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Coroner puts justice department on notice over inquest

Key points:

  • A coroner has expressed alarm over the “unliveable, disgusting and inhumane” cells in a prison wing where a teenager died after self-harming.
  • Coroner Philip Urquhart on Friday shared his preliminary observations, following more than a week of evidence that he said “breached” the unit’s closed doors.
  • The coroner said the unit, inside a maximum-security prison built for adults, was unfit for housing youth detainees and they could not be treated in a way that reflected the community’s values.
WARNING: Aboriginal and Torres Strait Islander readers are advised that this article contains an image of a person who has died.
A supervisor in the controversial teen unit at Casuarina Prison has claimed Cleveland Dodd's damaged air vent was meant to be repaired the day before he self-harmed. (9News)
A supervisor in the controversial teen unit at Casuarina Prison has claimed Cleveland Dodd’s damaged air vent was meant to be repaired the day before he self-harmed. (9News)

A coroner has expressed alarm over the “unliveable, disgusting and inhumane” cells in a prison wing where a teenager died after self-harming.

Cleveland Dodd was found unresponsive in the early hours of October 12, 2023 inside his cell in Unit 18 at Perth’s Casuarina Prison, becoming the first juvenile to die in detention in Western Australia.

The 16-year-old had made eight threats to self-harm and numerous requests for medical treatment in the hours before he was discovered and taken to hospital.

He died eight days later.

Coroner Philip Urquhart on Friday shared his preliminary observations as part one of the inquest came to a close, following more than a week of evidence that he said “breached” the unit’s closed doors.

The coroner said the unit, inside a maximum-security prison built for adults, was unfit for housing youth detainees and they could not be treated in a way that reflected the community’s values.
He also raised concerns about the system for monitoring detainees deemed to be at risk of harming themselves and said there was serious doubt it could be done in Unit 18.

“Unliveable, disgusting and inhumane, just three descriptions of the conditions of cells at Unit 18 by 2023,” he said.

“What also concerns me is that many of these cells had no running water not just for the odd day, or odd hour but lengthy periods of time.”

A coroner has expressed alarm over the "unliveable, disgusting and inhumane" cells in a prison wing where a teenager died after self-harming. (9News)
A coroner has expressed alarm over the “unliveable, disgusting and inhumane” cells in a prison wing where a teenager died after self-harming. (9News)

Urquhart also noted evidence about the lack of staff training and junior staff filling senior roles, along with the extensive use of confinement that resulted in some detainees spending more than 20 hours per day in their cells.

“The evidence again coming to me is that it wasn’t just on the odd occasion,” he said.

“It was day in, day out and on some of the evidence week in and week out.”

The coroner also put the Department of Justice on notice and told the court it had failed to provide requested information.

He read out a series of questions he wants answers to before the inquest resumes on July 22, including how it is that Unit 18 was chosen as a place to house children.

Cleveland Dodd's family outside of the inquest on Friday. Hearings into his death will now resume in July. (9News)
Cleveland Dodd’s family outside of the inquest on Friday. Hearings into his death will now resume in July. (9News)

“This is the end of part one of the inquest but it’s only just begun,” he said.

“We have so much more to look at and I will do my very best to find answers.”

The inquest also heard that every Unit 18 cell had damage that detainees could have used to inflict injuries on themselves.

A damaged air vent in the ceiling has been linked to Cleveland’s fatal injury.

The unit’s management team was aware of the damage and it was scheduled for repair on October 11, but that didn’t happen.

Urquhart said he inspected Unit 18 after the teen died and found damage to the air vents in seven of the 16 cells he examined.

The inquest has been told other cells had exposed wiring and broken plumbing, and were filthy.

Cleveland’s cell had no running water and he also made multiple calls from his cell in an agitated state asking for drinking water, before he was found motionless.

The inquest has heard night shift staff ignored those requests because a senior officer had 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.

The United Nations stipulates “drinking water shall be available to every prisoner whenever he or she needs it”.

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Cleveland Dodd inquest told Unit 18 officer believed teen’s death was preventable

Key points:

  • In short: The youth custodial officer who found Cleveland Dodd unresponsive in his cell is giving evidence at an inquest into the teenager’s death.
  • Daniel Martin Torrijos was disciplined in 2021 for failing to check detainees’ cells seven times when required, but indicating he had on paperwork, at Banksia Hill Juvenile Detention Centre.
  • What’s next? Cleveland’s family are bracing for “more pain” as the inquest continues to hear evidence from Unit 18 staff until the end of the week.
YOUTUBE: The officer who found Cleveland Dodd unresponsive in his cell says the boy’s death was avoidable.

The youth custodial officer who found Cleveland Dodd unresponsive in his cell has told an inquest into the teenager’s death that the tragedy could have been avoided.

WARNING: This story discusses incidents of self-harm and contains the name and image of an Indigenous person who has died.

Cleveland Dodd, 16, died after self-harming in his cell in Unit 18, a youth wing of maximum security adult Casuarina Prison.

Youth custodial officer Daniel Martin Torrijos found Cleveland unresponsive in his cell in the early hours of October 12, 2023.

Cleveland Dodd told officers eight times on the night in question that he was going to kill himself. (Supplied: Family)
Cleveland Dodd told officers eight times on the night in question that he was going to kill himself. (Supplied: Family)

The inquest has heard Mr Torrijos had been disciplined previously in 2021 for failing to check detainees’ cells seven times when required, but indicating he had on paperwork, while working at Banksia Hill Juvenile Detention Centre.

Some detainees were required to be checked on in their cells as often as every 15 minutes.

Mr Torrijos said it was “unrealistic” to meet the required number of cell checks, and had told authorities detainees should have been monitored via cameras.

“It was dangerous for the detainees, it was putting them in danger and they should be under camera,” he said.

Bail denial not passed on: officer

Questioned during the inquest, Mr Torrijos said officers “struggled” to receive training on cultural awareness, CPR, and restraint techniques.

“We’ve just been struggling to function, let alone do the … training,” he said.

