grey and, even if a very large amount of money were to be spent on the facility, it is unlikely that it could ever conform to contemporary prison standards. The buildings reflect years of relative neglect by successive governments and even when it was built, forty years ago, the Prison would have been out of date and totally inappropriate in its design for the rigours of a Tasmanian winter. Moreover, it was built as a Maximum Security Prison and remains so, even though the demand has never been for a full maximum security facility. When additional stresses, such as an unexpected surge in prisoner numbers or a significant change in the nature of the prisoner population occur, as has happened at Risdon, there is an inevitable strain on resources and management. Staff morale drops, inmate unrest and dissatisfaction escalate and the system begins to crack. This is what had happened at Risdon, and had been happening for a significant period of time prior to the investigation. The Ombudsman's Report follows a coronial inquiry into five deaths in custody that occurred between August 1999 and January 2000. In March 2011 the Coroner found that in four of the five cases, management of the complex: ...failed to provide a physical environment which would minimise the risk of self harm and a system of care which would recognise a vulnerability to suicide and actively promote steps to prevent it. The Ombudsman reported again, this time in 2010, when he initiated an investigation of his own accord following receipts of a number of complaints during 2007 and 2008 which made him concerned about the conditions under which the prisoners in the high risk management unit, called Tamar, were being held. In his report, the Ombudsman commented that: I was concerned that the conditions in Tamar might not be humane. Further, he found: that there is no formal practice for informing prisoners of the reasons for their placement in the unit, and that the management of the unit does not comply with national or international standards in this regard. that prisoners are not adequately informed about the rules and conditions which apply to them in the unit, and that this is not compliant with national standards. that prisoners have been held in the unit for indeterminate periods of time, on the basis of perceived dangerousness, and that this is incompatible with national standards and standards