A regional title fight should have been called off before concussed boxer Davey Browne was fatally struck in the 12th and final round of the professional bout, a NSW coroner has found.
Browne, 28, died in hospital as a result of brain death four days after he was knocked to the canvas of a regional IBF super featherweight fight at the Ingleburn RSL on September 11, 2015.
Deputy State Coroner Teresa O'Sullivan said his death was preventable in her inquest findings handed down at the Glebe Coroner's Court on Thursday.
Browne received a flurry of punches to the head causing him to fall back onto the ropes at the end of the 11th round.
Ms O'Sullivan said the referee made an error of judgment when he didn't deem Browne had been knocked down and therefore failed to apply an eight count.
The inquest heard Browne was concussed and in a "perilous state" at the time.
"As a result of concussion and probably combined also with exhaustion, Davey was, at the end of round 11, injured to such an extent as to be unable to defend himself or to continue the contest," the coroner said.
If this had been recognised by referee Charlie Lucas, ringside doctor Lawrence Noonan or combat sports inspectors Paul Toweel and Darren Perkins the fight should have been stopped, she said.
"Action could have been taken to examine Davey and stop the fight prior to the point when it ended in the 12th round.
"The evidence clearly establishes that it was the blow in the 12th round that killed him."
The coroner recommended doctors be given greater powers to stop combat sports contests and examine competitors, particularly for "trigger" events such as a knockdown or suspicion of concussion.
Professor Brian Owler, a neurosurgeon who gave evidence at the inquest, on Thursday said the Australian Medical Association remained against boxing but was pleased the coroner made recommendations to make the dangerous sport safer.
"We need to make sure that the recommendations are followed and that doctors who attend boxing events are well trained," the AMA representative said.
"But also that they have the ability to interrupt a boxing match to ensure those participating are going to be safe ... and have the confidence and backing of the sport."
NSW Sports Minister Stuart Ayres says Browne's death was a tragedy.
"The government will carefully consider each of these recommendations and respond as soon as practically possible," he said in a statement on Thursday.
Outside court, Browne's widow Amy Lavelle said the findings brought some satisfaction and closure.
"What the coroner found is what I've felt from the start.
"It's just good to hear it ... that it was preventable and hopefully it never happens again and no one else has to go through this."
Ms Lavelle said "any one of us could have jumped in" but ultimately it was the role of boxing officials to act as a safeguard.