Systemic failures within the justice system have been blamed for the tragic death of an Indigenous teenager who took his own life while in detention, according to a coroner’s report.

Cleveland Dodd, a 16-year-old, was discovered unconscious in a cell within the youth section of a troubled high-security adult prison located south of Perth, early on October 12, 2023.

He was urgently transported to a hospital in critical condition but sadly passed away about a week later. This marked the first instance of a juvenile death in a detention center in Western Australia.

Coroner Phil Urquhart has called for the immediate closure of the unit and recommended launching a special inquiry with authority exceeding that of the coroner’s court to investigate its establishment.

“No child in detention should be subjected to the conditions Cleveland and other young detainees experienced in Unit 18 during the period leading to his tragic decision,” Urquhart stated today.

Prolonged periods of solitary confinement, isolation, intense boredom, eating meals alone, a lack of access to health, education and running water were the norm for Cleveland and the other detainees, he said.

“There were serious deficiencies in the way our young people were treated in detention,” Mr Urquhart said.

“Cleveland’s death was not because of human error by those working on the floor … it was because of serious long-standing deficiencies in the system.”

The coroner made 15 adverse findings and 19 recommendations, including that a forum is established to explore whether the Department of Justice should have sole management over youth justice.

His findings included that Cleveland was subject to excessive solitary confinement in his cell and was not properly monitored while in there.

Cleveland’s damaged cell also had a hanging point the authorities were aware of that had not been repaired, and he had been denied access to counselling services despite requesting it on numerous occasions and making threats to self-harm.

During the inquest, the court heard youth justice was in a crisis at the time of Cleveland’s death.

Staff described the appalling conditions in which the young people were being detained and the chaotic operating environment at Unit 18, with some saying it was a “war zone”.

In the 12 days before he harmed himself, Cleveland spent between one and two hours out of his damaged and unfurnished cell each day.

Former Department of Justice director general Adam Tomison conceded it was “cruel, inhuman and degrading” treatment when cross-examined.

The inquest heard Cleveland self-harmed about 1.35am and staff didn’t open his cell door to help him for more than 15 minutes, with paramedics arriving a further 15 minutes later.

The teen was partially revived and taken to hospital but suffered a brain injury because of a lack of oxygen.

He died, surrounded by his family, on October 19, 2023.

The WA government has previously said many improvements have been made in youth justice since Cleveland died and that a purpose-built facility to house detainees from Unit 18 will be completed within three years.

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