Misunderstandings, assumptions, and "departures" from normal procedure caused the accidental release of an alleged domestic violence offender from custody earlier this month.
The blunder saw Scott Alan Insull, 41, walk free from court after he was charged with choking and assaulting his girlfriend in early September.
Mr Insull, prosecutors say, used his erroneous release to contact the alleged victim, before being recaptured interstate a day later.
The mistake put Mr Insull at large during a time typically thought to be high risk in domestic violence cases.
The government ordered an urgent internal review of the error after being alerted to it by Fairfax Media.
That review, expected to be tabled in the Legislative Assembly on Thursday, has found Insull's mistaken release was the result of numerous departures from "usual court administrative procedures".
Mr Insull first appeared in the ACT Magistrates Court on September 2, a day after the offences are alleged to have occurred.
He made a bail application and told the court he had an address in Sydney he could stay at, to keep him out of Canberra and away from the complainant.
Prosecutors asked for time to check the legitimacy of the home, and Insull was supposed to remain in custody until such checks were made.
In an unusual move, the court gave him bail but imposed a condition that he was to remain in custody until the Office of the Director of Public Prosecutions was satisfied with the address and had contacted authorities to let them know.
It is understood that condition created significant confusion, and was interpreted incorrectly.
Mr Insull was released immediately. Subsequent checks suggested the residents at the Sydney address did not want the detainee there, the court heard.
Upon learning of the mistake, the court issued a warrant for Mr Insull's arrest.
Attorney-General Simon Corbell said the government is already acting to prevent a repeat, by clarifying the roles of magistrates' associates, corrections officers and bail officers during the bail process.
Mr Corbell said written policies, procedures and training material would all be reviewed and updated to ensure a full understanding of "custody arrangements" as set out in territory law.
"The review found that Mr Scott Alan Insull was released as a result of a number of departures from the usual court administrative processes," Mr Corbell said.
"There was also a misunderstanding as to the order made and incorrect assumptions regarding whether the precondition to bail in the magistrate's order had been met."
All recommendations of the review, presented by Chief Magistrate Lorraine Walker, were accepted by the government.
The report was also accepted by Justice Minister Shane Rattenbury, who told the ABC earlier this month he was deeply troubled by the incident.
A new electronic case management system, which will allow the court to record bail details electronically, is expected to help clarify bail decisions.
Mr Insull's case returned to court this week.
He is accused of choking his girlfriend twice. According to court documents, the woman thought she was going to die.
He allegedly stabbed her tyres with scissors, and shoved her with his elbow, causing her to fall and lose consciousness.