A chain of shortcomings and failings allowed Phillip John Smith to escape to Brazil - and an overhaul of systems and information sharing between government agencies is needed.
The findings of a high-level inquiry headed by retired High Court judge Dr John Priestley QC and Simon Murdoch have been released this afternoon.
Stricter monitoring of prisoners who are temporarily released "outside the wire" and into the community is one of a number of recommendations, which the Government has promised to act on.
Some of the findings of the report, for which 116 people were interviewed, will make for embarrassing reading for authorities.
The escape could have been thwarted before it even began if Corrections had simply checked with Smith's nominated sponsor that the prisoner was expected to stay with him overnight.
"The sponsor in fact knew nothing of the release, and would certainly have said so if asked," the report concludes.
There were shortcomings in various agencies systems and processes as well as simple failings that acted as "links in a chain" in their failure to prevent Smith's escape, the report states.
"Had one been absent, then the escape almost certainly would not have occurred."
Smith, a murderer and child sex offender, fled New Zealand in November while on temporary release from Spring Hill Prison, but was caught in Rio de Janeiro after being recognised by a fellow backpacker in a hostel.
He had obtained a passport issued in his birth name Phillip John Traynor, some 16 months before he left New Zealand on November 6.
About eight hours before he boarded the flight he had been released from Spring Hill prison on a temporary release of 74 hours, and he was meant to stay with designated sponsors.
Smith did not return to Spring Hill on November 9, and it was only on the following day that it was confirmed he had left New Zealand.
Failings identified by the inquiry include:
• Corrections' staff failed to adequately assess the extra risk Smith posed on temporary release, and there was no contact made with one of his sponsors. For example, if Smith's nominated sponsor was contacted before the day of his release, they would have confirmed they had no knowledge of his stay, and the escape would have been thwarted.
• When it was confirmed that Smith was not with his sponsors, Spring Hill staff were much too slow to inform police that a prisoner had escaped. A manager called police on the night of November 8 to give them a "heads up", but there was no insistence on any immediate action and the situation was not outlined as an escape.
"Remarkably, however, it does not appear that any of the three most senior managers at Spring Hill (all home but roughly 80 km apart) appreciated that Mr Smith had escaped. Actions which should follow an escape were not triggered," the report states.
It was not until the next day that Corrections told police Smith had escaped - four days after his release.
• When police were notified that Smith was at large, the crime squad should have been engaged earlier, and an urgent request to Interpol made. Victims were not contacted as early as they should have been, potentially creating a risk for them. Police protective support for the victims was slower than desirable.
• Internal Affairs was unaware Smith's passport application was from a prisoner, meaning it did not matter if it was in the name Traynor or Smith. Customs' border alerts system was not triggered when Smith departed as at that time people in his category were not routinely loaded into the system.
The inquiry said there needed to be better cooperation between police and Corrections in the management of temporary releases, which it noted were a valuable part of prisoner rehabilitation and very rarely breached. Police and Corrections had not specifically agreed how to coordinate the monitoring of temporary releases.
A "step change" was desirable in how information is shared between government agencies - for example, providing Customs with better information on who should not be able to leave the country. Once those systems are in place, police could develop an official identity for everyone charged with an offence.
Smith's escape was not a sign that systems and practices of agencies were broken in a fundamental way, the report states, and "we acknowledge the difficulties these agencies face in allocating resources and balancing priorities".
Responding to the report, Justice Minister Amy Adams and Corrections Minister Peseta Sam Lotu-Iiga said the Government accepted or accepted in principle 34 of the 39 recommendations.
The remaining five recommendations "raise wider issues which the Government will consider as part of this work".
Those recommendations include serious offenders not being able to hold a passport without permission from authorities, Corrections compiling information on all serious offenders who have passports, and giving the Minister of Internal Affairs the discretion to cancel passports for certain people.
"The report highlighted vulnerabilities that need to be addressed including the way we deal with identity and information sharing across the justice sector, and other related agencies such as Customs and Internal Affairs," Ms Adams said.
"A number of refinements across agencies have already been made which will significantly reduce the likelihood of a similar occurrence happening again."
State Services Minister Paula Bennett said she was confident the review, and work programme to be headed by Ms Adams, would see flagged vulnerabilities addressed.
