Each death represents a person whose life mattered
In 2025, New South Wales recorded 66 deaths in custody and police operations — the highest toll in recent memory — as state coroner Teresa O'Sullivan released her annual accounting of lives lost within the machinery of the justice system. The numbers reveal not a single failure but a convergence of pressures: overcrowded remand populations, persistent self-harm despite costly infrastructure reforms, and a record toll on Indigenous Australians whose overrepresentation in custody reflects wounds far older than any policy. Across every category of death, the coroner's message was the same — these are not data points, but people whose absence echoes through families and communities.
- NSW deaths in custody surged to 66 in 2025 — up 18 from the prior year — with Indigenous deaths reaching a record 12, a milestone the coroner called 'profoundly distressing.'
- Nine prisoners died by hanging despite $16 million spent removing ligature points from nearly 800 cells, exposing the limits of infrastructure reform when deeper systemic pressures go unaddressed.
- Indigenous remand numbers have climbed 63 percent over five years, driven by rising bail refusals, pushing a vulnerable population into a system that is visibly failing to keep them alive.
- Five deaths remained unexplained, troubling enough to trigger expanded toxicology testing ordered by the state's chief health officer — a gap in knowledge that unsettles an already strained accountability framework.
- Beyond prison walls, police pursuit crashes accounted for a third of the 27 deaths in police operations, prompting the coroner to call for formal safeguards before pursuits are initiated.
New South Wales recorded 66 deaths in custody and police operations in 2025, up sharply from 48 the year before. State coroner Teresa O'Sullivan released the findings on Thursday, describing a system under visible strain. Thirty-nine deaths occurred inside prisons. Twelve of those who died were Indigenous Australians — a record high — and O'Sullivan wrote that each "represents a person whose life mattered and whose loss is felt deeply by families, loved ones and communities."
The most persistent pattern was suicide by hanging. Nine of the 39 custody deaths were recorded as intentional self-harm, almost all by hanging — 22 percent of the total. The figure is particularly confronting because Corrective Services NSW has spent $16 million since mid-2024 removing ligature points from nearly 800 cells and replacing doors, beds, and fittings. A Guardian Australia investigation had previously documented at least 57 inmate deaths by hanging across the country, often in locations flagged repeatedly by coroners. The spending has not stopped the deaths.
Half of the 12 Indigenous deaths resulted from self-harm or accidental overdose. O'Sullivan noted that even deaths attributed to natural causes can point to preventable failures — inadequate medical care or insufficient supervision. The broader context is stark: the Indigenous remand population in NSW has grown 63 percent over five years, driven by rising bail refusals. Fifteen of the 39 who died in custody in 2025 were awaiting trial.
Five deaths had no identified cause, prompting the state's chief health officer to order expanded toxicology testing. No new drug trends emerged, but the unexplained gap remains a concern. Outside prisons, 27 deaths arose from police operations — a third involving pursuit crashes, and five during restraint or containment. O'Sullivan called for formal safeguards before police engage in pursuits.
The report was delivered to attorney general Michael Daley. The coroner's language was measured but unambiguous: prevention spending and policy reform have not yet interrupted a pattern of loss that is being felt, concretely and personally, by communities across the state.
New South Wales recorded 66 deaths in custody and police operations during 2025, a sharp climb from the 48 deaths reported the year before. The state coroner, Teresa O'Sullivan, released the annual accounting on Thursday, and the numbers tell a story of a system under strain. Thirty-nine of those deaths occurred inside prisons. Twelve of them were Indigenous Australians—a record high that O'Sullivan described as a "profoundly distressing milestone." Each death, she wrote, "represents a person whose life mattered and whose loss is felt deeply by families, loved ones and communities across the state."
The most visible pattern in the data is suicide by hanging. Nine of the 39 deaths in custody were recorded as intentional self-harm, and all but one involved hanging. That accounts for 22 percent of all deaths in custody. The persistence of this method is particularly striking because Corrective Services NSW has spent $16 million since mid-2024 to address it. The agency removed ligature points from nearly 800 cells and replaced cell doors, grills, beds, basins, and tapware. Another 145 cells were slated for completion by July 2025. Yet the deaths continued. A Guardian Australia investigation published last June had documented at least 57 inmate deaths by hanging in 19 separate prisons across the country, in locations authorities knew about but failed to remove, often after repeated warnings from coroners.
