An Aboriginal woman who died in police custody after three visits to hospital was subjected to "unprofessional and inhumane" treatment by police, an Australian coroner has said.
Coroner Ros Fogliani said that the woman, known as Ms Dhu, had also received "deficient" health care.
Ms Dhu, whose full name is not used for cultural reasons, was arrested in August 2014 for unpaid fines.
Her family insists someone should be held accountable for her death.
Ms Dhu's death and her family's fight for justice have become a symbol for Aboriginal rights in Australia.
Delivering a series of recommendations at Perth Central Law Courts, Ms Fogliani said the law in Western Australia should be changed to end the imprisonment of people for non-payment of fines.
She also said police officers should undergo cultural competency training to better understand Aboriginal people's health concerns.
After being arrested on 2 August 2014, Ms Dhu, 22, was taken into custody at South Hedland Police Station, near the remote mining town of Port Hedland.
She began to complain of rib pain from a previous injury and was taken to South Hedland Health Campus. A doctor found no signs of infection and had her returned to custody on the basis that her pain was due to "behavioural issues".
The next day, Ms Dhu was still complaining of pain and was returned to hospital. But Ms Fogliani said her temperature was not taken, a chest X-ray was not performed and "errors were made and there was a missed opportunity to treat Ms Dhu for her infection".
She added: "On this presentation, antibiotics would have been potentially life-saving for Ms Dhu."
The following day Ms Dhu "continued to suffer a catastrophic decline in her health" but Ms Fogliani said: "The behaviour towards her by a number of police officers was unprofessional and inhumane.
"Their behaviour was affected by preconceptions they had formed about her."
CCTV footage played at the inquest showed officers dragging Ms Dhu, who appears to be unconscious, from her cell to a police vehicle.
She was taken to hospital for a third time where she died from septicaemia and pneumonia resulting from a broken rib.
In her conclusion, Ms Fogliani says: "It is profoundly disturbing to witness the appalling treatment of this young woman at the lock-up on 4 August 2014.
"In her final hours she was unable to have the comfort of the presence of her loved ones, and was in the care of a number of police officers who disregarded her welfare and her right to humane and dignified treatment."
Speaking outside the court, Ms Dhu's family said they were not satisfied with the coroner's recommendations because no-one had been held accountable for her death, broadcaster ABC reported.