Inquest into the Death of Cleveland Keith DODD

Contributing factors

• inadequate custodial staffing and supervision
• excessive in-cell confinement amounting to solitary confinement
• failure to place on appropriate mental health monitoring (ARMS level 1) despite multiple self-harm threats
• detainee in cell with obvious ligature anchor point (damaged ceiling vent)
• covered CCTV cameras preventing observation
• lack of mental health services access
• absence of Individual Engagement Plan
• inadequate nursing model (no 24/7 nursing coverage)
• lack of dedicated observation cells
• absence of model of care at Unit 18
• lack of staff training and induction for Unit 18
• premature opening of Unit 18 with insufficient preparation
• poor physical environment including cell damage and unsanitary conditions

Coroner's recommendations

1. Clothing worn by custodial staff in youth detention centres should be non-uniform to distinguish from adult prison officers
2. Additional case managers appointed at Banksia Hill (six additional permanent FTE positions)
3. Suicide Prevention Governance Unit expanded to include youth-specific clinician and reference group
4. Additional training provided for Youth Custodial Officers for Unit Manager and Senior Officer positions at Corrective Services Academy
5. Mandatory and comprehensive training for custodial staff transitioning from adult estate to youth estate
6. All custodial staff receive training on findings of Banksia Studies regarding neurodevelopmental impairments
7. Funding provided to ensure qualified instructors at Corrective Services Academy
8. Young persons placed in custody screened for neurodevelopmental and mental health disorders within first week
9. Mental health team member based at Unit 18 for day shifts seven days per week if Unit 18 remains open
10. Remuneration and pay structures for health and allied health service providers aligned with Department of Health comparable positions
11. Youth carer roles implemented within youth detention centres (separate from YCOs) with degree-level qualification
12. Shorter shift system piloted for custodial staff (eight or 10 hour shifts instead of 12 hours)
13. Funding extended to Aboriginal Legal Service Youth Engagement Program for post-release case management services
14. COPPs amended to mandate minimum two hours out of cell time per 24-hour period for detainees not confined for disciplinary breach
15. Forum established comprising relevant government entities and stakeholders to consider whether youth justice should remain within Department's responsibility, with report prepared for State Government
16. Unit 18 operate only as temporary facility pending completion of new purpose-built youth detention centre incorporating rehabilitation, trauma-informed and culturally appropriate care principles
17. If Unit 18 continues beyond transition period, alternative recommendation for closure and alternative arrangements
18. Department establish separate Youth Directorate independent from adult Corrective Services