The inquest heard Mr Torrijos was unaware Unit 18 had specific behaviour standards and management policies, and that some detainees were put under individual engagement plans.

He was also not aware Cleveland had been refused bail earlier on the day the 16-year-old told officers he was going to kill himself on eight separate occasions.

YOUTUBE: Nadene’s son was locked up to keep him and the community safe. Instead, he lost his life.

Mr Torrijos said he would typically be informed of that kind of information — and it would have informed how he managed Cleveland — but that night, he was not told.

The inquest was told Cleveland asked for water as many as 12 times that night, but wasn’t given any.

Mr Torrijos said he had been instructed not to open Cleveland’s cell to give him water because he had already been given six cups earlier in the day.

Outside court, Cleveland’s grandmother Glenda Mippy questioned why officers weren’t able to give Cleveland water.

Glenda Mippy, the paternal grandmother of Cleveland Dodd. (ABC News: Keane Bourke)
Glenda Mippy, the paternal grandmother of Cleveland Dodd. (ABC News: Keane Bourke)

“All the kids was locked in their cells, so what were they doing? They didn’t have time to pass the kid a cup of water?” she said.

Youth custodial officer Toni Priestley, who was also on shift at Unit 18 the night Cleveland was found unresponsive, did not attend the inquest but had a statement read out on her behalf.

Ms Priestley said she made a request to senior officer Kyle Mead-Hunter to unlock Cleveland’s cell and give him water.

“Kyle did not approve this request as he said Cleveland had just been given water with dinner,” she said.

CCTV footage played in the inquest showed Mr Torrijos looking into Cleveland’s cell about 1:50am, when the officer said he found the teenager unresponsive.

He then walked away to retrieve keys, arriving back at the cell about 90 seconds later.

Mr Torrijos said he moved as quickly as his arthritic knees allowed him to.

While getting the keys, Mr Torrijos said he informed senior custodial officer Kyle Mead-Hunter that “Cleveland’s f****** hanging”.

The inquest heard Mr Mead-Hunter put on his duty belt and boots, and CCTV footage showed him leaving a room that initially had its lights off, buttoning up his shirt, and walking with his hands in his pockets to Cleveland’s cell.

In her statement, officer Priestley said she was on a break at that time.

“I had on my headphones and had my back to the rest of [the room] … I didn’t know what was going on when the incident first started,” she said.

She eventually noticed and called a “code red medical” which prompted medical staff, and eventually paramedics, to arrive at Unit 18.

Unit 18 staff watched movies

Under questioning, Mr Torrijos said staff would often watch movies or other downloaded material on a computer during the night at Unit 18, and previously at Banksia Hill.

“To help you stay awake, it was just something you did,” he said.

“The computer was there. It wasn’t something that we were told not to do.”

Mr Torrijos said night shifts were often quiet enough to allow time for staff to watch movies, but he would always stop if something needed to be done.

The teenager self-harmed in his cell in Unit 18, a youth wing of the adult Casuarina Prison. (ABC News: Mitchell Edgar)
The teenager self-harmed in his cell in Unit 18, a youth wing of the adult Casuarina Prison. (ABC News: Mitchell Edgar)

Concluding his evidence, Mr Torrijos said Cleveland’s death was preventable.

“It was a tragedy that happened, and it could have obviously been avoided,” he said.

Coroner Philip Urquhart said he believed the officer had done everything in his power to help Cleveland, and hoped he would continue working in youth detention.

The inquest heard that, in 75 of the 86 days Cleveland was in Unit 18, he was kept in his cell for more than 20 hours.

In the month before he died he received a total of three hours of education split over “an occasional few minutes on an occasional day”.

Speaking outside court, Noongar Elder Uncle Ben Taylor said the conditions in Unit 18 were unacceptable.

“The system has failed, the government has failed,” he said.

‘More pain’ to come: grandmother

Cleveland’s family have travelled to Perth from all over WA to attend the inquest, including his mother Nadene Dodd, who has been supported by suicide prevention advocates Megan Krakouer and Gerry Georgatos.

Speaking after day three of the inquest, Mr Georgatos said failures in youth justice stemmed from the government failing to implement proven methods.

Gerry Georgatos says the lack of training for guards is an issue, and the government could learn from other countries. (ABC News: Cason Ho)
Gerry Georgatos says the lack of training for guards is an issue, and the government could learn from other countries. (ABC News: Cason Ho)

“They say that they will take it on, restorative approaches, rehabilitative approaches, therapeutic approaches — these are buzz words in Australia,” he said.

“When are we going to start getting the two years of training that guards in countries [receive which] have led to the lowering of recidivism and turning around of lives?”

Cleveland’s grandmother Roslyn Sullivan said the inquest had been difficult for the family.

“Seeing it on the video evidence, it’s really heartbreaking, because it’s all come down to them not really acknowledging his problems that he was bringing up to those guards,” she said.

“Today and onwards it’s going to be a bit more, bit more pain.”

The inquest will hear evidence from Unit 18 staff until the end of the week, and then recommence in July.

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Cleveland Dodd inquest: Youth wing in high-security prison ‘set up to fail’

Key points:

  • The corrections worker who found Cleveland Dodd after he self-harmed says the prison unit where the incident happened “was set up to fail”.
  • The youth custodial officer, who has 10 years’ experience, painted a bleak picture of WA’s youth justice system, including staff assaults, lockdowns , riots and escape attempts.
  • Crocker told the inquest Cleveland had been in detention since August 2022 and had been diagnosed with a major depressive disorder, a cannabis use disorder and a likely language disorder.

Warning: this report contains the name and image of Cleveland Dodd, with his family’s permission.

Cleveland Dodd, 16, (inset) died after self-harming in his cell at the youth Unit 18 wing of Perth’s maximum-security Casuarina Prison.
Cleveland Dodd, 16, (inset) died after self-harming in his cell at the youth Unit 18 wing of Perth’s maximum-security Casuarina Prison.

