WARNING: This story contains the name and image of an Aboriginal person who has passed.
Prison officers were watching movies and relaxing when an Indigenous teenager fatally self-harmed in youth detention.
Officers discovered at the in the early hours of 12 October, after he twice contacted them through the intercom and threatened to hurt himself.
He was taken to hospital in a critical condition, where he later died, .
West Australian Corrective Services Minister Paul Papalia on Friday released the interim report of an internal investigation which he said had uncovered significant failures.
"Operational procedures were not followed on the night," he told reporters.
"Youth custodial officers were not carrying radios ... (and) record keeping was poor and not up to standard."
West Australian Corrective Services Minister Paul Papalia said Unit 18 as Casuarina Prison would close as soon as a suitable replacement facility could be provided. Source: AAP / Aaron Bunch
The boy was also being held in a damaged cell and its closed-circuit camera was covered in toilet paper, obscuring its view.
"Two of the five staff required to wear body-worn cameras on the night did not sign out their devices," he said.
Papalia said it was also found staff were watching movies in the control room at the time Cleveland self-harmed.
Guard was partially undressed in office nearby
Another guard was partially undressed and "resting" in a darkened office nearby.
"None of these things are acceptable," he said.
"Collectively, they are disturbing and confirm the need for significant cultural change."
WA Corrective Servies Minister Paul Papalia said the report's findings were "disturbing". Source: AAP / Richard Wainwright
It started at 3pm the day before he died when the CCTV camera in his cell was covered with toilet paper.
At 1:22am, Cleveland called the control room where staff were watching a movie, and made his first threat to self-harm.
Five minutes later, Cleveland made another call stating his intention to hurt himself.
The control room officer told Cleveland an officer would come to talk to him.
This happened less than a minute later and the pair spoke briefly before the guard moved on to speak to two other inmates.
At 1:40am, he returned to the teen's locked cell and found him unresponsive.
The officer then went to a supervisor's darkened office to retrieve Cleveland's cell keys and advise the senior officer about the incident.
The officer who found Cleveland was not carrying a radio.
At 1:42am, another youth detainee contacted the control room via the intercom and raised concerns for Cleveland's well-being.
Cleveland Dodd, 16, died after being found unresponsive in his cell at Unit 18. Source: AAP, Supplied / Approved and Supplied by Cleveland Dodd's family
A nurse and two other officers also responded and a code red was called throughout the prison at 1.53am.
Paramedics arrived 15 minutes later and found Cleveland still had a pulse.
Death being investigated by coroner, commissioner replaced
Cleveland's death is also being investigated by the coroner and the Corruption and Crime Commission has started inquiries following allegations of serious misconduct.
The corrective services commissioner has been replaced and a prison officer has been suspended pending the outcome of the investigation into Cleveland's death.
Papalia said Unit 18 would close as soon as a suitable replacement facility could be provided but declined to put a timeline on the closure.
In a statement, Cleveland's family said it continued to grieve and "our beloved is buried before his time, long before."
"Our son, brother, grandson is back on Country but to be buried, and his spirit rests strong with our ancestors," they said.
Opposition spokesperson for corrective services Peter Collier said the Cook government had allowed a flawed system to operate despite being warned such a tragedy was possible.
"It's hard to imagine what more could have gone wrong at Unit 18 in the lead-up to Cleveland's death," he said.
Community leaders call for Unit 18's closure
More than 130 community leaders have signed an open letter to Premier Roger Cook calling for the immediate closure of Unit 18, where "there have been 20 suicide attempts and more than 350 instances of self-harm".
"You can choose to care for the children your government is responsible for," the letter said.
Indigenous justice advocate Gerry Georgatas said updated operational policies that included better oversight and rehabilitation programs should have been implemented long ago.
Readers seeking support can contact Lifeline crisis support on 13 11 14, visit or find an . Resources for young Aboriginal and Torres Strait Islanders can be found at .
