Warning: this article includes the name and image of an Aboriginal person who has died. It also discusses distressing themes, including suicide.
Cleveland Dodd was found unresponsive in the early hours of October 12, 2023, inside his cell in Unit 18 at Perth's Casuarina Prison, becoming the first juvenile to die in detention in Western Australia.
The 16-year-old had made eight threats to self-harm and multiple requests for medical treatment and drinking water in the hours before he was discovered and transported to hospital, where he died eight days later.
A coronial inquest into his death in Perth on Wednesday heard the situation in the unit was so bad before the incident, that registered nurse Fiona Bain started keeping a diary of events to preserve her mental health.
Unit nurse detailing 'inhumane' treatment
She agreed it was like working on the front line of a war zone and that she was overwhelmed and there was a "huge" staff turnover.
The coroner heard some detainees were held in cells without running water for more than 22 hours per day.
They ate their meals and went to the toilet in the cells, which were described as disgusting, dirty and grimy, but could not wash themselves.
"There's leftover food in there, the smell of possibly urine, faeces, sweat ... a lot of graffiti, a lot of damage to the cells," she said.
Ms Bain agreed the cells were unliveable, inhumane, a health risk and an "appalling state of affairs".
The inquest also heard some boys had not been outside for months during their limited recreation time because the Department of Justice placed two sea containers in the basketball court area.
They were on-site for about eight months and the plan was to use them as offices, but it did not happen and they were eventually removed.
Ms Bain said the department had planned to increase the number of detainees in Unit 18 before Cleveland died and she raised concerns with a manager about the lack of facilities but was ignored.
Night of Cleveland Dodd's death
She told the coroner she was in her office on October 12 when she heard youth custodial officer Daniel Torrijos tell a senior officer in a panicked tone: "I need the keys, I think Cleveland has (harmed himself)."
"I was thinking what's going on but we heard it that often about boys," she said.
She said numerous staff members passed her office on their way to Cleveland's cell soon after that but none bothered to advise her.
The court heard CCTV vision showed Ms Bain walk towards the wing where Cleveland's cell was before turning back and collecting emergency medical equipment.
"I knew it was dire and it was an emergency but I didn't actually know what happened at that stage," she said.
Ms Bain also told the coroner some senior officers did nothing when detainees covered the cameras in their cells or scratched them, as Cleveland had done before fatally harming himself.
It prevented staff in the unit's control room from being able to check on their welfare, and was an issue for detainees who required increased monitoring after they threatened to harm themselves.
Ms Bain said the problem was so widespread before October 2023 that it was common to see most of the screens in the control room blanked out and that some senior officers ignored the issue, saying there was nothing that could be done.
Premier Roger Cook said the evidence was distressing and disturbing.
"But I'm pleased that evidence is there and I'm pleased that those stories have been told,' he told reporters at an unrelated media conference.
"It's all part of the journey that we need to go on to make sure that we improve the way that we address juvenile justice issues."
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