The corrections worker who found Cleveland Dodd, the first juvenile to die in WA youth detention, after he self-harmed says the prison unit where the incident happened “was set up to fail”.

Youth custodial officer Daniel Torrijos discovered Cleveland unresponsive inside his cell in the troubled youth wing – Unit 18 – in a high-security adult prison in the early hours of October 12, 2023.

The 16-year-old had made eight threats to self-harm in the hours before Torrijos unlocked his cell door at Casuarina Prison.

Staff fought to save his life before paramedics arrived and transported him to hospital, where he died surrounded by his family on October 19.

Torrijos told an inquest on Friday the prison wasn’t prepared for the boys when the unit opened in 2022, and a lot of his colleagues didn’t want to work there because they knew it was “chaos”.

“It was set up to fail and that’s how it was perceived by a lot of officers,” he said.

“Everyone didn’t feel that positive that it was going to be successful at Unit 18.”

Torrijos said many of the boys sent to the unit were in “destructive mode” and had been involved in major incidents at Banksia Hill Youth Detention Centre before they were transferred to the unit.

“They went in and the place was destroyed,” he said.

“It was set up for adult prisoners, it wasn’t set up for kids who had been wrecking their cells.”

The youth custodial officer, who has 10 years’ experience, painted a bleak picture of WA’s youth justice system, including staff assaults, rolling lockdowns due to staff shortages, riots and escape attempts.

Cleveland’s death sparked outrage and grief in the community. It also triggered an expedited coronial inquest, the first of its kind in WA, to examine the policies and procedures at Unit 18 and Cleveland’s treatment.

Counsel assisting the coroner Anthony Crocker told the inquest during his opening on Wednesday that Cleveland’s death “by apparent suicide” was an “immense tragedy”.

“That this death, the death of a child, occurred … on the grounds of a maximum-security adult male prison, begs the question – how could such a thing happen?” he said.

The court heard Cleveland had been locked in his cell, which had no running water, for most of the day before he self-harmed.

He was frustrated with the length of time he had been in custody, and had earlier in the day learned he had been denied bail and would remain behind bars.

Cleveland had covered a CCTV camera in his cell with tissue paper, blocking the view of correctional staff monitoring him, but they didn’t bother to uncover it until they were fighting to save his life.

He made calls asking for medical treatment and water as the night wore on, but the officers working that night were reluctant to open detainees’ cell doors “due to staffing numbers and risk issues”.

Crocker told the inquest Cleveland had been in detention since August 2022 and had been diagnosed with a major depressive disorder, a cannabis use disorder and a likely language disorder.

A neuropsychologist said his behaviour could have been caused by early life trauma, language difficulties, exposure to family and domestic violence, drug use and poor supervision.

A mental health worker at the facility said Cleveland was “oppositional defiant” and “extremely violent and aggressive … He needs to be at Unit 18”.

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Cleveland Dodd inquest: Overview of evidence during first sitting of coronial inquiry into Unit 18 death

Key points:

  • Cleveland’s death in October is now subject to a fast-tracked coronial inquest, which started earlier this month.
  • The 16-year-old high-risk detainee threatened to harm himself eight times on his final night in Unit 18, his inquest was told on the first day.

  • The unit was created within the maximum-security adult male Casuarina Prison in July 2022 after a massive riot at Banksia Hill.

Supporters of Cleveland Dodd’s family outside the court where his inquest has been carried out. Credit: Iain Gillespie/The West Australian
Supporters of Cleveland Dodd’s family outside the court where his inquest has been carried out. Credit: Iain Gillespie/The West Australian

“I’ve been patient for seven years now . . . can you check when I got locked up?” “That was a long time ago . . . I was little then.”

Those were confronting words spoken by Meekatharra teenager Cleveland Dodd to a youth custodial officer on the October 2023 night he fatally self-harmed in his cell at the makeshift youth wing at Casuarina Prison known as Unit 18. He died days later in hospital.

As the first juvenile in WA to die in custody, Cleveland’s death in October is now subject to a fast-tracked coronial inquest, which started earlier this month.

Evidence has been heard from the first tranche of witnesses, many of them the YCOs dealing with Cleveland on that fateful night, including the officer who found him in his cell.

The inquest began on Wednesday, April 3 and was adjourned on Friday, April 12.

SLOW TO RESPOND

The 16-year-old high-risk detainee threatened to harm himself eight times on his final night in Unit 18, his inquest was told on the first day. He had been let outside his cell twice that day — October 11 — and felt his pleas to speak to a psychologist or mentors were being ignored.

Cleveland also made multiple calls on his intercom asking for water as his cell had no taps because they had been removed after being damaged.

“Everyone gives their animals water,” Cleveland’s grandmother Glenda Mippy said outside court.

“Why did they put my grandson in a cell that had no tap?”

While he was not the only detainee to self-harm or threaten to do so that day, the inquest was told Cleveland’s final warning was just two words: “I’m through.”

However, detainees made such remarks so frequently, it was suspected custodial officers were desensitised.

Video footage shows an officer walking at a leisurely pace after Cleveland was found hanging.

Other revelations to shock Cleveland’s family include one officer putting on his boots and buttoning up his uniform before responding; guards not carrying radios; the CCTV camera in Cleveland’s cell being left covered with wet toilet paper for all but 23 seconds of 11 hours that day; and it taking nine minutes for paramedics to see Cleveland after arriving at the facility.

‘I THOUGHT HE WAS PLAYING SOME SORT OF TRICK’

The YCO who found Cleveland in his cell, Daniel Torrijos, was the first witness called and claimed he did not run to alert authorities because he had arthritic knees, and he did not call out for help because he was in shock and focused on that one task.

Mr Torrijos said he had been talking with a different detainee — who had also tried to take his own life — earlier that day, and tried to extricate himself from that conversation to peer into Cleveland’s cell.

He said at first, he thought “I was seeing things”.

“I thought he was playing some sort of trick. I looked at his face and it was still,” Mr Torrijos said.

“I couldn’t really believe what I was seeing. He was definitely gone.”

