It was only a matter of time before a youth died in custody, the prison watchdog has told an inquest into the first juvenile to die in West Australian youth detention.
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 supervision unit, in breach of state laws and international obligations.
The situation had been deteriorating for several years, with detainees' behaviour becoming increasingly challenging and volatile in response to being locked in their cells for long periods.
"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 Banksia Hill wasn't fit for purpose and the ISU was poorly maintained.
It said it was managing a difficult cohort of detainees, "who have been involved in a number of incidents of damage to infrastructure and self-harm and suicide attempts".
It said the department had complied with state law and the international rules weren't enshrined in WA legislation.
Mr Ryan elevated his concerns in early 2022 to the then corrections minister Bill Johnston, saying an "immediate circuit breaker" was needed.
The minister acknowledged the centre was inadequate and said the government would boost funding to increase security at the site, which was contrary to Mr Ryan's recommendation for a more therapeutic approach.
He did not address Mr Ryan's concerns about the government acting unlawfully or in contravention of its obligations.
Counsel Assisting Anthony Crocker asked Mr Ryan if he was a watchdog with no teeth, to which he replied "it's frustrating" but the report had been published in parliament and made public.
Several months later, Unit 18 was created in a "rush" at Casuarina Prison, an adult maximum-security male prison, and a major incident occurred within days, leading to some detainees being locked in their cells for up to 23 hours per day.
Mr Ryan said correctional staff used to dealing with adult offenders were surprised by the amount of damage the youths had caused.
Cleveland was transferred to the unit from Banksia Hill in September 2022.
Mr Ryan told the court the unit should be closed immediately because its not fit for young offenders but there were no other practical alternatives.
He said the justice department needed urgent, well-resourced reform that adopted a trauma-informed care model for youth offenders in place of a custodial model.
"It involves significant cultural change of all of the staff. It requires significant infrastructure change," he said.
The court heard there were 60 boys and five girls in detention in WA, with nine of those boys held in Unit 18.
About 75 per cent of all detainees are Indigenous.
Mr Ryan said out-of-cell time had improved at both facilities, with some detainees spending up to 9.5 hours out of their cells per day at Banksia Hill in June and nine hours at Unit 18.
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