The NSW coroner has described the spate of Indigenous deaths in custody as "profoundly distressing" as the state records the most ever in a single year.
Teresa O'Sullivan made the rare public comments in an open letter on Wednesday to raise what she called the "entrenched over-representation" of Indigenous prisoners.
She said 12 Aboriginal and Torres Strait Islander peoples had died in NSW custody this year so far.
"This is a profoundly distressing milestone," she said.
"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 across the state.
"They are individuals whose deaths demand independent and careful scrutiny, respect and accountability."
Magistrate O'Sullivan referred to figures fro