www.silverguide.site –

There were a record number of New South Wales deaths in custody and police operations last year, with almost a quarter of prisoner deaths recorded as self-harm, a coroner’s court report states.

Of those who killed themselves, most were by hanging, despite millions being invested to remove ligature points.

The state coroner, Teresa O’Sullivan, released her annual deaths in custody and police operations report on Thursday. It found 66 deaths in custody or as a result of police operations were reported last year – 18 more people than in 2024.

Thirty-nine of the deaths were in custody. Of those, 12 were First Nations people, a record high.

Nine of the 39 deaths in custody were reported as intentional self-harm. All but one of them died by hanging, making up 22% of the total deaths.

Last June, a Guardian Australia investigation revealed that nationally, at least 57 inmates had died in 19 separate prisons using hanging points that authorities knew about but failed to remove, often despite repeated suicides and stark warnings from coroners.

In response to questions during that investigation, Corrective Services NSW said it had invested $16m to make prisons “safer” by removing ligature points.

“This has included the removal of ligature points from almost 800 cells, as well as replacing cell doors, grills, beds, basins and tapware. An additional 145 cells are expected to be completed by July 2025,” tit said.

On Friday, a government spokesperson said the work to remove ligature points under the program was ongoing.

Last October, O’Sullivan released a rare statement announcing the state had already hit the record number of 12 Indigenous deaths in custody with three months still left in the year.

This week’s report showed half of those deaths were either by self-harm or accidental overdose, five were from natural causes, and the cause of death for one was unknown.

The coroner noted that death by natural causes inside prisons may still lead to findings in inquests to come that preventable issues – such as quality of care, treatment or supervision – contributed.

“This is a profoundly distressing milestone,” wrote the coroner about the record number of Indigenous deaths in custody.

“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.”

The report was sent to the state attorney general, Michael Daley.

O’Sullivan said that the number of people on remand in NSW prisons was at a record high due to an increase in bail refusals.

The number of Indigenous people on remand had surged by 63% in the past five years. Fifteen of the 39 people who died in custody in 2025 were on remand.

The causes of five, or almost 13% of the deaths in custody, were unknown. The coroner noted this was a “concerning” increase that triggered the state’s chief health officer, Dr Kerry Chant, to undertake additional toxicology testing of coronial samples to determine if a public health investigation was needed.

“Closer investigation of these deaths and additional toxicology screening did not reveal any new drug trends or issues of concern,” the coroner wrote.

Twenty-seven of the 66 deaths were as a result of police operations. A third of those were crashes via police car pursuits, which the coroner said marked an “increasing trend” with the “need for safeguards or qualifiers before police engage in a pursuit” being raised by coroners.

Three of the deaths that occurred as a result of police operations were in the context of the administration of sedation for agitation management.

Five of the total 27 deaths, or 18.5%, occurred in the course of a police operation to contain or restrain someone.

• Indigenous Australians can call 13YARN on 13 92 76 for information and crisis support; or call Lifeline on 13 11 14 or Mensline on 1300 789 978