The ringside doctor at a fight where an Australian boxer died should have intervened when he showed signs of concussion, a Sydney coroner found Thursday, while also criticising the referee for not stopping the bout.
Davey Browne Jr died in hospital from a brain injury four days after he was knocked out 30 seconds from the end of the super featherweight 12-round contest against Carlo Magali of the Philippines in Sydney in September 2015.
Deputy New South Wales state coroner, magistrate Teresa O'Sullivan, said the 28-year-old father-of-two's death was "preventable".
"The seriousness of his condition at the end of round 11 was recognised by a number of witnesses present at the time, albeit with the benefit of hindsight," she said in her findings.
"Action could have been taken to examine Davey and stop the fight prior to the point when it ended in the 12th round."
O'Sullivan criticised attending physician Lawrence Noonan, who said he did not act because the referee had not stopped the fight, and recommended that a ringside doctor's obligations to intervene should be strengthened.
She described Noonan's approach as a "manifestly inadequate method to assess whether Davey had sustained or recovered from concussion and whether he was fit to continue", and also censured referee Charlie Lucas.
"Mr Lucas's failure to recognise the seriousness of Davey's condition serves to emphasise the need for an examination by a ringside doctor who is trained to detect concussion, to properly assess a fighter's fitness to continue," she said.
She called for more comprehensive state regulations, noting it was a "striking feature of the evidence that many witnesses did not know which rules applied to this contest, and had a flawed understanding of the rules".
Regulations around boxing differ across state lines in Australia.
Browne's widow Amy Lavelle said outside the court she was hopeful the findings would prevent future incidents.
"I guess it just provides a bit of satisfaction and pleasure to gain acknowledgement about what happened," the Australian Broadcasting Corporation reported her as saying.
"He was a very gentle person. He was just a fighter in the ring, it was a sport for him. He was very skilled at it and he had many titles."