Mr Torrijos said he walked “as quick as I could go” to alert his senior officer, Kyle Mead-Hunter.

First he had to turn the light on in the office of Mr Mead-Hunter, who appeared to be emerging “from a reclined position”, counsel assisting the Coroner Anthony Crocker said in his opening address.

Mr Mead-Hunter, who has been suspended from duty, had been in a darkened room and appeared to be putting on his boots and buttoning up his shirt when the alarm was raised about Cleveland

“I was just in shock. I don’t know,” Mr Torrijos replied when asked why he didn’t again ask for help on his return to Cleveland’s cell. “I was just focused on getting (access to the cell). I just wanted to get him down.”

Mr Torrijos, like other officers on shift that night, was not wearing a radio — a breach of Department of Justice policy.

If they had been carrying their radios, he could have called in a code red medical emergency, Coroner Phil Urquhart pointed out.

Mr Torrijos said Unit 18 was perceived by his colleagues as “set up to fail”.

The unit was created within the maximum-security adult male Casuarina Prison in July 2022 after a massive riot at Banksia Hill.

The cells in Unit 18 were so damaged they were “unliveable”, Mr Torrijos told the inquest. Despite complaints from staff, “no one listened to us”, he said.

“We were travelling blind a lot of the time at Unit 18,” he said.

“It was an accident waiting to happen.

“We just tried to function as best as we could.”

Mr Torrijos and Mr Mead-Hunter had both previously faced disciplinary action for breaching professional standards, the inquest was told.

Mr Torrijos was fined in 2021 after CCTV footage of him performing a night shift at Banksia Hill revealed he had not performed seven cell checks, despite “tick and flick” reports indicating he had.

Cell check records for that shift were ticked from 7.15pm until 6am despite Cleveland being taken to hospital about 2.30am.

Mr Torrijos told the inquest threats from juvenile detainees were “constant”, the vast majority were “not serious” and, while checked not all were recorded because “you’d be writing things down all night long”.

Mr Mead-Hunter was disciplined a month before Cleveland’s death, but details of his indiscretion have not yet been revealed. He is due to give evidence during the inquest’s second sitting.

After his grilling, Mr Torrijos said: “It’s a tragedy . . . obviously could have been avoided. It’s a build-up of things over the years.”

SOCIAL MEDIA & MOVIES

During the evidence of another YCO, Nina Hayden, it emerged Mr Mead-Hunter was found to have breached department policy by using YouTube, Instagram and a chat forum for “over four hours straight” while on duty in January last year.

He was also found to have contravened the code of conduct by going into an office, closing the door, and turning a light off, emerging more than an hour later.

Ms Hayden was also questioned about three calls Cleveland made to her on his in-cell intercom on the night of the tragedy, saying he had a headache and wanted to see nurse Fiona Bain.

Cleveland was told by Ms Hayden during the final call — a little over an hour before he was found having self-harmed — that she had asked the nurse to “come up” and to “be patient”.

“I just can’t recall when,” Ms Hayden said.

Asked if she referred to Cleveland when she spoke to Ms Bain, Ms Hayden said: “I just remember speaking to her.”

After being told to be patient, the 16-year-old said to Ms Hayden: “I’ve been patient for seven years now . . . can you check when I got locked up?” When the answer came, he said: “That was a long time ago . . . I was little then.”

At that point, Cleveland’s heartbroken mother Nadene Dodd left the courtroom in tears.

When asked if his reflective words gave her any extra cause for concern, Ms Hayden said: “We had conversations about different things. He didn’t just talk to us to complain.”

Ms Hayden told the inquest she was “nervous” about acting as a senior officer despite still being on probation, and admitted she was not aware of various Unit 18 policies. She said she had been given no training and about two hours notice before being thrust into an acting senior role.

Ms Hayden also admitted YCOs were not told about a detainee’s status on a system that rated their risk of self-harm — known as the At-Risk Management System — and had to look the information up for themselves.

UNIT 18 ‘INHUMANE’

Ms Bain, the nurse on duty that night, told the inquest she was so affected by what she had seen at Unit 18 that she kept a diary for her “own mental health”, testifying the facility was “inhumane”.

The diary contained descriptions of the high-security unit “like being in a war zone”, with “huge” staff turnover and fewer experienced staff leading to “incidents”.

“I’m literally here to pick up the pieces,” she wrote.

Ms Bain, who Cleveland asked to see that fateful night, agreed the diary helped her process what she had seen at work.

She described the cells as “disgusting” and said some of the boys having no running water in their quarters where they ate and used the toilet was “an appalling state of affairs”.

Coroner Phil Urquhart pressed further, asking if she would go so far as to label Unit 18 “inhumane”, and she concurred.

Because no code red was called, Ms Bain did not bring medical equipment the first time she went to Cleveland’s cell.

Ms Bain wept in court and stood as she apologised to Cleveland’s family at the conclusion of her testimony.

In her statement, Ms Bain described Unit 18 as a “leaky boat” destined to sink “no matter how much you patch it up”.

“That’s an overwhelming understatement,” the coroner remarked.

Ms Bain said she did not recall a lot about that night, but said the entire Unit 18 population would be on suicide watch if policies for ARMS were followed to the letter.

Ms Bain said threats by detainees were frequent — “there could be 50 of them a day” — but some were clearly not serious.

“We’ve had weekends where we’ve had to deal with a detainee continually self-harming for hours and hours on end and having no access to mental health,” she said.

Outside court, asked if she had anything to say to the family, Ms Bain said: “That I’m sorry.”

Day shift unit manager Christina Mitchell said providing the level of supervision a child on ARMS required was “very difficult”, with detainees covering up their in-cell CCTV cameras and door hatches.

“It was quite impossible, really,” Ms Mitchell said.

“I felt helpless that I couldn’t control what was going on.”

Ms Mitchell said rolling lockdowns meant detainees often only had an hour a day out of their cells, pacing the halls of their wing because they couldn’t go outside.

