Cleveland Dodd was found unresponsive inside a cell in Unit 18, the trouble-plagued youth wing of a high-security adult prison south of Perth, in the early hours of October 12, 2023.
The 16-year-old was taken to hospital in a critical condition and died about a week later, becoming the first juvenile to die in a West Australian detention facility.
Coroner Phil Urquhart said the unit should be closed urgently and a special inquiry with more powers than the coroners court should be convened into how it came to be established.
"No child in detention deserves to be treated in the way Cleveland and the other young people in Unit 18 were treated at the time he decided to end his life," he said on Monday.
Prolonged periods of solitary confinement, isolation, intense boredom, eating meals alone, a lack of access to health, education and running water were the norm for Cleveland, he said.
"There were serious deficiencies in the way our young people were treated in detention," Mr Urquhart said.
"Cleveland's death was not because of human error by those working on the floor ... it was because of serious long-standing deficiencies in the system."
The coroner made 15 adverse findings and 19 recommendations, including that a forum be established to explore whether the Justice Department should have sole management over youth justice.
He also found Cleveland's damaged cell had a hanging point authorities were aware of and he had been denied access to counselling services despite requesting it numerous times and making threats to self-harm.
Cleveland's mother Nadene Dodd said the pain she suffered when the coroner delivered his findings was as intense as when her son died.
"I believed that my son Cleveland would be safe and that he would be treated humanely," she said in a statement after the hearing finished.
"But the evidence before the inquest into his tragic death at Unit 18 confirmed that Cleveland was neither."
Cleveland was the victim of institutional abuse and neglect and was in unbearable physical and psychological pain when he self-harmed, she said.
"It breaks my heart to know that Cleveland spent 23 hours a day, for days on end, locked down in a filthy cell with no end in sight," she said.
"I can understand why my son lost hope and the will to live."
Outside court, Cleveland's Aunty Eunice Mippy said her family was upset and hurt over the coroner's findings and recommendations, during which he detailed the treatment her nephew had endured inside Unit 18.
"We want someone to be held accountable for our nephew's death, for what's been done and what's been happening in that place," she said.
WA Corrective Services Minister Paul Papalia rejected the coroner's call to urgently close Unit 18 and transfer the detainees to the state's other centre, Banksia Hill.
"We know what happens when you put the cohort who are currently housed and managed in Unit 18 in with the other population of Banksia Hill," he said, referring to a 2023 riot that caused extensive damage.
"There is no facility in the state more fit for purpose than Unit 18 to house this cohort."
Conditions inside WA's youth detention centres had "significantly improved" since Cleveland's death, with increased out-of-cell hours, Mr Papalia said.
The inquest heard Cleveland self-harmed about 1.35am and staff didn't open his cell door to help him for more than 15 minutes, with paramedics arriving a further 15 minutes later.
The teen was partially revived and taken to hospital but suffered a brain injury because of a lack of oxygen.
He died, surrounded by his family, on October 19, 2023.
13YARN 13 92 76
Lifeline 13 11 14
Kids Helpline 1800 55 1800 (for people aged 5 to 25)
