Overview
- Coroner Philip Urquhart found the teenager’s care in Unit 18 was inhumane and said the wing should be closed as a matter of urgency.
- He ruled the death was not caused by on‑shift human error but by serious, long‑standing system deficiencies that largely rest with the Department of Justice.
- The findings include 19 recommendations and 15 adverse findings, a call for a special inquiry into how Unit 18 was created, and a forum to reassess youth‑justice governance.
- Evidence detailed prolonged solitary confinement, minimal out‑of‑cell time, lack of mental‑health and education services, periods without running water, and known cell hazards left unremedied.
- The WA government says conditions have improved and it will not close Unit 18 until a purpose‑built replacement opens in about three years, with the coroner suggesting detainees be moved back to Banksia Hill in the interim.