Yorta Yorta woman Tanya Day, 55, died of a brain haemorrhage on December 22, 2017, 17 days after she hit her head in a fall in a Castlemaine police station cell following her arrest for public drunkenness.

On Thursday, coroner Caitlin English delivered her findings on Ms Day's death, following a two-week inquest last year.

Ms Day was travelling from her home in Echuca to Melbourne, first by coach to Bendigo, then by train.

Shortly after leaving Bendigo, the conductor began checking tickets and came across Ms Day lying on the seat, with her feet across the aisle.

He asked for her ticket and destination, to which she gave unrelated answers, and he determined she was an "unruly" passenger under V/Line guidelines.

The conductor contacted the driver to call police, which necessitated the train making an unscheduled stop at Castlemaine.

At Castlemaine railway station, two officers boarded the train and found Ms Day asleep.

When roused, her replies did not make sense and she smelled of alcohol, so they arrested her and removed her from the train.

Ms Day was taken to a cell at the police station at 3.56pm.

The sergeant on duty requested Ms Day be checked every 20 minutes, but at some point the sergeant and the watch house keeper agreed to change this to every 40 minutes, requiring a verbal response from her every second check.

At 4.49pm the watch house keeper checked on Ms Day through the window.

One minute later, she got up, stumbled and hit her forehead hard against the wall.

Between then and 8.03pm, Ms Day was observed four times on the monitor and twice through the cell window - both times, the watch house keeper recorded that he had received a verbal response from her.

It was at 8.03pm that the watch house keeper and sergeant went to see Ms Day with the intention of releasing her.

They noticed a bruise on her forehead, and to some questions Ms Day only groaned.

Paramedics were called and Ms Day was taken to Bendigo Health, where it was discovered she had a bleed on the brain.

That night she was airlifted to St Vincent's Hospital and underwent surgery, but died on December 22.

Ms English found the police officers in charge of custody that day, Sergeant Edwina Neale and Leading Senior Constable Danny Wolters, performed inadequate checks.

The officers gave evidence they wanted Ms Day to "sleep it off".

The coroner said if physical checks had been conducted every 20 to 30 minutes in accordance with police rules, Ms Day's deteriorating condition might have been discovered earlier.

But there was a gap of 68 minutes between two physical checks at one point, she said, and an 81-minute gap between the last physical check and when police entered the cells at the end of the four hours Ms Day spent in custody.

Ms English found the physical checks were not up to standard, noting a doctor's evidence that Ms Day's blood alcohol concentration of 0.3 meant she would not have been able to have a meaningful conversation.

The coroner said there was an opportunity lost for Ms Day's survival, although an expert gave evidence even in optimal circumstances her chances of survival would have been less than 20 per cent and she would have sustained significant impairment.

Sergeant Neale and Leading Senior Constable Wolters viewed Ms Day's behaviour in the cell as simply that of an intoxicated person, Ms English said.

She concluded this approach, consistent among police witnesses, "appears to be a systemic attitude and failure in both recognising the medical dangers of intoxication and complying with the mandatory terms of the governing policy and procedures regarding the management of person in care or custody".

Ms English also found that Ms Day, as a person deprived of her liberty who was reliant on police for her welfare, "was not treated with humanity and respect for the inherent dignity of a human person".

Ms English found there was minimal evidence that arresting officers had complied with Victoria Police's medical checklist guidelines, but they did make contact with Ms Day's family and other agencies at the police station.

Ms English said she was not satisfied Ms Day's Aboriginality played a role in the police decision to arrest her for public drunkenness, and determined this was instead done for her own safety and the liability of the officer.

But the coroner found unconscious racial bias played a part in the V/Line conductor's decision to call police and have the train make an unscheduled stop at Castlemaine.

Conductor Shaun Irvine told the court he made the decision to get police intervention out of concern for Ms Day's safety, but also gave evidence he had never called police to remove a passenger who was asleep before.

Ms English rejected Mr Irvine's claims that he had "no preference either way" as to whether Ms Day was removed from the train, finding that when the conductor called for police, there was a strong prospect she would be taken off.

While Ms Day was sleeping, the coroner said, Mr Irvine told other passengers she was "trouble".

"I find the decision to define her unruly and to call for police rather than pursue other options has been influenced by her Aboriginality," Ms English said.

The coroner found Victoria Police responded quickly after Ms Day's hospitalisation for the police officers in contact with her to be interviewed, but did not review her time in custody nor draw any learnings from it.

Ms English said the totality of evidence suggested an indictable offence might have been committed regarding Ms Day's death, and ordered the matter be referred to the Director of Public Prosecutions.

The coroner made a number of recommendations, including the abolition of public drunkenness as a crime - something the Victorian government has already committed to - training for all Victoria Police staff regarding rules, guidelines and standard operating procedures in relation to people in custody, and a review of V/Line's training materials regarding unconscious bias, with the input of Indigenous people.

Ms Day was the second person in her family to die in custody - the 1982 death of her uncle, Harrison Day, was examined in the Royal Commission into Aboriginal Deaths in Custody.

Australian Associated Press