The first juvenile to die in youth detention in Western Australia threatened to self-harm eight times in the hours before he was found unresponsive in his cell.
Cleveland Dodd's last night in the troubled youth wing of a high-security adult prison on October 12, 2023, was detailed on Wednesday, the first day of an inquest in Perth.
Counsel assisting the coroner Anthony Crocker said the 16-year-old Indigenous boy had been locked in his Unit 18 cell, which had no running water, for most of the day.
He was also frustrated with the length of time he had been in custody after being denied bail.
Cleveland also covered a CCTV camera in his cell with tissue paper, blocking the view of correctional staff monitoring him, but they didn't bother to uncover it until they were fighting to save his life.
Cleveland made multiple calls asking for medical treatment and water as the night wore on but Casuarina Prison officers were generally reluctant to open detainees' cell doors at night "due to staffing numbers and risk issues".
"At 1.35am, Cleveland made a call (from his cell via the intercom to a control room) and again threatened to self-harm," Mr Crocker said during his opening submissions.
"This was the eighth time since lockdown that night when Cleveland threatened to self-harm."
A staff member visited Cleveland's cell and briefly spoke to him before moving on to check on another detainee.
"It appears that at about this time Cleveland (self-harmed)," Mr Crocker said.
"The detainee next door to Cleveland made a cell call to (the control room) and said, "Cleveland's trying to kill himself, he's not talking back to me ... it's an emergency, bro'."
A video played to the inquest showed a staff member banging on Cleveland's cell door soon after, but he didn't have keys.
The officer walked at a "hurried pace" to fetch them from a manager's office, which was next to Unit 18's nursing post but did not ask for help.
He also wasn't carrying a radio, which was Department of Justice policy.
At 1.51am, the officer opened Cleveland's cell door and was joined soon after by a manager, who did not "appear to be hurried", Mr Crocker said.
A code red alert was issued at 1.54am as staff tried to revive the teen.
Paramedics arrived at 2.06am, but did not get access to Cleveland, who was found to be in cardiac arrest, for nine minutes.
The teen was partially revived and taken to hospital but suffered a brain injury due to a lack of oxygen.
"Cleveland died, surrounded by his family, on 19 October, 2023, at 10.14pm," Mr Crocker said.
Mr Crocker told the inquest Cleveland had been in detention since August 2022 and had been diagnosed with a major depressive disorder, a cannabis use disorder, and a likely language disorder.
A mental health worker at the facility said he was "oppositional defiant" and "extremely violent and aggressive ... He needs to be at Unit 18".
Coroner Phil Urquhart earlier said it was the first inquest to be held for a young person who had died by "apparent suicide" in a youth detention centre contained in a maximum-security prison built to house adults.
The expedited inquest has also included an unprecedented early level of involvement from the coronial investigators, including examining Cleveland's cell soon after his death and supervising evidence gathering.
Despite this, Mr Urquhart said the inquest would be a limited fact-finding exercise and he could not make findings of negligence or guilt for criminal offences.
"This inquest like every other is not a royal commission," he said.
The hearings are expected to take 21 days and will happen in two parts - the first set to conclude on April 12 and the second expected to start in July.
Witnesses who worked at Unit 18 including three youth custodial officers, a nurse and a manager are scheduled to start giving evidence on Friday, with a full day set aside for each.
Outside court, Cleveland's grandmother, Glenda Mippy, expressed outrage.
"Eight times he told them he was going to hurt himself and none of them took it seriously," she said.
"They left that left him there in that cell until something happened."
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