Youth justice in crisis before teen's death: coroner
Cleveland Dodd was found unresponsive inside a cell in Unit 18, a youth wing of the high-security adult facility Casuarina Prison in Perth, in the early hours of October 12, 2023.
The 16-year-old was taken to hospital in a critical condition and died a week later, causing outrage and grief in the community.
It led to a long-running inquest that started in April 2024, with coroner Philip Urquhart saying he might recommend for Unit 18 to be closed, as he delivered his preliminary findings on Tuesday.
"There can be no doubt the evidence from the inquest revealed that youth justice had been a crisis at the time of Cleveland's death and had been for some time," he told the coroner's court.
The coroner indicated he might recommend the justice department no longer oversee the youth justice estate.
He is considering calling for a special inquiry under the Public Sector Management Act into how Unit 18 came to be established in mid-2022.
"Everything must be done to minimise the risk of another death of a child in youth detention," Mr Urquhart said.
The coroner said evidence supported findings the justice department had failed to properly supervise Cleveland before he fatally harmed himself.
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, Mr 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", Mr 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.
13YARN 13 92 76
Lifeline 13 11 14
Everything must be done to ensure another child doesn't die in youth detention, a coroner has told an inquest for an Indigenous teenager who fatally self-harmed while in custody.
Cleveland Dodd was found unresponsive inside a cell in Unit 18, a youth wing of the high-security adult facility Casuarina Prison in Perth, in the early hours of October 12, 2023.
The 16-year-old was taken to hospital in a critical condition and died a week later, causing outrage and grief in the community.
It led to a long-running inquest that started in April 2024, with coroner Philip Urquhart saying he might recommend for Unit 18 to be closed, as he delivered his preliminary findings on Tuesday.
"There can be no doubt the evidence from the inquest revealed that youth justice had been a crisis at the time of Cleveland's death and had been for some time," he told the coroner's court.
The coroner indicated he might recommend the justice department no longer oversee the youth justice estate.
He is considering calling for a special inquiry under the Public Sector Management Act into how Unit 18 came to be established in mid-2022.
"Everything must be done to minimise the risk of another death of a child in youth detention," Mr Urquhart said.
The coroner said evidence supported findings the justice department had failed to properly supervise Cleveland before he fatally harmed himself.
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, Mr 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", Mr 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.
13YARN 13 92 76
Lifeline 13 11 14
Everything must be done to ensure another child doesn't die in youth detention, a coroner has told an inquest for an Indigenous teenager who fatally self-harmed while in custody.
Cleveland Dodd was found unresponsive inside a cell in Unit 18, a youth wing of the high-security adult facility Casuarina Prison in Perth, in the early hours of October 12, 2023.
The 16-year-old was taken to hospital in a critical condition and died a week later, causing outrage and grief in the community.
It led to a long-running inquest that started in April 2024, with coroner Philip Urquhart saying he might recommend for Unit 18 to be closed, as he delivered his preliminary findings on Tuesday.
"There can be no doubt the evidence from the inquest revealed that youth justice had been a crisis at the time of Cleveland's death and had been for some time," he told the coroner's court.
The coroner indicated he might recommend the justice department no longer oversee the youth justice estate.
He is considering calling for a special inquiry under the Public Sector Management Act into how Unit 18 came to be established in mid-2022.
"Everything must be done to minimise the risk of another death of a child in youth detention," Mr Urquhart said.
The coroner said evidence supported findings the justice department had failed to properly supervise Cleveland before he fatally harmed himself.
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, Mr 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", Mr 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.
13YARN 13 92 76
Lifeline 13 11 14
Everything must be done to ensure another child doesn't die in youth detention, a coroner has told an inquest for an Indigenous teenager who fatally self-harmed while in custody.
Cleveland Dodd was found unresponsive inside a cell in Unit 18, a youth wing of the high-security adult facility Casuarina Prison in Perth, in the early hours of October 12, 2023.
The 16-year-old was taken to hospital in a critical condition and died a week later, causing outrage and grief in the community.
It led to a long-running inquest that started in April 2024, with coroner Philip Urquhart saying he might recommend for Unit 18 to be closed, as he delivered his preliminary findings on Tuesday.
"There can be no doubt the evidence from the inquest revealed that youth justice had been a crisis at the time of Cleveland's death and had been for some time," he told the coroner's court.
The coroner indicated he might recommend the justice department no longer oversee the youth justice estate.
