Inquest into the Death of Cleveland Keith DODD

Delivered on : 28 November 2025

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : Yes

Recommendation No. 1

In order to enhance the environment of a youth detention centre, all custodial staff, including members of the SMT and seconded prison officers, should not wear uniforms and instead wear less formal attire such as polo shirts.

Recommendation No. 2

In order to enhance the support provided to detainees, the Department, as a matter of urgency, applies for funding so that an additional six case managers can be employed at Banksia Hill.

If this recommendation is implemented, the Department should pay heed to Ms Butt’s view that filling and retaining these positions would be more attractive if they were permanent positions.

Recommendation No. 3

In order to lower the risk of suicide and thereby enhance the care of detainees, the Department, as a matter of urgency, seek funding for an expansion of the SPGU to include 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.

Recommendation No. 4

In order to improve the operations of youth detention centres, the Department seeks the necessary funding to provide training at the Corrective Services Academy to YCOs for the positions of Unit Manager and Senior Officer.

Recommendation No. 5

In order to improve the operations of youth detention centres, the Department seeks the necessary funding so 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. This training should be provided to prison officers and those in senior management positions who are making the transition.

Recommendation No. 6

In order to improve the care of detainees, all custodial staff (including those in supervisory or managerial positions) must receive as part of their training as a YCO or as part of their transition from the adult estate to the youth estate, detailed and comprehensive instruction and information of the findings made in the Banksia Studies, and how those findings inform and impact the care of detainees with neurocognitive disabilities.

Recommendation No. 7

In order to effectively implement the Recommendation No.6, the Department should ensure there is ongoing funding to ensure the instructors at the Corrective Services Academy are appropriately qualified to provide the training as described in the above recommendation.

Recommendation No. 8

In order to enhance the care of detainees, the Department and the Department of Health continue their collaborative approach to have young persons who are placed in custody (including those on remand) screened for neurodevelopmental and mental health disorders with a follow-up assessment if required. Sufficient funding should be obtained to ensure this process is implemented on a permanent basis.

Recommendation No. 9

Should Unit 18 remain open until the completion of the proposed youth detention centre, and in order to maintain an appropriate level of mental health care to detainees in Unit 18, the Department is to seek urgent funding for the allocation of a mental health team member to be based in Unit 18 for day shifts seven days a week.

Recommendation No. 10

In order to improve its care of prisoners and detainees, the renumeration and pay structures of health service and allied health service providers in the adult and youth custodial estates should be, at the very least, commensurate with those of comparative health service and allied health service providers in the Department of Health. The Department should seek urgent funding to address this imbalance.

Recommendation No. 11

Should Unit 18 remain open until the completion of the yet-to-be-built youth detention centre, and in order to provide the necessary support to detainees in Unit 18, the Department seeks funding for the allocation of youth carers, separate from YCOs, to support and guide detainees in every aspect of their daily activities in detention.

Recommendation No. 12

In order to determine whether more effective care can be provided to detainees, a pilot program be introduced by the Department that has a mixed-shift system in place for custodial staff working eight or 10 hour shifts, four to five days per week.

Recommendation No. 13

To reduce the risk of reoffending and to assist with the reintegration of detainees back into the community, that funding be provided to the ALSWA’s Youth Engagement Program so that it can extend its case management services to detainees being released from detention. The Department should support any application made to the State Government for such funding.

Recommendation No. 14

In order to enhance the care of detainees, the Department amends the relevant COPPs to mandate the requirement 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.

Recommendation No. 15

A forum be established comprising of relevant government entities (e.g. the Department, the Department of Communities, the Department of Health, the Department of Education, the Department of Housing and Works, the Mental Health Commission) and stakeholders (e.g. ALSWA, the Children’s Court, the OCIS, the Commissioner for Children and Young People, the Kids Research Institute Australia, Aboriginal community organisations such as Derbarl Yerrigan and Social Reinvestment WA) to consider whether youth justice should remain entirely within the Department’s responsibility and that a report of its findings be prepared for the State Government to consider.

Recommendation No. 16

Pursuant to section 24H of the Public Sector Management Act 1994 (WA), a special inquiry be held to investigate the manner in which Unit 18 came to be Western Australia’s second youth detention centre.

Recommendation No. 17

In order to provide an appropriate level of therapeutic care to detainees who require that care the most, Unit 18 should be closed as a youth detention centre as a matter of urgency.

Recommendation No. 18

Should my recommendation to immediately close Unit 18 not be implemented, the Department suspends 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.

Recommendation No. 19

Should Unit 18 remain as a youth detention centre until the yet-to-be built second youth detention centre becomes operational, a closure date be immediately announced for Unit 18. The purpose of such a closure date is that it will provide the necessary impetus to fund, design and construct the new youth detention centre in an expedited manner.

