Aboriginal woman Tanya Day died two weeks after a fall in a regional Victorian police cell in 2017.
But she shouldn't have.
The Yorta Yorta's grandmother's death was "clearly preventable", coroner Caitlin English said in handing down her findings on Thursday.
Prosecutors have been told to investigate two police officers for possible criminal negligence.
Evidence heard during an inquest showed the indictable offence of negligent manslaughter may have taken place, the coroner found.
"Ms Day's death was clearly preventable had she not been arrested and taken into custody," Ms English said
The 55-year-old woman's children said it was a "bittersweet" day.
"This is a historic day for Aboriginal people in this country, and a bittersweet day for our family," they said in a statement on Thursday.
"This isn't the end of the road, but it is the beginning of justice for our mum."
Ms Day was arrested for public drunkenness at Castlemaine train station and taken to a police cell to "sober up" on December 5, 2017.
Despite claims of of regular physical and verbal checks of Ms Day while she was in the cell, the coroner found they were inadequate.
Two officers - Leading Senior Constable Danny Wolters and Sergeant Edwina Neale - only conducted brief checks.
Ms Day's serious fatal fall happened at 4.51pm and she wasn't physically checked until just after 8pm.
"The quality of the physical checks were quick and cursory," Ms English said.
They failed to notice Ms Day's injuries and the two officers told the coroner they thought she was sleeping off alcohol.
In particular she questioned Leading Senior Constable Wolters' evidence and his differing versions of what happened.
"I did not find Leading Senior Constable Wolters to be a credible witness," she said.
There was an "inherent contradiction" in what he said in the triple-zero call about him seeing Ms Day falling, when he did not.
The coroner also found V/Line train conductor Shaun Irvine made a "snap decision" and showed unconscious bias.
"I find the decision to define her as unruly and to call for police rather than pursue other options has been influenced by her Aboriginality."
But she did not find the police officers who took Ms Day from the train platform and arrested her showed systemic racism in their decision.
Victoria Police said it would review the inquest findings and respond in "due course".
Though there are "sparks of justice" in the coroner's findings, her family still struggle with their loss.
"We have lost our mother in the cruellest of circumstances. Our family will never be the same," they said.
"While there are sparks of justice in today's decision, this country has so much further to travel."
OTHER RECOMMENDATIONS:
* Amend legislation to allow the coroner in charge of a coronial investigation to give an investigating police officer directions in relation to an inquest
* A falls risk assessment to be added to Victoria Police guidelines for people in custody who appear to be drug or alcohol-affected
* Review in training for police and education around the Royal Commission into Aboriginal Deaths in Custody to ensure knowledge and compliance
* Training to be implemented for Victoria Police for medical risks of people who are alcohol-affected
* V/Line review training materials to include input from the Aboriginal and Torres Strait Islander community about unconscious bias and provide training to staff on how to reduce bias
* Review the current volunteer model for the Aboriginal Community Justice Panel.
Australian Associated Press
