00:00Christine Mitchell raised red flags about Unit 18 time and again, with colleagues and
00:07senior management, along with staff at Banksia Hill.
00:15She told the inquest her message was that staff simply couldn't cope with the level
00:19of self-harm, saying we cannot continue doing this, it's breaking people, it's traumatic,
00:25something needs to change.
00:34Ms Mitchell said she hoped something good may come out of the tragedy, her sentiment
00:39echoed by Cleveland Dodds family.
00:41We shouldn't be here, we are here to put in place procedures for this not to happen again,
00:47any family, we wouldn't want any family going through what we're going through.
00:50This has blown my mind, I'm going to go insane after listening to what I listened to, we're
00:55only halfway through.
00:56The inquest has provided the clearest picture yet of the facility in which Cleveland Dodd
01:01decided to end his life.
01:03It has also raised many more questions, most directed at the facility's senior management.
01:10For Coroner Philip Urquhart, a burning question after a week of evidence is what inquiries,
01:16if any, were made after Unit 18 was commissioned in relation to its effectiveness, and if no
01:22inquiries were made, why not?
01:25It will be one of many senior management will have to answer in the second part of the inquiry
01:31beginning later this year.
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