Deputy State Coroner Magistrate Liz Ryan investigated the death of 24-year-old Jordan Wayne Cruickshank who died during a police operation in May 2018.

Magistrate Ryan released her recommendations on October 10 following a two-day inquest into Mr Cruickshank's death in Milton Local Court in early September.

While she found police officers involved in the incident did not act unlawfully or improperly she made a number of recommendations on how next of kin and particularly those of Aboriginal or Torres Strait Islander heritage should be treated.

Mr Cruickshank was pronounced dead at Shoalhaven District Hospital in the early hours of May 6, 2018.

He had been taken there by ambulance after being found unconscious in the backyard of a house in Bomaderry following a short foot pursuit with police.

On the night of his death a police operation was underway to arrest him for outstanding driving charges.

The inquest heard two police officers had been pursuing him on foot before they lost sight of him. Shortly after he was found unresponsive and slumped in a backyard by a resident, who alerted police.

Police and later NSW Ambulance paramedics performed CPR and took Mr Cruickshank to Shoalhaven Hospital but he could not be revived.

Immediately after his death, a critical incident was declared with NSW Police's Professional Standards Command [a team of officers from another police district] taking over the investigation.

Officers in charge of the investigation attended the home of Mr Cruickshank's mother Debbie Walker and her de facto partner Tim Foster, to give her the tragic news.

Officers described how Ms Walker became extremely upset upon hearing what happened and retreated into her bedroom, shutting the door.

Police spoke to Mr Foster, explaining there would be an independent investigation into Jordan's death, giving him a contact number.

But Ms Walker or Mr Foster were not told Ms Walker had the right to view her son's body, information required to be given to the family under the Professional Standard Command's Critical Incident Guidelines.

Nor was Ms Walker told she was able to formally identify her son's body herself, police saying Ms Walker had been so upset they didn't want to further distress her.

It was conceded that even when a relative is deeply distressed he or she may very much want and need to see the body of their loved one and Ms Walker ought have been given the opportunity to see her son.

Mr Cruickshank's body was formally identified by comparison with police fingerprint records.

An autopsy report of forensic pathologist Dr Elsie Burger found Mr Cruickshank had died of methamphetamine toxicity in the background of atrioventricular node artery dysplasia. Toxicological analysis of his blood had detected methamphetamine in a concentration where potentially toxic levels overlap with lethal levels. Small concentrations of cannabis and naloxone were also present.

Atrioventricular node artery dysplasia describes abnormality in the atrioventricular, or 'AV' node of the heart, which controls the heart rate, by slowing electrical currents from the upper chambers of the heart before they reach the lower chambers.

Prolonged use of stimulant drugs is associated with structural change such as AV node artery dysplasia.

In her report Dr Burger commented that methamphetamine can cause potentially fatal electrical rhythm disturbances in the heart and in Mr Cruickshank's case the abnormalities in his AV node may have made him more susceptible to this phenomenon, with his flight from police, most likely involving production of adrenaline and may have increased the effect.

At the close of the inquest a statement from Ms Walker spoke of Jordan's love of his family, playing cricket and football and his many friendships and of her deep sadness that she had not been able to see his body after he died and say her last goodbyes, a source of enduring grief for her.

"Visual identification of a son or daughter who has died is likely to be the saddest experience a parent can ever have," Magistrate Ryan said.

"But it is also a precious opportunity for the parent to see their loved one for the last time.

"Jordan's mother never saw him again after being told of his death, and this has added to her sorrow."

Magistrate Ryan has recommended the Commissioner of Police consider adding an item to the Senior Critical Incident Checklist, of advising the next of kin of their right to view the body of the deceased.

She also recommended the consideration of introducing a mandatory training course and/or disseminating training material on the obligations of senior police under the equivalent section to Critical Incident Guidelines, which includes that specific notifications need to be made if the deceased person is from the Aboriginal or Torres Strait Island community.

She emphasised the need for officers to familiarise themselves with the appropriate local contacts for those notifications, including Aboriginal Community Liaison Officers.

Magistrate Ryan said having reviewed the evidence and other evidence contained in the coronial brief she was satisfied the police officers involved in this operation did not act unlawfully or improperly.

"This is important for Mr Cruickshank's family to hear, as in the aftermath of his death rumours had circulated that he had been harmed by police officers and that this may have caused or contributed to his death," she said.