In what was a scathing critique of at least five police officers, NSW Coroner Mary Jerram said the officers involved in the death of Roberto Laudisio Curti earlier this year acted like "schoolboys in Lord of the Flies" with little or no understanding of what threat or crime was supposedly being averted by the chaotic and violent struggle.
Mr Curti was chased by police down Pitt Street in Sydney city centre, tasered several times, sprayed with almost three cans of OC spray, handcuffed and restrained by seven officers on the ground during the incident in March this year.
Commissioner Andrew Scipione said he accepted the Coroner's recommendations and said the force would "carefully examine" the issues Ms Jerram asked them to.
However, Mr Scipione said he stood by the use of Tasers as a weapon for officers, saying they "save lives".
Ms Jerram handed down 35 pages of findings in Glebe Coroner's Court on Wednesday morning following a two-week inquest into the death of the 21-year-old Brazilian student and football player.
In concluding, Ms Jerram recommended the five officers, including Probationary Constable Daniel Barling, who tasered Mr Curti five times after he was handcuffed, be disciplined.
She said the actions of police "during the pursuit and restraint of Roberto Laudisio Curti be referred to the Police Integrity Commission" for investigation
All five officers referred for further investigation to the Police Integrity Commission (PIC) remain "in the workplace" but that would be reviewed, the Commissioner said.
Ms Jerram also called for an immediate review of the vague and confusing standard operating procedures relating to the use of OC spray, Tasers, handcuffs, restraint and positional asphyxia, particularly the use of multiple Taser shots and its "drive stun mode" as a pain compliance tool.
In addition, she said the police should review "communication procedures to ensure that signs of mental disturbance in any person who is the subject of a police report be communicated and officers trained further to respond accordingly".
Finally, she urged an examination of the NSW Police VKG (police radio) procedures be undertaken, "to ensure accurate categorisation of any incident reported".
Commissioner Scipione said a review had been commenced today into the training and Standard Operating Procedures (SOPS) with regard to the use of Tasers, other appointments and other methods of restraint, as had a review of the VKG procedures.
"This was a tragic series of events and I do express my deepest sympathy and sadness to the Curti family, fully understanding the depth of feelings they have been experiencing," he said.
"It is a terrible thing to lose someone you love. I am a Police Commissioner but I am also human and I am a father.
"Police have a special responsibility in our society and we have been granted special powers to protect the community. It is important that those powers are exercised properly."
He said complaint investigations in relation to some of the officers involved have already been initiated with the Professional Standards Command.
Earlier Ms Jerram said "the actions of a number of the officers were ... reckless, careless, dangerous and excessively forceful".
"They were an abuse of police powers [and] in some instances even thuggish. Roberto's only foes during his ordeal were the police ... Certainly, he had taken an illicit drug, as has become all too common in today's society. But he was guilty of no serious offence. He was proffering no threat to anyone."
While stopping short of recommending criminal charges, Ms Jerram delivered a damning indictment on the entire episode. "It's impossible to believe that he would have died but for the actions of police," she said.
Before being chased by police down Pitt Street, Mr Curti had jumped the counter of a convenience store in a paranoid, LSD-induced psychotic state and taken two packets of biscuits. It was reported over police radio as an armed robbery.
Ms Jerram said many officers had lied to the inquest and "conveniently forgotten" evidence.
She said the most senior officer present during the violent struggle on Pitt Street, Inspector Gregory Cooper, gave evidence that was so conflicting and self-serving it "hardly deserves narration".
He claimed that he told the junior officers to stop using their Tasers. None of those officers heard the order and the Coroner said it was likely he never made it but was seeking to shift the blame onto other officers in court.
Ms Jerram suspected that some officers were angry and emotional because they had been hit by Taser shots and inadvertently sprayed during the botched arrest.
However, she said it was not right to refer the matter to WorkCover for further investigation as it was about "policing issues warranting investigation by policing bodies".