A coroner’s investigation has highlighted systemic shortcomings within the justice system that led to the tragic death of an Indigenous teenager who took his own life while in custody.

In the early hours of October 12, 2023, Cleveland Dodd was discovered unresponsive in a cell within the troubled youth section of a maximum-security adult prison located south of Perth.

The 16-year-old was rushed to the hospital in critical condition, but sadly passed away about a week later, marking the first instance of a juvenile fatality in a Western Australian detention center.

Coroner Phil Urquhart has urged the immediate closure of the unit and recommended a comprehensive inquiry, with greater authority than the coroner’s court, to investigate the circumstances that led to its formation.

“No child in detention should endure the treatment Cleveland and his peers in Unit 18 experienced at the time he chose to end his life,” he stated.

Cleveland and other detainees faced extreme conditions, including prolonged solitary confinement, isolation, severe boredom, solitary meals, and insufficient access to health care, education, and even basic necessities like running water, he explained.

“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.

13YARN 13 92 76, Lifeline 13 11 14, Kids Helpline 1800 55 1800