The actions of police officers who knelt on a man's back while restraining him during a brawl did not contribute to his death, a Sydney coroner has found.
Deputy Coroner Paul MacMahon said yesterday the police officers involved in the arrest of Steven Bosevski in October 2010 showed a "gross error of judgment" in handling the overall situation.
But he was satisfied positional asphyxia did not play a part in the man's death.
Instead, he found Mr Bosevski died from cardiac arrest as a result of several factors including his medical background, morbid obesity, drug-taking and "a period of intense physical exertion that occurred while being restrained".
Mr Bosevski, 35, died after being restrained by police at the St George Leagues Club in southern Sydney in the early hours of October 4, 2010.
Mr Bosevski, his identical twin brother Steve and another brother Tony had been involved in a brawl at the club while celebrating St George Illawarra's NRL premiership win.
When Mr Bosevski hit a police officer, he was struck repeatedly by a baton, handcuffed twice and placed face down on the ground by police officers.
He died within minutes.
"I cannot be satisfied ... that restraint asphyxia played a part in Steven's death," Mr MacMahon said in his findings at Glebe Coroners Court yesterday.
"I cannot therefore be satisfied that the officers placing their knee on Steven's back was a contributing factor to his death."
The inquest heard Mr Bosevski was on the ground in a prone position for three minutes, 44 seconds before he was rolled over and found to be unconscious.
Mr MacMahon said the officers involved had a responsibility to ensure he was regularly checked, but he accepted their evidence that they were concerned for their safety at the time.
"Once the situation was under control, Steven was checked," Mr MacMahon said.
"No criticism should therefore be made of the officers for any failure to check on Steven's well-being earlier."
However, Mr MacMahon said the incident might never have occurred had police handled it differently.
"The CCTV footage makes it clear that at the time they entered the area there was no fight," he said.
Instead, the intervention of the officers appeared to have "ignited" the situation, even though they were not acting in a "hostile fashion", he said.
But he stopped short of recommending any of the officers involved in the incident face disciplinary action.
Instead he recommended further training for officers involved in crowd control situations.
Mr Bosevski's sister, who was in court for the finding, put her hand to her mouth as it was handed down.
She did not comment outside court. AAP