Warning: This story contains the name and images of a deceased Indigenous person.

The 16-year-old was taken to hospital in a critical condition and died a week later, causing outrage and grief in the community.

A lawyer representing Cleveland’s mother, Nadene Dodd, criticized the level of care provided by Justice Department staff to the teenager during submissions to the Coroner’s Court of Western Australia on Monday.

“Cleveland was subjected to institutional abuse, cruel and inhumane treatment,” Steven Penglis told the inquest.

The teen spent more than 22 hours a day in his cell for 74 of the 86 days he was detained in Unit 18 before he self-harmed, he said.

Over that period, he had four hours of recreation time, equating to about three minutes a day.

The lawyer, Penglis, highlighted that Cleveland’s cell lacked running water, and he requested water six times in the hours leading up to his fatal injury. This was part of the evidence discussed during the inquest, which began in April 2024.

Cleveland’s grandmother Roslyn Sullivan said animals were treated better than her son was as a Unit 18 detainee.

“You get treated more better if you’re in the zoo,” she said outside court.

“No running water, no tap to wash his hands, no tap to wash his body.

“That place shouldn’t have even been there.”

Cleveland threatened to self-harm eight times and requested medical attention.

Penglis explained that the teen’s actions were the result of multiple events, including being refused bail, an unsuccessful attempt to reach his mother on her birthday, and severe, untreated dental problems.

“Cleveland’s death was preventable and predictable,” he said.

Nadene Dodd described her son’s treatment as “horrific neglect” and inhumane.

“It was both barbarous and criminal,” she said outside the court.

“If people are not held to lawful account, then justice will have been denied.”

Aboriginal Legal Service lawyer Julian McMahon said the inquest revealed there was a readiness across all levels of the Justice Department to accept the unacceptable.

“What happened at Unit 18 was horrific,” he said in his submissions.

There was an “epidemic of self-harm” among a cohort of mostly Indigenous children, he said.

“By self-harm, I mean attempted suicide,” McMahon said.

There had been at least 17 self-harm threats in the 24 hours before Cleveland fatally injured himself, he said.

Lawyers for senior Justice Department staff said their clients shouldn’t be subject to adverse findings, including former director-general Dr Adam Tomison.

How the facility was run wasn’t his responsibility and Corrective Services staff should have followed policy, lawyer Jerome Allan said

Tomison previously agreed children had been subject to appalling, cruel, inhumane and degrading treatment in Unit 18 under his watch.

The Justice Department apologised to Cleveland’s family and said there were many issues in Unit 18 in 2023, including damaged infrastructure, excessive detainee confinement and staff shortages.

On the night Cleveland self-harmed, he was not properly supervised and should have been given more water, lawyer Tim Russell said.

“More should have been done,” he said.

But the department did not accept Unit 18 was unfit for youth detainees.

The inquest previously heard Cleveland self-harmed about 1.35am and paramedics arrived at 2.06am, but did not get access to him for nine minutes.

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

For 24/7 crisis support run by Aboriginal and Torres Strait Islander people, contact 13YARN (13 92 76).