A coronial inquest into the death of Cleveland Dodd has heard a nurse who was on duty the night the teenager self-harmed in his cell describe the Unit 18 facility as a "war zone".
WARNING: This story discusses incidents of self-harm and contains the name and image of an Indigenous person who has died.
Cleveland was 16 when he died after self-harming in his cell at the youth section of the adult maximum security Casuarina Prison.
On the night Cleveland was found unresponsive he told officers he was going to kill himself on eight separate occasions.
He had covered the CCTV camera in his cell with tissue paper for 11 hours before he self-harmed.
Detainees at Unit 18 are put on an At-Risk Management System (ARMS) which determines the level of supervision required.
The highest level requires constant surveillance.
Nurse Fiona Bain, who was on shift that night, has told the inquest there were times senior management and officers did not act to ensure detainees could be monitored.
Detainees cells' CCTV were often covered by tissue paper or were damaged, and cell viewing windows were also often covered.
Ms Bain told the inquest officers would often alert senior staff that they were unable to monitor at-risk detainees.
"There have been occasions that you can recall where a senior officer did nothing?" Coroner Philip Urquhart asked.
"That's correct," Ms Bain replied.
Coroner Urquhart described this as "effectively a shrug of the shoulders".
Unit described as 'war zone'
The inquest heard Ms Bain kept a diary of her experience at Unit 18 to help with her mental health.
Counsel assisting Anthony Crocker said her diary entries described the unit as a "war zone".
"The staff were on the front line of a war," Mr Crocker said, to which Ms Bain replied: "Exactly."
"You used language of, 'I'm literally here to pick up the pieces' … you identify 'the changeover of staff is huge'," Mr Crocker said.
Ms Bain described the condition of Unit 18 cells as "liveable" but "inhumane" — she told the inquest many did not have running water, were dirty, and some smelt of urine, faeces and sweat.
Shipping container plan
Ms Bain's diary also contains her recount of "the container incident", when two shipping containers, each the length of a basketball court, were brought into Unit 18.
"Management had this idea of putting containers in the boys' recreation area and having more boys from Banksia (Hill Detention Centre) in the unit," the entry read.
The inquest heard the containers were going to be used as office spaces for senior management, in order to free up room in the unit for more detainees.
Ms Bain said she told the assistant superintendent it was a bad idea to bring in more detainees due to staffing pressures, and the lack of a dedicated medical space and mental health team.
"How are we going to facilitate the amount of staff that we would require for more boys in the unit?" Ms Bain said.
"I think his [the assistant superintendent's] mannerism towards me was, 'well, I'm going to do it anyway'."
Premier 'disturbed' by evidence
WA Premier Roger Cook welcomed the evidence heard by the inquest as key to improving juvenile justice.
"I think we continue to be disturbed and distressed by some of the evidence which is presented at the coroner's court, but I'm pleased that evidence is there, and I'm pleased those stories are being told," Mr Cook told reporters.
"It's all part of the journey that we need to go on to make sure we improve the way we address juvenile justice issues."
The inquest previously heard from an officer that it was impossible to treat detainees humanely and lawfully within Unit 18.
When quizzed about why that was the case, Mr Cook said he did not have "insights in terms of the operations of Unit 18", and deferred to Corrective Services minister Paul Papalia.
Pressed on how much longer detainees would be treated inhumanely, Mr Cook said he did not have a definitive answer.
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"I'm not saying that they're experiencing that [inhumane, unlawful treatment] at the moment, but I am saying that we are about a government of change," he said.
Ms Bain told the inquest the approach to uncovering obstructed cell cameras has become much more proactive at Unit 18 since Cleveland's death.
Letter to father not delivered
Before Cleveland self-harmed, he wrote a letter to his father Wayne Gentle, with the help of youth custodial officer Daniel Torrijos.
The sealed letter was not delivered to Mr Gentle until after the inquest started.
Coroner Urquhart demanded "answers" about why it wasn't delivered, or brought to the attention of the court sooner.
The inquest on Wednesday heard Superintendent Doug Coyne would apologise to Cleveland's father for the late delivery of the letter, which Mr Urquhart said was "entirely appropriate".
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