Coroner’s extraordinary public letter after shock number of deaths

The state’s top coroner has taken the rare step of issuing an open letter after NSW reached the “profoundly distressing milestone” of recording the highest-ever number of Aboriginal and Torres Strait Islander deaths in custody in a single year.

Teresa O’Sullivan told The Sydney Morning Herald after her appointment in 2019 that preventing Indigenous deaths in custody was a priority for her court.

State Coroner Teresa O’Sullivan takes the rare step of speaking out, as NSW records its highest-ever annual number of deaths in custody of Aboriginal and Torres Strait Islander people.Credit: Brook Mitchell

But the number of Aboriginal people in custody has increased by almost 20 per cent in the past five years, while the non-Aboriginal prison population declined in the same period.

“Twelve Aboriginal and Torres Strait Islander peoples have died in custody in NSW so far in 2025 – the highest number ever recorded in a single year, with more than two months remaining in the calendar,” O’Sullivan wrote in the letter, released on Wednesday.

‘Not mere statistics’

“This is a profoundly distressing milestone. These are not mere statistics. 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. They are individuals whose deaths demand independent and careful scrutiny, respect and accountability.

“Recent data from the NSW Bureau of Crime Statistics and Research (BOCSAR) underscores the scale of the issue. As of June 2025, there were 4386 Aboriginal adults in custody, representing 33.4 per cent of the total adult prison population – despite Aboriginal people comprising only a small proportion of the NSW population.”

O’Sullivan said the number of Aboriginal people in custody had increased by 18.9 per cent over the past five years, while the non-Aboriginal prison population had declined by 12.5 per cent.

“Nearly half of Aboriginal adults in custody (45.6 per cent) were on remand or refused bail awaiting further court outcomes. The number of Aboriginal people on remand has surged by 63 per cent over the same five-year period,” she wrote.

“These figures reflect the entrenched over-representation of First Nations peoples in the criminal justice system – a systemic issue that compounds the risks and vulnerabilities contributing to the rising number of deaths in custody.”

O’Sullivan said the NSW Coroners Court, which sits under the umbrella of the Local Court, “remains committed to investigating every death in custody independently and thoroughly, in line with its statutory responsibilities”.

“Inquests will be conducted with impartiality, transparency and cultural sensitivity, ensuring that the voices of affected families and communities are heard and respected.”

The Human Rights Commission took aim at the “national shame” of Indigenous deaths in custody in June.

Race Discrimination Commissioner Giridharan Sivaraman said there could be “no doubt structural and systemic racism are at the heart of the problem”.

‘A name, a story, a family’

The Aboriginal Legal Service in NSW and the ACT said the deaths were a preventable tragedy and the state had set a “horrifying record”.

“A prison sentence should not be a death sentence,” said its chief executive, Karly Warner.

“Every one of these people had a name, a story, a family. They were loved and their families and communities will carry the scars of their loss.”

Warner said the state was “driving more Aboriginal women, children and men into prison than ever before through punitive laws and policing practices”.

“We have solutions to reduce deaths in custody but too many are sitting on the shelf, gathering dust.

“We call on the government to stop passing laws which contradict its obligations to reduce Aboriginal over-representation in police cells, courts and prisons, and instead work in partnership with Aboriginal communities to implement evidence-based, community-led solutions to reduce imprisonment.”

A NSW government spokesperson said each of the 12 deaths was “a tragedy and the government takes this issue seriously”.

“We are working to reduce all preventable deaths in custody including by improving design and safety across correctional centres and have invested $16 million to make our prisons safer by removing ligature points.

“A thematic review of Aboriginal deaths in custody is due to report back next year. The review will be guided by an external reference group including many Aboriginal experts with considerable relevant experience, chaired by Professor James Ward.

“The review will make recommendations on how [Corrective Services NSW] can reduce deaths in custody and improve the experience of Aboriginal people in custody, in a report to the minister for corrections.”

Start the day with a summary of the day’s most important and interesting stories, analysis and insights. Sign up for our Morning Edition newsletter.