Carl Williams' death raises important concerns about the monitoring systems in place at Barwon Prison.
The report finds that Corrections Victoria failed in its statutory obligations to Mr Williams and identifies major deficiencies in relation to how intelligence information is gathered, coordinated and shared within Corrections Victoria.
The report makes 57 recommendations. One is a matter for the Minister for Corrections to consider, while the Department of Corrections has accepted 54 of the 56 recommendations. The remaining 2 are being accepted in principle.