“I couldn’t stay in one of those cells for 23 hours a day,” she said.

PRELIMINARY FINDING

Mr Urquhart said he was satisfied with the way guards and Ms Bain tried to save Cleveland.

He told the court he was “putting aside other matters” that went on in the notorious unit within Casuarina Prison on the night Cleveland took steps to end his own life in his cell.

These included the 16-year-old threatening to self-harm eight times before being discovered, and repeatedly asking to see nurse Fiona Bain, to no avail.

‘EVERY CELL A SUICIDE RISK’

The inquest was told every cell in Unit 18 had damage that detainees could have used to inflict injuries on themselves.

A damaged air vent in the ceiling has been linked to Cleveland’s fatal injury.

The unit’s management team was aware of the damage and it was scheduled for repair on October 11, but that did not happen.

“At that moment in time there were obstructions around why we couldn’t move certain people,” Ms Mitchell said.

Mr Urquhart said he inspected Unit 18 after the teen died, and found damage to the air vents in seven of the 16 cells he examined.

A SHATTERED FAMILY

Cleveland’s family and supporters have been at the inquest, listening to their evidence and at times watching harrowing CCTV footage, hopeful this painful process will lead to meaningful change in the juvenile justice system.

Mr Urquhart granted a request by Cleveland’s mother to view, in private, body-worn camera footage of him being resuscitated and transported to hospital.

The teen’s father, Wayne Gentle, has been watching the inquest via video link from Greenough Regional Prison after a bid for early parole was denied.

It emerged during the inquest that a letter Cleveland had written to his father in August last year had failed to be sent to him. Mr Urquhart told the inquest Mr Gentle would receive a letter of apology and he would be wanting answers as to why he had never received that letter.

Outside court, Cleveland’s aunt Bonnie Gentle said the family had seen the teen’s cell and it “wasn’t fit for any kid”.

“While Cleveland lay in that cell gasping for breath to save himself, they strolled down the hallway,” Ms Mippy said. “They just took their time. No one was running around, no one was panicking. Nothing.”

The inquest has been told Cleveland’s childhood was marred by exposure to domestic violence, drugs and antisocial crowds, and he had been diagnosed with major depressive disorder. He was detained for the first time at the age of 12.

The inquest will resume on July 22.

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Cleveland Dodd threatened self harm eight times on the night he took his own life, inquest reveals

Key points:

  • Cleveland Dodd had expressed suicidal thoughts and threats of self-harm on multiple occasions leading up to his death.
  • Cleveland’s calls for help and reports from another detainee were delayed due to malfunctioning radios and staff not following procedures.
  • An inquest will investigate the events leading to Cleveland’s death, the care he received, and the appropriateness of detaining youths at Unit 18.
16-year-old Cleveland Dodd died in hospital after being found hanging in cell.
16-year-old Cleveland Dodd died in hospital after being found hanging in cell.

On the first day of the inquest into the death of Cleveland Dodd, Counsel Assisting the Coroner Anthony Crocker provided a detailed account of the events leading up to the teenager’s tragic demise at unit 18.

The breakdown of the 16-year-old final moments, presented hour by hour, shed light on his history of self-harm and expression of suicidal thoughts and the chaos involved.

Throughout his childhood, Cleveland exhibited indications of a challenging upbringing and prior encounters with law enforcement. By the age of 12, he had already had encounters with the police.

In his initial remarks, Mr Crocker noted that Cleveland had been subjected to domestic violence, substance abuse, association with antisocial groups, and a lack of proper supervision during his early years.

Mr Crocker provided a detailed account of numerous instances where Cleveland had made threats of self-harm and expressed suicidal ideation over the course of his life.

A neuropsychological evaluation identified Cleveland as having a major depressive disorder, cannabis use disorder, and a potential language impairment.

It was revealed by Mr Crocker that in the lead up to Cleveland’s death he conveyed his distress about the lack of water and the noise coming from other detainees’ cells to the youth custodial officers via the intercom.

It was also mentioned that Cleveland had made threats of self-harm on eight different occasions from 8pm to 1.35am on the night he was discovered unconscious in his cell.

The timeline showed Cleveland was seen on CCTV leaving his cell only twice on October 11, 2023. The first time was for a 20-minute virtual court appearance, and the second time was at 4.40pm for recreation time.

This was two hours after he had inquired why he was not being allowed out and the duration of the recreation period was limited to only 59 minutes.

On top of his frustrations there had been a planned power outage At 11.30pm, all staff at Casuarina Prison units 15 to 18 were instructed to get ready to switch to emergency power due to a scheduled power outage.

Unfortunately, the staff in Unit 18 did not receive this message due to a malfunctioning radio, resulting in a “severe” response.

During the court proceedings, it was revealed Cleveland placed two calls to check on the power situation at 11:39pm, followed by complaining of a headache and asking for a nurse just after midnight.

At some point during the evening Cleveland had covered his CCTV camera with wet tissue, which prevented officers from seeing him, it would remain that way until youth custodial officers attempted to resuscitate him.

At 1.50am, the detainee in the cell next to Cleveland called a youth custodial officer through his intercom. He told custodial officer Daniel Torrijos: “Cleveland is hanging in his cell’.

Mr Torrijos response was delayed by their failure to carry a radio.

On CCTV Mr Torrijos was captured as he approached senior custodial officer Kyle Mead-Hunter to inform him of the situation. Mr Mead-Hunter, who had been reclining in a darkened office, promptly stood up, put on his shoes, and buttoned his shirt.

Following this incident, a code red was immediately declared from the control room, and emergency services were contacted at 1.55am. The prison staff initiated CPR while waiting for the paramedics to arrive.

At 2.15am, just nine minutes after their arrival at the prison, the paramedics assessed Cleveland’s condition. They determined that he was experiencing cardiac arrest and promptly removed him from the cell for further medical attention.

Cleveland died in hospital in October 2023 following self-inflicted injuries in his cell at Unit 18, a juvenile facility known for controversy located within the high-security Casuarina Prison for adults.

