on 19 November 1936, Henry Doyle Mosely was appointed as Royal Commissioner to investigate, report and advise upon the following matters:

1) The methods observed in connection with the custody of criminally insane persons at the Claremont Mental Hospital and the precautions observed to prevent their escape; and

2) The circumstances of the escape of Edward Nicholas Kelly and John Edward Rowe on the 7th day of November, 1936 from the said hospital;

and to make recommendations for improving the methods of preventing escape of criminally insane patients from the hospital.

In his report, Mosely summarised his recommendations as follows:

1) Certain criminally insane persons to be transferred from Claremont Hospital for the Insane to Fremantle Prison;

2) Board of Specialists in Mental Diseases to decide place of detention of criminally insane persons;

3) Increased staff at Hospital for the Insane;

4) Immediate examinations of all locks and check of all keys;

5) Members of staff to hand in keys when going off duty;

6) External doors to have double or treble locks and automatic locking; and

7) Installation of clock system of check on vigilance of attendants in Wards.