Several senior managers within Northern Territory's Correctional Services knew about the alarming conditions at the Don Dale Youth Detention Centre but nothing was done, a royal commission has heard.
More than 30 of the department's middle and senior managers expressed a raft of concerns about the territory's youth detention centres during a one-day "World Cafe" workshop on May 18.
The workshop, based on a model used by the United Nations, was held as an independent inquiry team headed by Queensland's former Corrective Services boss Keith Hamburger was compiling a scathing report about the NT's detention system for the government.
Giving evidence to the royal commission into the detention of children in the NT on Monday, Mr Hamburger described how Correctional Services managers expressed their concerns while sitting around small tables with "little vases in the middle with a flower".
The idea, he said, was to create a relaxed atmosphere for managers to talk freely.
They came up with a list of 36 risks associated with the Don Dale and Alice Springs juvenile detention centres including the lack of health services, indigenous staff, appropriate facilities, and diversionary programs.
The safety of staff and detainees was described as "questionable".
The group's preferred alternatives to the centres included periodic detention and group homes.
"If that was a representation of upper and middle management Mr Hamburger, why was nothing happening," commissioner Margaret White asked.
"It does seem fairly astonishing if they aren't the people right down at the coal face but the more senior people there might have been some initiatives taken to implement these obviously very sound principles."
Mr Hamburger said the lack of a strategic plan for the centres was possibly to blame.
"I would think it's fair to say that a lot of these people felt frustrated that they knew these things were happening but couldn't get a resolution," he said.
Earlier, Mr Hamburger told how shocked he was by the Don Dale and Alice Springs centres, describing them as "human storage" facilities that were a far cry from the therapeutic environments needed to rehabilitate young offenders.
His team's report, handed to the NT government on July 31, called for the centres to be closed.
Mr Hamburger said they were so stunned by what they found - concrete cells with holes gouged in the walls, "shocking" shower facilities and beds with non-fire retardant mattresses - they alerted the Correctional Services boss Mark Payne immediately.
Footage of six young offenders being tear gassed and spit hooded at Don Dale shocked the nation in July and sparked the royal commission.
Mr Hamburger said after seeing the footage broadcast by ABC's Four Corners in he realised his report couldn't just recommend tinkering with the Correctional Services bureaucracy and needed a "circuit breaker" in the form of a new statutory authority led by indigenous people to deliver detention services.
He also revealed that just days after the broadcast, the-then NT chief minister Adam Giles asked both him and Mr Payne to assure him that no child would die in detention that night.
Neither was able to.
The commission continues.