Cleveland Dodd was found unresponsive in the early hours of October 12, 2023 inside his defective cell in Unit 18 at Perth's Casuarina Prison, becoming the first juvenile to die in a detention facility in Western Australia.
The 16-year-old had made eight threats to self-harm, numerous requests for medical treatment and covered his cell's CCTV camera in the hours before he was discovered and taken to hospital.
He died eight days later, causing outrage and grief in the community.
WA's Corruption and Crime Commission was tasked with investigating serious misconduct allegations made against correctional officers working when Cleveland harmed himself.
An inquiry into Cleveland Dodd's death found no evidence of serious misconduct at Casuarina Unit 18. (Aaron Bunch/AAP PHOTOS)
It found Unit 18, a standalone youth wing at the maximum-security adult prison, was trapped in a cycle of destruction.
"The cells were defective because the young people destroy them," it said.
"They are repaired and then damaged again."
Cleveland was placed in a damaged cell that facilitated his self-harm because it was the best of a bad lot, "and there was no serious misconduct involved in the decision to keep him there".
The commission found staff had not ignored Cleveland's threats of self-harm.
"While they were not recorded as they should have been, they were not disregarded," the report said.
A review of the cell calls showed officers were generally concerned by Cleveland's threats despite detainees making multiple similar calls daily.
The report, tabled in state parliament on Tuesday, said officers responded to Cleveland's final two threats within a minute.
But the failure to uncover his cell CCTV camera was likely to have played a significant role in his death because staff were not able to monitor him.
The commission found the officers working when Cleveland had self-harmed did not follow justice department policy requiring them to uncover his camera, but that it was not serious misconduct.
The investigation also examined the actions of the senior officer overseeing Unit 18, who was asleep on the job when Cleveland self-harmed.
Although the officer acted with no urgency once he was alerted to Cleveland's self-harm, he did reach the teen's cell within 40 seconds and assisted with CPR, the commission said.
"There is no evidence to suggest that the public officers involved committed an offence punishable by two or more years' imprisonment in the execution of their duties," it said.
"Consequently, the commission is not satisfied on the balance of probabilities that serious misconduct has occurred and has formed no opinions of serious misconduct."
A wide-ranging coronial inquest into Cleveland's death is also under way, with the next hearing scheduled in July.
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