The troubled youth wing of an adult prison where an Indigenous teenager fatally self-harmed should be closed "as a matter of urgency", a coroner has told a court.
More funding should be provided for training corrections staff and the prison watchdog's powers should be beefed up, with coroner Philip Urquhart also calling for the justice department to be stripped of its role overseeing young people.
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 also led to an expedited inquest in early April this year, which sat for 34 days, with the final evidence being heard on Wednesday before Mr Urquhart delivered his provisional recommendations.
The coroner indicated he would call for Unit 18's policies and procedures to be overhauled and that trauma-informed culturally appropriate care be implemented at a proposed new youth detention centre.
Mr Urquhart said he would also potentially recommend more caseworkers and mental health workers be employed in youth detention centres, that the health department take responsibility for detainees with mental health issues and that support be provided to help detainees transition into the community.
He said staff should also work shorter shifts and wear more relaxed uniforms and that if Unit 18 was to remain open detainees shouldn't be held there for any longer than six weeks, with two months in between stays and increased access to lawyers.
"It is not appropriate that a cell block in a maximum security adult prison should be used long term as a youth detention facility," Mr Urquhart said.
The long-running inquest also heard from Cleveland's heartbroken mother Nadene Dodd, who described conditions in "the hellhole of Unit 18".
"I thought my son was safe ... and that he would leave detention, rehabilitated ... better not worse off," she said in a statement read to the court by a friend.
"My boy never stood a chance of regaining consciousness after he was found ... His mind and his spirit died in that cell, not in the hospital."
Ms Dodd said images shown to her of Cleveland "surrounded by uneaten plates of food cannot be unseen".
"The concrete box in which he took his last breaths was barren and filthy," she said.
"My son didn't deserve to be treated the way that he was treated. My son didn't deserve to die.
"Institutional abuse of children is unacceptable."
Ms Dodd said governments must be held to a higher not a lower standard.
"It breaks my heart to know that from the moment he was transferred to Unit 18, Cleveland never got the chance to go outside, to feel the sun on his skin, to breathe in fresh air, to look at the sky," she said.
"Instead, he spent his time locked down for almost 24 hours a day, day in and day out, for weeks on end.
"He lost the will to live inside a state-run facility where he was supposed to be kept safe."
Ms Dodd said the West Australian government "sent my boy to Unit 18 and kept him there long after they knew the conditions were unliveable, inhumane, disgusting".
Ms Dodd said she would not let Cleveland's short life be meaningless.
"His legacy will be to highlight the many ways in which the system failed him and to bring about real reforms," she said.
"To ensure no child has to endure what he did in Unit 18."
Ms Dodd said the justice department and corrective services personnel responsible for youth justice must be held to account.
The case will return to court in June for closing submissions ahead of the coroner's final findings and recommendations.
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