Grant Cook died from a brain injury less than 12 hours after he stepped onto the pitch for a rugby league preliminary final in country NSW, an inquest has found.
The 28-year-old was trying to help the Murwillumbah Mustangs earn a place in Northern Rivers Regional Rugby League decider in September 2016 when he was involved in a tackle that would eventually kill him.
Mr Cook fell to the ground while unbalanced before his head hit the ground, Deputy State Coroner Derek Lee said in his inquest findings released on Friday.
He stayed on the field for up to six minutes before game footage showed him holding and rubbing his head, and then making his way to the bench.
The father-of-two soon collapsed and convulsed on the ground.
Mr Cook was placed in the recovery position, with a triple-zero call made at 3.32pm before emergency services arrived about 25 minutes later.
NSW Ambulance paramedics found Mr Cook to be unconscious, with no pulse or respiration. He was later taken to Gold Coast University Hospital, where he died about 2am the following day.
Mr Lee said in his findings the now-defunct body that governed the NRRRL in 2016 had no relevant policy concerning the detection and management of head injuries in players.
He found no fault with the club's trainers present on the day, but recommended NSW Rugby League - which now governs the NRRRL - develops training programs to allow players and staff to detect and treat head injuries.
Mr Lee said the care and treatment provided to Cook by NSWA paramedics was appropriate. But he found that an explicit request for a helicopter should have been made.
He recommended that the circumstances of Mr Cook's death form a case study in education and training packages provided to NSWA staff.
A week after Mr Cook's death the Murwillumbah Mustangs went on to win the NRRRL premiership, which was dedicated to his memory.
"The resolve, courage and resilience shown by the team in such circumstances is a reflection of how highly Grant was regarded, and the enormity of his loss to his family, teammates, friends and local community," Mr Lee said in his findings.
"It is small comfort to know that Grant was lost...at a time when he was playing a game that he loved and which was one of his life's passions.
"Grant's many positive qualities as a husband, father, son, brother, and mate has undeniably left a lasting memory on many people."
Australian Associated Press