youth justice services have drawn attention to the need for substantial reform. And yet, there is little evidence to suggest that progress is being made towards implementing change. In this paper we review recommendations made to Australian youth justice agencies, identifying common themes and those recommendations that are most likely to result in reform. We apply learnings from quality assurance and clinical governance in healthcare to identify some ways forward for the sector, as well as acknowledging some of the specific barriers to change that arise in justice sector reform.

Keywords

Leadership, Reform, Root Cause Analysis, Safety and Quality, Quality Assurance

INTRODUCTION

The need to improve the quality of youth justice systems, both across Australia and globally, is widely recognized (Case & Hazel, 2023; Clancey et al., 2020), with recent years seeing repeated calls for the development of more compassionate, develop-mentally appropriate, and culturally responsive service delivery models (e.g., Butcher et al., 2020). And yet despite the many recommendations that have been put forward - from a series of Royal Commissions, inquiries and audits – substantive progress does not appear to have been made. In fact, dissatisfaction continues to be expressed about the quality of current services, with calls for reform growing ever louder (see submissions to the Senate Inquiry, 2025). Perhaps most tellingly, it is now over thirty years since the landmark Royal Commission into Aboriginal Deaths in Custody handed down its 339 recommendations for change, many of which have only been partially implemented or remain unaddressed (see Anthony et al., 2021; Department of Prime Minister and Cabinet, 2018). Similarly, despite the Northern Territory Government accepting the 227 recommendations in response to the Royal Commission into the Protection and Detention of Young People in the Northern Territory (2017), progress in achieving action against these recommendations remains slow, and some completed recommendations have effectively been undone by successive governments (such as re-raising the age of criminal responsibility; see Law Council of Australia, 2019). In their submission to the Australian Government’s Senate Inquiry into Youth Justice, the National Aboriginal and Torres Strait Islander Legal Service (2025) draw attention to a range of recommendations over 30 years that have not been implemented. These include: a recommendation for the development of national youth justice standards (1997 National Inquiry into the Separation of Aboriginal and Torres Strait Islander Child from their Families), Law Reform inquiry into the disproportionate rate of incarceration of Aboriginal and Torres Strait Islander people, and 24 recommendations from the national Children’s Commissioner’s 2024 ‘Help Way Earlier’ report (with no announcement to formally respond to these recommendations). The conclusion drawn many is simply that “Australia continually fails to implement evidence-based reform to our child justice systems which would reduce offending behavior and make our communities safer” (Australian Human Rights Commission, 2024 p.9)

The purpose of this paper is to present an analysis of why multiple recommendations to improve Australian youth justice systems have proven so difficult to meaningfully and sustainably action. We present an analysis of recommendations made to agencies involved in the care of children and young people who are involved with the justice system, applying a novel approach (derived from models of quality assurance developed in healthcare) to determine the likelihood, effectiveness, and sustainability (or ‘strength’) of suggested improvements to service quality and safety. In this way we seek to leverage multi-sectoral expertise by drawing upon decades of lessons learnt from reforming healthcare regulatory systems. Our key findings can then be used as a springboard for discussion about how specific conceptual models and pragmatic frameworks can help the sector to build a systemic culture of quality governance, to make recommendations more actionable, and to better engage with a process of service reform.

The Australian Youth Justice System

Australia has a federal system under which responsibility for youth justice services in Australia is devolved to each of the eight States and Territories. Although the processes are comparable across the country, there is some variation in the philosophical approach adopted, such as in relation to the age of criminal responsibility, presumption of bail, sentencing regimes and the administrative positioning of departments (see Malvaso et al., 2024). Despite these differences, common factors in the youth justice system across Australia is the significant and substantial over-representation of First Nations young people (who are 27 times more likely to be in detention and 19 times more likely to be under community supervision than their peers), rural over-representation, and a growing number of young people in detention (see AIHW, 2024). Approximately 2 in 3 (65%) of young people under youth justice supervision also had involvement with child protection services within the previous10 years. 

