It was only a matter of time before a youth died in custody, the prison watchdog has told an inquest for the first juvenile to die in West Australian youth detention.
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Cleveland Dodd was found unresponsive inside a cell in the trouble-plagued youth wing of a high-security adult prison in the early hours of October 12, 2023.
The 16-year-old was taken to hospital in a critical condition and died about one week later, causing outrage and grief in the community.
Inspector of Custodial Services Eamon Ryan told the Perth inquest he issued a show-cause notice to the justice department amid concerns for youth detainees in Banksia Hill Youth Detention Centre's intensive support unit in late 2021.
Mr Ryan was worried detainees were being subjected to cruel, inhumane and degrading treatment in the intensive support unit, in breach of state laws and international obligations.
It was a situation that had been going on for several years and in response the detainees' behaviour had become more challenging and volatile.
"What we were seeing was a downward spiral and there was an increased number of suicide attempts," he told the coroner on Tuesday.
"I was really concerned that it was only a matter of time and there was an element of luck in the fact that a suicide hadn't taken place."
The department responded to the notice and a preliminary report authored by Mr Ryan following an inspection of the facility, stating that Banksia Hill wasn't fit for purpose.
It also said it was managing a difficult cohort of detainees and compliant with state law but the international rules weren't enshrined in WA legislation.
Mr Ryan elevated his concerns to the then corrections minister Bill Johnston, who also said the centre was inadequate in a letter in early 2022.
He did not address Mr Ryan's concerns about the government acting unlawfully.
Several months later Unit 18 was created in Casuarina Prison, an adult maximum security male prison.
Cleveland was transferred to it from Banksia Hill in September 2022.
The inquest previously heard Cleveland made eight threats to self-harm, and numerous requests for medical treatment and drinking water in the hours before he was discovered.
Night-shift staff ignored those requests because a senior officer informed them Cleveland had been given six cups of water with his dinner and his cell was not to be unlocked.
But CCTV footage shows Cleveland was given only three cups of water when his evening meal was delivered to his cell about 6pm, along with a bladder of milk.
Cleveland's threats to self-harm on October 11 and 12 started after his fifth request for water was ignored.
He had also covered a CCTV camera in his cell with tissue paper, blocking the view of correctional staff monitoring him from a control room, but it wasn't uncovered until they were fighting to save his life.
Officers were generally reluctant to open detainees' cell doors at night "due to staffing numbers and risk issues". But a guard did visit Cleveland's cell and speak to him through the door before moving on to check on another detainee.
It was about this time Cleveland self-harmed.
A video shows a staff member banging on Cleveland's cell door soon after, but he didn't have keys to open it or a radio to call for help.
The officer left Cleveland and walked to senior officer Kyle Meade-Hunter's office on another floor to collect the keys.
Cleveland's cell door was opened at 1.51am, with a code red alert issued two minutes later 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 due to a lack of oxygen.
He died, surrounded by his family, on October 19.
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Australian Associated Press