Orders/Rules : N/A

Suppression Order : Yes

1. That there be no reporting or publication of the identity of any other detainee, or any information regarding any other detainee or detainee’s actions, that might reasonably be anticipated to reveal their identity.
2. Suppression of the identification of Cleveland Dodd’s siblings from publication and any evidence likely to lead to their identification.
3. Suppression of the identification of [complainant’s name] from publication and any evidence likely to lead to their identification.
4. That there be no publication of photographs of the Department of Health’s East Metropolitan Unit and no reporting of what is depicted in those photographs.
5. That there be no reporting or publication of:
   1. the number of staff currently working night shift in Unit 18;
   2. information regarding the location of keys, issuing to and carriage of specific keys by specific personnel, and unique identifiers on keys;
   3. information regarding nominated locations for emergency response procedures within prisons or detention centres;
   4. information regarding radio channels or frequencies used within prisons or detention centre; and
   5. information regarding layouts, buildings and structures within prisons or detention centres (other than C-Wing of Unit 18 and the location of the control room).

Summary :

Cleveland Keith Dodd (hereafter referred to as Cleveland at his family’s request) died on 19 October 2023 at Sir Charles Gairdner Hospital (SCGH) from complications of ligature compression of the neck (hanging). He was 16 years old.

In the early hours of 12 October 2023, Cleveland had self-harmed in a hanging incident (the hanging incident) when he was a detainee at the Unit 18 youth detention centre in the grounds of Casuarina Prison (Unit 18). Consequently, his death was caused while he was a person held in the care of the CEO of the Department of Justice (the Department) and was subject to a mandatory inquest. Cleveland’s death was the first of a child detained in the custody of the Department in Western Australia.

Cleveland began his final period in detention at Unit 18 on 17 July 2023, where he remained for 87 days before he was found in his cell after the hanging incident.

The Coroner was satisfied that in the days before the hanging incident, Cleveland was enduring a number of hardships. He continued to be solitarily confined to his cell under confinement orders, his requests to see a psychologist were not fulfilled, his bail application on the afternoon of 11 October 2023 was adjourned for eight days, and he was not able to speak by telephone to his mother later that day.

On the night of 11 October 2023, Cleveland was deliberately kept awake by the detainee in the neighbouring cell making loud noises and there was an unexpected power outage at about 11.30 pm. During the night, Cleveland threatened to self-harm eight times to custodial staff during intercom cell calls. In his final cell calls Cleveland was despairingly trying to work out the number of days he had spent “locked up”.

Shortly after his final cell call threatening to self-harm, a youth custodial officer (YCO) conducted a cell check on Cleveland. The YCO briefly spoke to him through the cell door and noted nothing amiss. He then spoke to two other detainees in the cell wing. After 12 minutes, the YCO checked Cleveland again and saw that he was hanging from the cell’s ceiling vent. The ceiling vent had been damaged to enable it to be used as a ligature anchor point. When Cleveland did not respond, the YCO went to the Senior Officer’s office and obtained the keys to the cell door.

The door to Cleveland’s cell was unlocked and the YCO quickly lifted Cleveland to take his weight and removed the ligature (a torn t-shirt) from Cleveland’s neck. Resuscitation was immediately commenced by Unit 18 and Casuarina Prison staff, and continued until paramedics arrived. A return of spontaneous resuscitation was achieved and Cleveland was taken by ambulance to Fiona Stanly Hospital and then to SCGH. Scans revealed a hypoxic brain injury that was deemed to be non-survivable. Cleveland died one week later.

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

The Coroner also found that Cleveland had spent 74 of his last 87 days in Unit 18 locked in his cell for longer than 22 hours each day. This amounted to solitary confinement as defined by the United Nations’ international definition of solitary confinement (less than two hours out of a cell per day). The Coroner was satisfied that this was not only entirely inappropriate, but inhumane. The Coroner was also critical of the routine making of daily confinement orders against all detainees in Unit 18. Every day during Cleveland’s last period in detention was subject to a confinement order. One reason given for virtually all of these confinement orders related to insufficient staffing numbers.

Although findings were also made against eight employees of the Department, the Coroner was satisfied the actions of Unit 18 staff on duty during the night of Cleveland’s hanging incident did not cause or contribute to his death. Any shortcomings in Cleveland’s supervision and treatment that night was because the Department had not given staff the resources to provide an appropriate level of care to Cleveland.

The Coroner made 19 recommendations which included the closure of Unit 18 as a matter of urgency and the establishment of a special inquiry under section 24H of the Public Sector Management Act 1994 (WA) to investigate the manner in which Unit 18 came to be Western Australia’s second youth detention centre. Another recommendation was that a forum be created comprising of relevant government entities and external stakeholders to consider whether youth justice should remain entirely within the Department’s responsibility and that a report of the forum’s findings be prepared for the State Government to consider.

Catch Words : Death in Custody of a Child : Suicide : Adequacy of the Treatment, Care and Supervision : Recommendations

Last updated: 8 December 2025

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