It was revealed that he sustained a brain injury as a result of oxygen deprivation, and his situation was getting worse.

The inquiry, scheduled to last for 21 days spread out over the upcoming four months, will closely examine the events leading up to Cleveland’s self-harm incident, the standard of care he received, and the suitability of allowing operations at Unit 18 to proceed.

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As Cleveland Dodd’s Custody Death Goes to Inquiry, Kids Are Still Held in an Adult Prison

Key points:

  • The First Nations teenager was revived on being found, only to die in hospital a week later
  • There have been 562 Indigenous deaths in custody since the Royal Commission in 1991
  • Banksia Hill is the only child prison in WA, and it has increasingly been the focus of court cases, as treatment has been described as how animals might be caged
Cleveland Dodd was found unresponsive in his prison cell at around 2 am during routine checks at Perth’s Casuarina Prison
Cleveland Dodd was found unresponsive in his prison cell at around 2 am during routine checks at Perth’s Casuarina Prison

Cleveland Dodd, a 16-year-old First Nations boy, was found unresponsive in his prison cell at around 2 am during routine checks at Perth’s Casuarina Prison, an adult maximum-security facility that’s been operating Unit 18, a wing for child inmates, and yet he hadn’t even been convicted of a crime.

The remanded teenager was found unconscious because he’d attempted to take his own life. And 12 hours prior, he’d heard that his bail hearing had been delayed for a third time, which meant there was a chance of getting out, but in the meantime, he’d have to remain in the notorious Unit 18.

Dodd’s family said in a 20 October statement that he’d “never, ever self-harmed prior to being unlawfully locked down, day after day, inside Unit 18, and drove him to take his own life in desperation, in the early hours of October 12, 2023”.

The First Nations teenager was revived on being found, only to die in hospital a week later, as life support was turned off after 10 pm on 19 October. Dodd had even made two calls to staff warning of what he was going to do, but those on duty paid him little attention.

“We, as a First Nations people, have been suffering from one generation to another, and we cannot stand by and watch this carnage on our children”, the family continued, pointing to the crisis in Aboriginal deaths in custody and the overrepresentation of First Nations people in prisons.

But as the coronial inquest into the Aboriginal boy’s death in an adult prison begins on Wednesday, Unit 18 continues to operate, as WA premier Roger Cook and corrective services minister Paul Papalia determined there is nowhere else to lock up 20-odd minors, they claim, must be isolated.

A system deliberately left broken

“It is society who killed Cleveland. It is governments who killed this 16-year-old. It is the sins of a nation which took this boy to a grave,” WA prison reformist Gerry Georgatos told Sydney Criminal Lawyers. “The maltreatment of children in juvenile prisons is a systemic determinant.”

“Deaths in custody are ongoing because of governments and departments diabolically minimising fallout from deaths in custody,” he continued. “Reprehensibly standing by the custodial officers rather than ensuring the procurement of truth.”

“There have been 562 Indigenous deaths in custody since the Royal Commission,” read the Deaths in Custody Real-Time Dashboard run by the Australian government on 1 April. The Royal Commission into Aboriginal deaths in custody handed down its final report on 15 April 1991.

No prison officer, police officer or corrections health officer has ever been convicted in relation to a First Nations deaths in custody, despite many questionable circumstances relating to force applied or neglect. No one has ever been convicted, even when events are captured on camera.

“Let us make no mistake that prisons, child and adult, are all-out punitive affairs,” Georgatos said, and further asserted that as these deaths are ongoing, widespread and well-known, with nothing ever being done to repair the situation, it suggests the system is running to plan.

A system killing with impunity

Having researched such deaths academically, and worked in suicide prevention and with inmates, Georgatos outlines that Dodd’s death, as all custodial deaths, triggers the immediate circumstances but also those of a system that involves Australia “incarcerating in higher numbers year after year”.

Of the 42,274 adults in the Australian prison system in December, 14,463 of these inmates were First Nations people, which accounts for 34 percent of the prisoner population, yet when looking at the entire continent Aboriginal and Torres Strait Islander peoples account for only 3.2 percent of people.

This makes them amongst, if not the, most incarcerated group of people on the planet. And this is occurring within one of the richest economies on Earth – indeed, locking up people is an expensive venture, even if their human rights are neglected.

Another factor in the equation is Australian authorities love locking up kids, and in most jurisdictions, including WA and NSW, this continues to apply to those aged as young as 10, and the open secret about the struggle to raise the age is the issue mainly affects Indigenous communities.

“The high-volume exposure of First Peoples, young and old, to incarceration is the most immediate cause of Black deaths in custody,” Georgatos underscored, “mass incarceration of First Peoples.”

Minister, these are children

But the immediate circumstances of Dodd’s death, which the WA coroner will be considering, is why WA Corrective Services, the state of WA and the Cook government consider it acceptable to lock a kid up in an adult gaol, especially when they’re yet to be convicted of a crime.

Just weeks after Dodd took his own life rather than spend more time in Unit 18, the Cook-Papalia joint statement saw both men stating their thoughts were with the family, however no thought was given to the underlying causes of death, although that didn’t mean Unit 18 was left unaddressed.

“The Western Australian government is committed to the urgent improvement of Unit 18,” advised the corrections minister, “to making it a better place, until we have an alternative location suitable for managing the complex cohort housed there.”

And by late November, the Cook-Papalia tag team was spruiking a new $1 million prison wing at Banksia Hill Detention Centre to lock up around 20 kids, aged anywhere between 10- to 17-year-olds, whom continue to be imprisoned in Unit 18 to this day.

Sticking kids in adult facilities is a breach of their human rights. These corrections centres for adults are not places designed to cater for children. And in December, it was outlined in the press that at times these youths are being locked down for 24 hours a day.

Banksia Hill is the only child prison in WA, and it has increasingly been the focus of court cases, as the circumstances of treatment have been condemned as akin to the way animals might be caged. And Georgatos has been organising a class action on behalf of hundreds of former detainees.