The composition of those who died reveals deeper pressures within the system. Half of the 12 Indigenous deaths in custody resulted from self-harm or accidental overdose. Five were attributed to natural causes, and one remained unexplained. O'Sullivan noted that deaths from natural causes inside prisons may still prompt coroner findings that point to preventable factors—inadequate medical care, poor treatment, insufficient supervision. The surge in Indigenous deaths reflects a broader trend: the number of Indigenous people on remand in NSW prisons has jumped 63 percent over the past five years. Fifteen of the 39 people who died in custody in 2025 were awaiting trial. O'Sullivan attributed the rise in remand numbers to an increase in bail refusals, pushing the remand population to a record high.
Another concern emerged in the data itself. Five deaths—nearly 13 percent of the total—had unknown causes. O'Sullivan flagged this as troubling enough to prompt the state's chief health officer, Dr. Kerry Chant, to order additional toxicology testing of coronial samples. The deeper investigation and expanded screening did not uncover new drug trends or public health crises, but the gap in knowledge remains unsettling.
Beyond the prison walls, 27 of the 66 deaths resulted from police operations. A third of those involved crashes during police pursuits—a pattern O'Sullivan identified as "increasing" and one that prompted her to call for "safeguards or qualifiers before police engage in a pursuit." Three deaths occurred in the context of sedation administered to manage agitation. Five deaths, or 18.5 percent of the police operation total, happened during restraint or containment efforts.
The report was delivered to state attorney general Michael Daley. It arrives at a moment when the prison system is visibly strained—record remand numbers, rising Indigenous incarceration, and a pattern of deaths that prevention spending has not yet interrupted. The coroner's language was measured but direct: these are not abstract statistics. They are people whose absence is felt by families and communities across the state.
Citas Notables
This is a profoundly distressing milestone. Each of these deaths represents a person whose life mattered and whose loss is felt deeply by families, loved ones and communities across the state.— State Coroner Teresa O'Sullivan
The need for safeguards or qualifiers before police engage in a pursuit has been raised by coroners, as police pursuit crashes marked an increasing trend.— State Coroner Teresa O'Sullivan
La Conversación del Hearth Otra perspectiva de la historia
Why does the hanging method persist so stubbornly, even after $16 million was spent to remove the means?
Because removing ligature points is a game of inches. You can take out the obvious ones—the pipes, the bars, the fixtures—but prisoners are resourceful and desperate. They find new points. And there's a lag between when a death happens, when a coroner investigates, when recommendations are made, and when prisons actually implement changes. By then, someone else has already found another way.
The Indigenous death toll is described as a historic high. What's driving that specifically?
It's not one thing. Half died by self-harm or overdose, which speaks to mental health crisis and substance use inside. But the bigger picture is that Indigenous people are being held on remand at record rates—up 63 percent in five years. More people inside means more exposure to the conditions that kill them. And those conditions—isolation, inadequate mental health care, the stress of awaiting trial—hit Indigenous prisoners harder.
What does it mean that five deaths had unknown causes?
It means the system doesn't fully know what's killing people. The coroner had to order extra toxicology work just to figure it out. That gap in understanding is dangerous because you can't fix what you don't understand. And it suggests the initial investigation process isn't capturing enough detail.
The police pursuit deaths are described as an "increasing trend." Why would that be happening now?
The coroner didn't say, but you can infer: more pursuits, higher speeds, less restraint. She's calling for safeguards before police even start chasing. That's a significant statement—it's saying the current rules aren't working.
How should we read the coroner's language about deaths from natural causes?
She's saying that even when someone dies of a heart attack or illness inside a prison, the coroner's job is to ask whether the prison failed them—whether they got proper medical attention, whether they were supervised adequately. A natural death in custody isn't necessarily a natural death without responsibility.