Labour's justice spokeswoman Jacinda Ardern said systemic failings had been exposed by the inquiry. Processes already in place would have stopped the escape had they worked, she said.
"Most concerning is that just one phone call would have thwarted Smith's plans to flee New Zealand."
Green Party co-leader James Shaw said the inquiry showed a huge range of errors.
"The scale of this breakdown is surprising and distressing."
Mr Shaw said resourcing appeared to be an issue, but so too was governance.
"In the Corrections portfolio the Government has stumbled from crisis to crisis...it feels to me like they are running around at the base of the cliff with their ambulance, rather than putting a fence at the top."
Last month the Herald revealed that corruption charges were laid against the prison guard who Smith claimed help him escape to Brazil.
His younger sister has been charged with helping him escape, which she denies, while a fellow inmate, Christopher Ryan Clifton, admitted making a false statement to help Smith get a passport.
On his return to New Zealand, Smith released a handwritten statement which claimed a Corrections officer helped him to obtain a passport and gave him a smartphone and movies. Smith further alleged he received "numerous benefits" from the time of their first meeting to some time between October and November 2012.
The sharing of prisoners' personal information across Government agencies is "crucial" to reducing the future risk of another Phillip Smith escape, Justice Minister Amy Adams said today.
Speaking after the release of an independent report into Smith's escape to Brazil found a chain of shortcomings and failings, Ms Adams accepted the system needed an overhaul.
Law enforcement agencies should be allowed "reasonably open access" to biometric information, fingerprints, photographs, passports, citizenship data, and NZTA files, to prevent prisoners from fleeing the country, she said.
"We cannot have a system that can be defeated by simply assuming another identity," she said.
"What's clear to me is that simply relying on a name record, which has been shown now on a number of occasions to not be a fail-safe process, is not enough and access to photographs, biometric information and fingerprints and the like I think is going to be crucial going forward in ensuring high risk offenders are properly tracked."
Some of the changes mooted could require legislation.
But Ms Adams hopes the bolstered system could be adopted "as fast as possible".
"I'm concerned to ensure that all of the recommendations are thoroughly worked through and that New Zealanders can be confident that this sort of combination of risk factors won't come together again and we won't see a repeat of this sort of behaviour," she said.
"We're committed to reducing that risk as far as possible, but it needs to be said that you can never entirely remove risk and the report makes that quite clear."
While departures such as Smith's are "incredibly rare" and carry a "minuscule risk level", the risk is still "unacceptable".
The removal of passports from high risk offenders is something the Government says it will look at.
But human rights issues surrounding that potential move is something Ms Adams said "needs to be looked at".
"The report and the reviewers were quite strong in their view that passports should simply be cancelled, [but] I think it's a little more complex than that. The core goal is to make sure that prisoners can't leave New Zealand inappropriately, that's what need to ensure and we'll work through which component pieces we need to ensure that."
The system needed to ensure that prisoners could not travel, and that could be ensured by either removing passports, cancelling them, or adopting a "border stop process".
"We need to ensure they can't travel ... whether that necessitates an automatic passport cancellation or it can be achieved another way, is what we have to work through," Ms Adams said.
The fact that Immigration was unaware that Smith was prohibited from travel when he got his passport, was "exactly at the heart of this whole issue of agencies working together", she said.
Sharing information and the right to the public to be kept safe is "far more important" than privacy rights of an offender, she added.
After Smith's escape, the Government immediately told Immigration and Customs of around 11,000 identities of high risk offenders who should not be travelling.
Since then, six offenders have been stopped at the border, Ms Adams said today.
Frontline agencies, including police, Corrections, Customs, and Immigration needed real-time automatic access to each others' databases, she said.
The cost of such system changes was not yet known, the minister said.
The public should still have confidence in Corrections, despite their failings in the Smith case.
"Things weren't done in the way they should've been done, and there is no excuse for that," said Ms Adams.
But she stressed that Corrections dealt with the most difficult people in society and on a whole they did "very good work".
She was "disappointed" that the victims were not told of Smith's escape and the victim notification process needs to improve.
With the implementation of the recommendations, the Justice Minister said she was "very confident" that the risk of a repeated escape will be, and has been, greatly reduced.