Recommendations from Youth Justice Inquiries

The last two decades have seen numerous public inquiries into youth justice systems across Australia, that have collectively put forward over 3,000 different recommendations (Stevens & Gahan, 2024). Some of the inquiries have been triggered by a high-profile safety or quality issue (e.g., the abuse or death of a young person in custody see for example Royal Commission into the Protection and Detention of Children in the Northern Territory, 2017; Queensland government’s Review of Youth Detention Centers, 2016; 2023 Inspection of Banksia Hill Detention Centre and Unit 18 at Casuarina Prison, 2023), with others arising when public attention is drawn to the broader failings of the system (e.g., following a media focus on the problem of youth crime or on the extraordinarily high rate of incarceration of First Nations young people). Table 1 below provides a consolidated summary of the main themes that identified in three reports that have sought to synthesize these recommendations. 

The sheer number of reviews and recommendations has created what is described as a ‘decidedly crowded’ and ‘overwhelming’ reform agenda (Clancey & Metcalfe, 2022, p.17), where stronger governance and accountability is identified as urgently needed to monitor the implementation of recommendations (Stevens & Gahan, 2024). Accordingly, our aim in this paper is to identify when calls for reform are most likely to have impact by applying a novel and transdisciplinary approach that has been widely used to strengthen the safety and quality of healthcare services after an adverse incident has occurred.

Learnings from Safety and Quality in Healthcare

The healthcare sector has a long history of improving the safety and quality of services through incident review, investigation, and outcome monitoring. Well-developed clinical governance processes have been developed that include service accreditation (see Australian Commission on Safety and Quality in Healthcare, 2021), and incident management processes to robustly examine when service and system processes have failed, to understand what went wrong and what can be done to prevent failure from occurring again (Australian Commission on Quality and Safety in Healthcare, 2025). 

One tool often used to achieve this is Root Cause Analysis (RCA); an independent investigation that examines system and process failures in high risk and high impact matters (see Safer Care Victoria, 2021). RCA seeks to apply methods originally developed for use in engineering to identify ‘lessons learnt,’ as well as the contributory and causal factors that resulted in actual or potential patient harm. A RCA seeks, generally, under legal privilege, to identify linear cause and effect relationships between components of a system (people, equipment, processes) and adverse outcomes. It is widely used (and often preferred) despite criticism that it minimizes the importance of human factors (such as the variability of people working in complex systems). An example of a quality improvement that has resulted from this process is ‘Ryan’s Rule’ – a means of escalating care and seeking second opinions when patients or their families are concerned that a person is clinically deteriorating and when feel that they are not being listened to by treating teams (Queensland Health, 2024). A range of other investigation methodologies (such as RCA squared and human factors reviews; see Peerally et al., 2017) are also now available that identify ways to enhance the safety or quality of services and minimize the likelihood of an adverse incident occurring again. 

It has been established that recommendations for reform in health care are more likely to be effective when they are written in a way that is easy for stakeholders to understand and that focusses attention on underlying causes (such defective processes and systems) rather than administrative tasks (see Australian Commission on Quality and Safety in Healthcare, 2025). This principle has enabled critical reviews of different health care recommendations against their relative ‘strength’ – based on type, effectiveness, and sustainability (Hibbert et al., 2018; Safer Care Victoria, 2025). Recommendations that are considered ‘strong’ are those that rely less on people’s actions, memory aides/reminders and are therefore more sustainable in efforts to achieve lasting change (e.g., replacing revolving doors to reduce patient falls), whereas ‘weak’ recommendations are those such as reminders, training, policy changes which - although often necessary to establish proficiency - are considered less likely to bring about behavioral change and therefore unlikely to provide sustained improvements in safety (e.g., issuing reminders to staff to check intravenous pumps every two hours).

In what follows, we apply this approach from health care to youth justice services to assess the relative strength of recommendations that have been put forward and the likelihood that they will result in sustained improvement to service quality and safety. To our knowledge, this is the first paper to have applied this approach from health care to germinate new ways of understanding the intransigent barriers and available enablers to implementing recommendations to reform youth justice services.   

METHOD

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