One quarter of inmates who suicided in NSW prisons in the past nine years did so within days of having been assessed as no longer at risk of self harm or suicide, and suitable for release from emergency intervention protocols.

Figures compiled from a Crikey analysis of coroners’ findings into deaths in custody -- part of a multipart investigation into the issue -- reveal coroners criticised the conduct of prison or health agencies in 45 of the 57 cases of suicide investigated in the past nine years. In 42 cases the inmate had one or more psychiatric illnesses, 25 had a known history of self harm, and 16 had previously attempted suicide, some while in custody.