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Warning: This article contains the name and image of an Aboriginal person who has died.
Long-standing failures in the justice system caused the death of an Indigenous teenager who fatally self-harmed in detention, a coroner has found.
Cleveland Dodd was found unresponsive inside a cell in the trouble-plagued youth wing of a high-security adult prison, south of Perth, in the early hours of October 12, 2023.

A 16-year-old boy tragically passed away after being hospitalized in critical condition, marking the first instance of a juvenile dying in a detention facility in Western Australia.

Coroner Phil Urquhart said the unit should be closed as a matter of urgency, and a special inquiry with more powers than the coroner’s court should be convened into how it came to be established.
“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,” he said on Monday.
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 due to human error by the staff on the ground … it was the result of deep-rooted and long-standing issues within the system,” a source stated.

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.

The cell where Cleveland was held had a known hanging point that had not been fixed by authorities. Additionally, Cleveland was repeatedly denied counseling services despite his multiple requests and expressed self-harm threats.

CLEVELAND DODD DEATH INQUEST

Following the inquest into Cleveland Dodd’s death, Bonnie Gentle and Eunice Mippy, his aunts, addressed the media alongside social justice advocate Megan Krakouer at the Central Law Courts in Perth on Monday, December 8, 2025. Source: AAP / Richard Wainwright/AAP Image

During the inquest, the court was informed that the youth justice system was in crisis at the time of Cleveland’s death.

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.

In the 12 days leading up to his tragic act, Cleveland was allowed out of his damaged and bare cell for only one to two hours each day.

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