He is considering calling for a special inquiry under the Public Sector Management Act into how Unit 18 came to be established in mid-2022.
"Everything must be done to minimise the risk of another death of a child in youth detention," Mr Urquhart said.
The coroner said evidence supported findings the justice department had failed to properly supervise Cleveland before he fatally harmed himself.
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, Mr 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", Mr 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.
13YARN 13 92 76
Lifeline 13 11 14
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WA's youth justice system in crisis before 16-year-old's death: coroner
The coroner said evidence supported findings the justice department had failed to properly supervise Cleveland before he fatally harmed himself. Loading 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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In handing down his early assessment of WA's first recorded death in youth detention, Coroner Philip Urquhart had the opportunity to provide a vote of confidence in how the Department of Justice responded to the tragedy. WARNING: This story discusses incidents of self-harm and contains the name and image of an Indigenous person who has died. Instead, he did the opposite, at least in part. The department has repeatedly argued the inquest's scope should be limited to only what is directly relevant to Cleveland Dodd's death, which came after he self-harmed inside his cell in a makeshift youth detention facility in 2023. In its closing submissions, it said "the general operation of youth justice in this state" should be looked into "at another time and in another place". That was despite Coroner Urquhart describing evidence heard by the inquest as revealing "youth justice was in a crisis at the time of Cleveland's death and had been for some considerable time". 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"There is evidence that has revealed aspects of the manner in which the department did its work which is worthy, in my view, of closer examination in a special inquiry," was the polite way he phrased it, pointing to some of the evidence he had heard. Among it, testimony from then-corrective services commissioner Mike Reynolds, who had been on leave around the opening of Unit 18, that it was a "bad decision" which was "destined to fail". He also pointed to evidence from Christine Ginbey, who had been in charge of youth detention at the time, saying the three weeks or so her team was given to get Unit 18 ready was "entirely unreasonable" and should have been closer to six months. While the idea of a special inquiry makes sense — given its scope can be much broader and isn't scope not as constrained as an inquest — it's hard to see the government willingly submit itself to another inquiry which almost certainly would not paint its work in a positive light. "I'm not going to add any more in relation to that, it's far too early," Corrective Services Commissioner Brad Royce said outside court. A state government spokesperson said it could not comment "until the inquest's final report is delivered". To its credit, the department has not been waiting for that final report to take action — something Coroner Urquhart did acknowledge. "We have had the opportunity throughout this inquest to understand the likely recommendations and we've acted on those," Commissioner Royce said. "From the time of the start of this coronial process you would see that there have been a lot of changes and I'd like to acknowledge that the staff at Corrective Services and our significant partners have put a lot of effort into the change that you've seen across the estate. "We acknowledge that we have a lot of work to do and we'll continue to work hard in that space." It is this change that Cleveland Dodd's family hope has a meaningful impact. "If Cleveland had all the right help … maybe he'd be here today with us," his grandmother Roslyn Sullivan said outside court. "All the things he went through, I wouldn't want another child to go through that." Despite the department's work, a key request of Cleveland's family — and what the coroner has flagged could be one of his key recommendations — remains just an idea. Since it opened there have been calls to close Unit 18, the argument being an adult prison will never be suitable to look after the state's most vulnerable youths. The government has maintained it cannot close the facility until a replacement is built, because it needs two distinct locations to manage young people in detention, lest the chaos that led to the opening of Unit 18 be repeated. The government promised to do that in late 2023, the month after Cleveland died. But the government is yet to allocate the project more than $11.5 million in last month's state budget — money it announced nearly a year ago for planning and early site works. That's not enough to satisfy Cleveland's family and those desperate for change. While not directly addressed by Coroner Urquhart, he did note he is still weighing up whether to recommend Unit 18 be closed when he hands down his final report. "Everything must be done to minimise the risk of another death of a child in youth detention in Western Australia," he said in closing the inquest's hearings yesterday. The ultimate test for this inquest — and any processes that follow it — is whether they result in real, lasting change in WA's long-troubled youth justice system. Former inspector of custodial services Neil Morgan wrote in 2017: "For the nine years I have been in this job, Banksia Hill has lurched from crisis to partial recovery and then back into crisis." Only time will tell if that cycle will be broken this time around. And while a specific examination into what went wrong at the department is not essential, it certainly wouldn't hurt efforts to deliver meaningful change.
