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.
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