Custody causing death

Levitt and Robinson Solicitors are leading the Banksia Hill Class Action, which was officially launched in 2021 and now has over 700 plaintiffs. And that firm will also be representing Cleveland Dodd’s family, when the coronial inquest into his death commences on Wednesday, 3 April.

“Australia killed Cleveland Dodd,” Georgatos made certain. And he added that enough resulting evidence from the multiple inquires could lead to reform. While Levitt and Robinson said early on that it considers this week’s inquiry will reveal the harms that continue to take place in Unit 18.

“Hopefully, the coronial inquest and the class action reveal just enough discoverable truth to ensure unnatural deaths in custody come to an end, and prisons are compelled to transform to positive wellbeing bastions where people are helped,” Georgatos continued.

“We often say, we weren’t put on this earth to bury our children. We also weren’t put on this earth to kill children, whether indirectly or otherwise,” the long-term social justice activist concluded.

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Cleveland Dodd’s family hope inquest will bring change

Key points:

  • Cleveland Dodd, a 16-year-old Indigenous boy, died by self-harm while in youth detention at a high-security prison.
  • His family is calling for a justice system overhaul.
  • An inquest is underway to investigate the circumstances surrounding his death.
Cleveland Dodd's grandmother Glenda Mippy, grandfather Stewart Dodd, mother Nadene Dodd and aunty Julie Dodd after their press conference in Perth on Tuesday, 2 April. Image: Aaron Bunch (AAP)
Cleveland Dodd’s grandmother Glenda Mippy, grandfather Stewart Dodd, mother Nadene Dodd and aunty Julie Dodd after their press conference in Perth on Tuesday, 2 April. Image: Aaron Bunch (AAP)

The heartbroken family of Cleveland Dodd, the first young person to die in youth detention in WA, hope an inquest will lead to an overhaul of the justice system.

Cleveland, 16, was found unresponsive after harming himself inside his cell in a troubled youth wing of a high-security adult prison in the early hours of October 12, 2023.

The Indigenous teen was taken to hospital in a critical condition where he later died, causing outrage and grief in the community.

His mother, Nadene Dodd, told media at a pre-inquest press conference on Tuesday that her family was “still reeling from the loss of my son”.

“The months since Cleveland’s passing have been fraught with grief,” she said in a statement read by lawyer Dana Levitt.

“With each new detail that comes to light about the night he died or about Unit 18 generally, I become more determined to get justice for Cleveland, and for all the other boys sent there.

“Children do not belong in adult prisons.”

Ms Dodd said the Department of Justice should have kept her son safe and “not let him die on their watch”.

“My boy’s cries for help fell on deaf ears.”

The first part of an expedited coronial inquest in Perth into Cleveland’s death starts on Wednesday and runs until April 12.

It is understood Coroner Phil Urquhart will close the court after the opening statement so that the lawyers involved in the inquest and some of Cleveland’s family can view Casuarina Prison CCTV footage from the night the teen self-harmed.

Witnesses who worked at Unit 18, including three youth custodial officers, a nurse and a manager each have a full day set aside for their evidence.

“I’m hopeful that Cleveland’s death is the catalyst for an overhaul of youth justice in Western Australia,” Ms Dodd said.

“The system, like my heart, is broken.”

Cleveland’s family on Tuesday will lead a march of about 70 people through Perth to the Department of Justice head office, where Ms Dodd and other speakers are expected to address a rally.

Ms Levitt, who is representing Cleveland’s family at the inquest, wants the inquest to bring “real and lasting” change to the youth justice system.

She said the justice department should “reassess what it’s doing, how it’s doing it, and whether it’s of any benefit to anyone”.

“We’re not setting up young people to do anything other than self-harm in prison,” she said.

“That’s the way the system is working at the moment.

“Children rarely come out better than they went in and for the most part they come out worse.”

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Aboriginal Counselling Services 0410 539 905

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Cleveland’s mum shares her memories – and her heartbreak – as inquest begins

 
Nadene Dodd and her young family should be at home in Laverton.
Instead, they are 950 kilometres away in a motel in Perth’s east, hoping they will finally get answers.
Cleveland Dodd’s mother, Nadene, with the last piece of artwork he produced in Unit 18. (Jesinta Burton)
Cleveland Dodd’s mother, Nadene, with the last piece of artwork he produced in Unit 18. (Jesinta Burton)

As Nadene Dodd unveils the brightly coloured dot-style turtle painting shielded by glass, her 18-month-old daughter leaps to her feet and grasps the wooden frame.

Warning: this report contains the name and image of Cleveland Dodd, with his family’s permission.

It’s the last piece of artwork her 16-year-old son Cleveland produced at the notorious Unit 18 youth wing in the adult maximum-security Casuarina Prison – the place at which he would choose to take his own life.

“Every time they [Cleveland’s siblings] see his photo, they call out ‘brother’ — they get excited,” Nadene said.

“I’ll tell them everything … when they get older.”

Nadene and her young family should be at home in Laverton, a tiny town on the western edge of the Great Victoria Desert.

Instead, they are 950 kilometres away in a motel in Perth’s east, anxiously awaiting the start of a coronial inquest on Wednesday they hope will finally deliver answers.

It has been almost six months since Nadene received a call in the early hours of October 12, telling her Cleveland — the eldest of her six children — had been rushed to hospital after trying to take his own life in his cell.

The shock was two-fold because she was unaware her son had even been relocated from Western Australia’s youth detention centre, Banksia Hill, to Unit 18 — a makeshift wing in a sprawling adult prison making headlines for its escalating violence and for subjecting children to prolonged isolation.

She spent the next week by her son’s bedside in Sir Charles Gairdner Hospital before making the gut-wrenching decision to switch off his life support prior to his passing at just after 10pm on October 19.

Cleveland Dodd with his sporting trophy.
Cleveland Dodd with his sporting trophy.

The teenager became the first minor to die in custody in WA, and the first in the country in more than a decade.

