Cleveland Dodd, 16, was found unresponsive after harming himself inside his cell in a troubled youth wing of a high-security adult prison in the early hours of October 12, 2023.
The Indigenous teen was taken to hospital in a critical condition and died about one week later, causing outrage and grief in the community.
Cleveland Dodd was found unresponsive in his cell in the youth wing of Casuarina Prison in Perth. (Aaron Bunch/AAP PHOTOS)
The inquest's first sitting in April heard Cleveland made eight threats to self-harm and numerous requests for medical treatment and drinking water in the hours before he was discovered in Unit 18 at Perth's Casuarina Prison.
Night-shift staff ignored those requests because a senior officer informed them Cleveland had been given six cups of water with his dinner and his cell was not to be unlocked.
But CCTV footage shows Cleveland was given only three cups of water when his evening meal was delivered to his cell about 6pm, along with a bladder of milk.
Cleveland's threats to self-harm on October 11 and 12 started after his fifth request for water was ignored.
He had also covered a CCTV camera in his cell with tissue paper, blocking the view of correctional staff monitoring him from a control room, but it wasn't uncovered until they were fighting to save his life.
Officers were generally reluctant to open detainees' cell doors at night "due to staffing numbers and risk issues" but a guard did visit Cleveland's cell and speak to him through the door before moving on to check on another detainee.
It was about this time Cleveland self-harmed.
A video shows a staff member banging on Cleveland's cell door soon after, but he didn't have keys to open it or a radio to call for help.
The officer left Cleveland and walked to a manager's office on another floor to collect the keys.
At 1.51am, the same guard returned to Cleveland's cell and opened the door.
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.
He died, surrounded by his family, on October 19.
The second sitting of an expedited inquest in Perth examining Cleveland's death starts on Monday and is scheduled to run until August 9.
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