Coroner Philip Urquhart has called for a "special inquiry" into how the notorious Unit 18 facility originally came into operation, among his 19 recommendations arising from the inquest into the death in custody of Cleveland Dodd.

He said "a special inquiry (should) be held to investigate the manner in which Unit 18 came to be Western Australia's second youth detention centre".

From the very beginning - in July 2022 - justice experts, Indigenous groups and youth advocates warned that Unit 18 was a dangerous concept that would not help young people.

Mr Urquhart said Unit 18, the youth unit within the maximum security Casuarina Prison, was an unsafe environment for inmates when Cleveland's death occurred, and should be closed despite improvements that have since been made,

Cleveland was found unresponsive in his cell in the early hours of October 12, 2023. The 16-year-old Yamatji boy died one week later after being kept on life support.

Cleveland had warned prison staff he intended to take his own life, the inquest noted. The staff asked him not to say such things. 13 minutes later, prison officers found him unresponsive in his cell, where the CCTV cameras had been covered by toilet paper for hours. Earlier that evening, Unit 18 staff several times rejected his request for a cup of water.

During his close to three months in custody Cleveland had repeatedly made threats of self-harm, but had been removed from the prison's list of "at-risk" children before he fatally self-harmed.

Cleveland had 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.

15 adverse findings against the Department of Justice

The Coroner made 15 adverse findings against the WA Department of Justice. They included findings Unit 18 was unfit to adequately care, treat and supervise detainees at high risk of self-harm; the failure to resolve the widespread practice of detainees covering their cell CCTV cameras for extended periods; the failure to remove Cleveland from a cell with an obvious ligature anchor point; the failure to place Cleveland onto its At Risk Management System on the night of 11 October 2023; and the failure to have adequate number of staff rostered for night shifts to ensure Unit 18 was operating safely.

Mr Urquhart noted Cleveland was 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.

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.

19 urgent recommendations for change

In addition to recommending that Unit 18 should be closed as a matter of urgency, and his call for a special inquiry into how the Unit was first established, the Coroner issued 17 other recommendations, including that the Department:

- hires six case managers at Banksia Hill; funds a youth-specific clinician and a youth-specific reference group to provide oversight and advice in relation to the management of detainees who are at high risk of suicide;

- provide training at the Corrective Services Academy to youth corrections officers for the positions of Unit Manager and Senior Officer;

- that mandatory and comprehensive training is provided by the Corrective Services Academy to those custodial staff moving from the adult estate to the youth estate;

- and the allocation of a mental health team member to be based in Unit 18 for day shifts seven days a week.

The Coroner also called for the allocation of youth carers, separate from YCOs, to support and guide detainees in every aspect of their daily activities in detention; that funding be provided to the Aboriginal Legal Service WA's Youth Engagement Program so it can extend its case management services to detainees being released from detention; and that detainees who are not confined to their cells for breach of discipline are to receive, "at the barest minimum", two hours out of cell time in every 24-hour period.

Another key recommendation that could, if implemented, drive a major shift in policy was the call for a new forum of relevant government agencies and stakeholders (such as the ALS WA, Children's Court, Inspector of Custodial Services, Commissioner for Children and Young People, and Aboriginal community organisations) to consider whether youth justice should remain entirely within the Department's responsibility and that a report of its findings be prepared for the WA Government to consider.

The Coroner recommended that should his recommendation to "immediately close Unit 18 not be implemented", the Department should suspend "the operation of Unit 18 as a youth detention centre for a fixed period to determine whether all or some of the detainees then in Unit 18 can be safely cared for at the newly refurbished Banksia Hill", and also called for a Unit 18 closure date to be "immediately announced".

Cleveland 'was in unbearable physical and psychological pain'

Nadene Dodd, Cleveland's mother, issued a statement after the Coroner brought down his findings on Monday.

"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."

Department to 'carefully review' Coroner's report

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... 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".

"Out-of-cell hours have increased significantly, supported by a major increase in Youth Custodial Officers... 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 Department said it will "carefully review the Coroner's report and consider opportunities for further improvement" to youth justice.