WA's youth justice system in crisis before 16-year-old's death: coroner
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He found staff failed to wear radios as per department policy, Cleveland was confined to his cell for excessive amounts of time and the teen's cell was in a condition that enabled him to self-harm.
The department had accepted many failings, including staff not following policies and procedures and Cleveland's lack of access to running water in his cell, Urquhart said.
He pointed to extensive evidence Cleveland was not receiving adequate mental health and therapeutic support, education, recreation and 'access to fresh air'.
'There is much evidence to suggest that these needs of Cleveland were not adequately met,' he said.
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', Urquhart said as he recapped some of the evidence.
'They described the soul-destroying daily confinement orders which kept detainees in their cells, sometimes for 24 hours a day,' he said.
'They described the lack of support and training given to them to do their jobs and they described the chronic shortage of staff.'
The coroner revisited evidence heard about the establishment of Unit 18, as he made a case for a special inquiry after the department and some other counsel made submissions it was beyond the jurisdiction of the court.
He said further adverse findings against the department and individuals would be confined to actions taken or not taken in Unit 18 and matters connected to Cleveland's death.
He said examples of these would be what staff did after Cleveland covered his in-cell observation camera and the damage in his unit that enabled him to harm himself.
The inquest previously heard Cleveland self-harmed about 1.35am.
At 1.51am, an officer opened his cell door and at 1.54am a red alert was issued as staff tried to revive the teen.
Paramedics arrived at 2.06am but did not get access to Cleveland, who was found to be in cardiac arrest, for nine minutes.
The teen was partially revived and taken to hospital but suffered a brain injury becauise of a lack of oxygen.
Cleveland died, surrounded by his family, on October 19, 2023.
AAP
Crisis support is available from Lifeline 13 11 14. For 24/7 crisis support run by Aboriginal and Torres Strait Islander people, contact 13YARN (13 92 76).
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