The death of a 16-year-old Indigenous boy in a Western Australian youth detention unit was the direct result of "serious longstanding deficiencies" within the justice system, a coronial inquest has found.
Coroner's damning findings and urgent recommendations
State Coroner Phil Urquhart, delivering his findings on Monday, issued 15 adverse findings and 19 recommendations following the death of Cleveland Dodd. The teenager was found unresponsive in his cell at Unit 18, the youth wing within the high-security Casuarina adult prison south of Perth, in the early hours of 12 October 2023.
He died in hospital a week later on 19 October 2023, becoming the first juvenile to die in a West Australian detention facility. Coroner Urquhart stated the death was not due to simple human error by frontline staff but was "caused by serious longstanding deficiencies in the system."
A culture of 'cruel, inhuman and degrading' treatment
The inquest heard shocking details of the conditions endured by young detainees. Cleveland and others were subjected to prolonged solitary confinement, intense boredom, isolation, and ate meals alone. They lacked consistent access to healthcare, education, and even running water.
In the 12 days before he harmed himself, Cleveland spent only between one and two hours each day outside his damaged and unfurnished cell. Former Department of Justice director general Adam Tomison conceded under cross-examination that such treatment was "cruel, inhuman and degrading."
Staff described Unit 18's operating environment as chaotic, with some likening it to a "war zone." The coroner found Cleveland's cell had a known hanging point that had not been repaired, and his requests for counselling services were denied despite repeated threats of self-harm.
Systemic failure and a call for urgent action
The coroner's key recommendations include the urgent closure of Unit 18 and the establishment of a special inquiry with greater powers than the coroner's court to investigate how the unit was created. He also recommended forming a forum to explore whether the Department of Justice should have sole management over youth justice.
"No child in detention deserves to be treated in the way Cleveland and the other young people in Unit 18 were treated at the time he decided to end his life," Coroner Urquhart said.
The inquest heard that after Cleveland self-harmed at approximately 1.35am, staff did not open his cell door to render aid for over 15 minutes. Paramedics arrived a further 15 minutes later. Although partially revived, the teenager suffered a fatal brain injury due to oxygen deprivation.
The WA government has stated that improvements have been made in youth justice since the tragedy and that a purpose-built facility to replace Unit 18 will be completed within three years.