But conflicting reports had already begun to emerge about the sequence of events that led to Cleveland attempting to take his life, being found and rushed to hospital.

“[Corrective Services] told us a lot of stories, but maybe if they had actually just checked on him, he would still be here with us,” Nadene said.

“They should have helped when he was singing out for help, but they didn’t.

“You think they will watch them 24/7, that they will keep them safe, and you believe your son will come home to you.

“No mother wants their kid, a 15-year-old kid, in Unit 18 — it’s the worst feeling you can feel. We went there, and no little kid should be in there.”

An internal probe the following month uncovered myriad systematic failures, with revelations guards had faked welfare check logs and were watching movies on the night Cleveland self-harmed.

The CCTV camera in Cleveland’s cell had been covered from 3pm until 1.53am by wet toilet paper, which was only removed after staff began CPR.

Cleveland Dodd with his younger siblings.
Cleveland Dodd with his younger siblings.

The teenager had for several weeks been in a cell with a broken air vent, which he used in his plan to take his own life.

He had made two calls to staff warning them of this plan.

But it was a fellow teenager in an adjacent cell who alerted the prison’s control room when Cleveland carried it out.

Following the internal investigation, Corrective Services Minister Paul Papalia announced a new operating model, a rapid increase in out-of-cell hours and a promise to close the facility as soon as practicable.

But the changes were cold comfort for Nadene.

“Why did it take my son taking his life for that to happen?” she said.

“I’m scared, I’m scared to know [more about] how my son has been treated.

“It’s really hard to sit and listen to everything that has been going on, about everything that came out about that prison.

“My son passed in a bad way, and it should never have happened.”

The boy Cleveland once was

Nadene was overcome by grief, but tried to find strength in remembering the outgoing, guitar-playing, basketball-loving boy she raised.

“He never got into trouble in Laverton, he went to school every day, he went to the drop-in centre, he loved going out bush … he loved life more than anything,” she said, flicking through her photo album.

“He was kind, he was loving to everyone, he was outgoing.

Cleveland Dodd with his mother Nadene.
Cleveland Dodd with his mother Nadene.

“He loved all sports, but basketball mainly, and taking his little brothers to school.

“And he was a perfectionist — he would always say, ‘Mum, wash my uniform, keep it neat and tidy’.”

A similar picture was painted by Cleveland’s former teacher at Laverton School, Ella Smillie, who said the bright boy with a big personality and an infectious smile had a special way of getting into the hearts and minds of all who knew him, including the staff he loved to yarn with.

Cleveland later left home and set out to find out more about his father’s lineage in Meekatharra, a small Mid West town about 760 kilometres north-east of Perth.

And it was there he begun to have issues with petty offences that became more serious, until he was intimate with the justice system by the age of 12.

But the strength of their relationship did not waver, Nadene said, as she retrieved an image of the card he drew her last Mother’s Day – now almost a year ago.

“I wish I could spend the day with you, Mum,” read the last card she would ever receive from him, decorated with flowers and hearts.

She broke down as she described discovering he had attempted to call her on October 11 – her birthday – hours before he took the steps to end his life.

She discovered the missed call after having her damaged phone screen repaired.

Gerry Georgatos wants Cleveland’s legacy to be an overhaul of the justice system.
Gerry Georgatos wants Cleveland’s legacy to be an overhaul of the justice system.

“I go to sleep every night and I wake up like this,” she said, wiping away tears with the sleeve of her shirt.

“If they knew Cleveland, they would know that he was a good, loving, caring kid.

“And he was just a kid. He was too young to be locked away in a prison like that, and it took his life.

“My son should have come home to me.”

It has been four months since Cleveland was laid to rest in Meekatharra, but Nadene struggled to talk about her son in the past tense and articulate what his legacy would be.

Youth detention expert and family advocate Gerry Georgatos, however, was adamant about what it should have been — a life such as anyone looked forward to, with children and grandchildren.

“Instead, he turned 16 in Unit 18 and didn’t survive six weeks after that,” Georgatos said.

“His legacy now will be to compel the sorts of changes that should have kept him alive and helped turn his life around.”

Georgatos is a suicidality researcher who has worked with large numbers of disadvantaged children and youth. He has been through decades’ worth of coronial inquests, and said little has changed.

Since the royal commission into Aboriginal deaths in custody in 1991, 562 more deaths in custody have been recorded, with most of the non-natural deaths classified as suicides.

According to the Australian Bureau of Statistics, Aboriginal and Torres Strait Islander prisoners account for one-third of all prisoners, despite making up just over 3 per cent of the population.

“The rate of deaths in custody, of recorded self-harm incidents, have been abominable, reprehensible, and have reinforced that we have entrenched, systemic deficits,” Georgatos said.

“It is not possible that this inquest won’t come out with damning findings, more damning and more profound than any inquest or inquiry to date — it will be the one that will compel long-overdue reforms, on the back of convictions.

“This unnecessary tragedy has been exposing a long-established culture of neglect and maladaptive misbehaviours in those vested with the immediate care of society’s most vulnerable children – the kids who finish in juvenile prisons.

“Deaths in custody occur because Australia spends on punishing and not on supporting.”

In the months since Cleveland’s death, more tales have emerged painting a grim picture of the culture inside Unit 18 — from allegations of guards making jokes about Cleveland’s death to claims, unveiled by ABC Perth, that youth custodial officers had made ghost noises in his cell as a further joke.

But Georgatos hoped the combined impact of the inquest, a Corruption and Crime Commission investigation and a class action inmates’ families have launched meant there would be justice over Cleveland’s death and the system would be overhauled.

“If Unit 18 was closed after its first week of abysmal fails, Cleveland would be alive,” he said.

“If the government transformed Banksia Hill into life-transformative, restorative models and Medicare rights were not denied to incarcerated children, Cleveland would be alive.

“If there was an external, independent Prisoner Notification Service for at-risk prisoners, along the lines of the police watchhouse Custody Notification Service, Cleveland would be alive.”

Crisis support is available from Lifeline on 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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