Cleveland Dodd coronial inquest findings call for Unit 18 to be shut down ‘as a matter of urgency’
In short:
Coroner Philip Urquhart has called for the urgent closure of Unit 18 following an inquest into the death of 16-year-old Cleveland Dodd, labeling his treatment “inhumane” and “institutional neglect.”
The findings attributed the tragedy to chronic understaffing and systemic failures rather than individual staff misconduct, resulting in 19 recommendations for reform.
WA’s troubled Unit 18 youth detention centre is dangerous and should be closed “as a matter of urgency”, warned Coroner Philip Urquhart Monday as he released findings of the coronial inquest into the death in custody of 16-year-old Yamatji boy Cleveland Dodd.
Mr Urquhart said Unit 18 had been an unsafe environment for inmates when Cleveland’s death occurred, and should be closed despite improvements that have since been made to its safety.
But he stressed that Unit 18 staff on shift were not responsible for Cleveland’s death. Instead, the main problem was that Unit 18 was chronically understaffed, and had been for years.
Cleveland was found unresponsive in his cell at Casuarina Prison in the early hours of October 12, 2023. The teenager, who died a week later after being kept on life support, was being held in Unit 18, a youth detention centre at the maximum security adult prison.
Cleveland had warned prison staff he intended to take his own life, the inquest noted. The staff asked him not to say such things. Some 13 minutes later, prison officers found him unresponsive in his cell, where the CCTV cameras had been covered by toilet paper for many hours.
Cleveland had been in custody for about three months, during which time he had repeatedly made threats of self-harm. But he had been removed from the prison’s list of “at-risk” youths before he fatally self-harmed. During that same evening, Unit 18 staff several times rejected his request for a cup of water. Cleveland had also continually been denied time outdoors, having been inside for more than 22 hours a day during 74 of his 86 days at Unit 18.
Mr Urquhart described Cleveland’s cell confinement as “deeply disturbing” and “inhumane”. Cleveland would have felt “despair and despondency” due to these conditions, he said.
Just five months before Cleveland’s death, Unit 18 had been exposed as having youths and staff in crisis by a May 2023 audit by WA Inspector of Custodial Services Eamon Ryan. Mr Ryan found rates of attempted suicide and self-harm in Unit 18 had reached unprecedented levels.
Similar failures in WA’s youth-justice system were uncovered by the coronial inquest into Cleveland’s death, and also by a 2024 Corruption and Crime Commission investigation into his case.
The CCC cleared prison staff of serious misconduct on the night Cleveland fatally harmed himself. But it found that Unit 18 was “trapped in a cycle of destruction”, with its staff poorly equipped to assess the seriousness of frequent self-harm threats made by youths.
Mr Urquhart said Cleveland represented the first death in WA of a child in custody, and described this inquest as the “saddest I have presided over”.
The Coroner said no child in detention deserved to be treated the way Cleveland and other Unit 18 inmates were treated when he took his life.
Intense boredom, lack of access to mental health services, education and even running water had become the norm for Cleveland and many fellow detainees, he said.
The Coroner made 15 adverse findings against the Department of Justice and issued 19 recommendations.
Cleveland was in ‘unbearable physical and psychological pain’
Nadene Dodd, Cleveland’s mother, issued a statement after the Coroner brought down his findings.
“The pain I feel today is as intense as it was when I heard that Cleveland had taken his own life on 12 October 2023,” she said.
“I believed that my son Cleveland would be safe, and that he would be treated humanely while he was held in detention. But the evidence before the inquest into his tragic death at Unit 18 confirmed that Cleveland was neither.
“I believe that Cleveland’s death was the product of institutional abuse and neglect, and it breaks my heart to know that Cleveland spent 23 hours a day, for days on end, locked down in a filthy cell with no end in sight.”
Ms Dodd said that by the early hours of the 12 October 2023, her son “was in unbearable physical and psychological pain and was unable to get even his most basic needs met”.
“For example, Cleveland’s repeated requests for water, and threats of self-harm and suicide, were ignored by custodial staff,” she said.
“I can understand why my son lost hope and the will to live. While I hope that Cleveland’s death, and Coroner Urquhart’s findings and recommendations will catalyse the change required to prevent other children from suffering the way my son did, it depends upon a seismic shift in the Department’s approach to youth justice, yet to be effected.”
Ms Dodd thanked Coroner Urquhart and Mr Anthony Crocker “for the efforts they made to investigate the cause of Cleveland’s death, and for their compassion, and Ms Shirley Tan, the Coronial Counsellor for her support”.
She also expressed gratitude to Gerry Georgatos, Connie Georgatos and Megan Krakouer for “being a constant source of support since Cleveland’s death in 2023”.
Ms Dodd thanked her family, including her uncle Stewart, aunt Gillian and Cleveland’s grandmother Glenda Mippy, “for being there to support me and my children”, and her legal representatives, Steven Penglis SC and Dana Levitt and solicitors from Levitt Robinson and Gilbert + Tobin, and Cleveland’s lawyers at the Aboriginal Legal Service of Western Australia for advocating for Cleveland when he was held in Banksia Hill and Unit 18.
Mr Georgatos said Cleveland’s family were very disappointed that staff at Unit 18 were not held accountable for their actions, and inaction, in the lead up to his death.
He said Cleveland’s family believes the Unit 18 staff should be pursued for workplace misconduct or even potential criminal conduct.
Many family members came to the court Monday from across WA, “hoping that they would get people properly held to account for failure of duty of care”, he said.
“They agree with the coroner that Unit 18 should be shut immediately.”
He said they also expressed hope that Cleveland’s tragic death may yet result in major improvements to WA’s youth custody system, and save the lives of other detained children.
Earlier in the morning a silent vigil was held outside the Boorloo court house in Cleveland’s memory.
The WA Department of Justice said “Cleveland’s passing was a tragedy” and that since late 2023, it has “implemented a comprehensive program to strengthen youth detention and improve outcomes for young people”.
“These reforms are guided by a Model of Care which sets out a therapeutic, trauma-informed approach to care across the youth estate (and) focuses on safety, cultural security, rehabilitation and throughcare, ensuring young people are supported to reintegrate successfully into the community,” the Department said in a statement.
“Out-of-cell hours have increased significantly, supported by a major increase in Youth Custodial Officers who are now equipped with body-worn cameras. In addition, staff receive training from the National Organisation for Fetal Alcohol Spectrum Disorders to assist with the management of young people.
“Mental health and cultural supports have also been expanded, and individual engagement plans are in place for every young person at Unit 18, developed with psychologists and Aboriginal Youth Support Officers The Aboriginal Services Unit provides cultural connection for young people.”
Director General Kylie Maj said the Department’s focus is on “creating a youth justice system that is safe, culturally responsive and rehabilitative, so young people have the best chance to turn their lives around”.
The Department said it will “carefully review the Coroner’s report and consider opportunities for further improvement” to youth justice.
Note: This report was updated at 1.09pm WST to include the Department of Justice response.
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