Careless or inappropriate jail or cell placement has contributed to at least 20 deaths in NSW prison custody in the past decade, according to a Crikey analysis of coronial reports. In three of those cases, inmates were killed by a cell mate whom prison authorities had previously identified as dangerous, violent or even homicidal.

Long Bay Prison Hospital inmate Craig Behr was one such victim. Behr died less than two hours after being locked in a cell with inmate Michael Heatley, who had told a psychologist just days earlier that he had been "experiencing homicidal urges for the past 18 months".