Queensland Director of Public Prosecutions Leanne Clare has been under enormous pressure following her ruling last week that there was not enough evidence to prosecute Senior Sergeant Chris Hurley over the death of Doomadgee in November 2004.

But legal figures believe a decision by Ms Clements to assume - probably incorrectly - that up to four punches allegedly delivered to Doomadgee's ribs and stomach caused the fatal injuries, contributed to Ms Clare's failure to recommend charges against Sergeant Hurley.

A different finding from the Coroner, based on the medical evidence available, could have shown that the Aboriginal man's death was in fact caused by the 200cm, 115kg Sergeant Hurley landing on the 180cm, 75kg Doomadgee. And that could have led to a different decision from Ms Clare on whether to recommend charges against Sergeant Hurley.

The evidence consistently given to the inquest was that there was a fall. The fall was witnessed by at least three people, and admitted by Sergeant Hurley.

Doomadgee suffered four broken ribs and his liver was "cleaved" almost in two - in fact hanging together only by a couple of blood vessels.

And the clear evidence was that this was caused by a "compression" injury - a huge weight from above being exerted on his abdomen, so great that it forced the soft flesh of his liver on to his spinal cord, causing it to rupture. He quickly bled to death.

Andrew Boe, counsel for the Palm Island Council, told the coronial inquest that the "most likely explanation for such an injury is that a knee, elbow or a closed fist was used with considerable deliberate force by Hurley" while Doomadgee was lying on the ground.

But in arriving at the conclusion that the punches caused the injuries, Ms Clements gave little weight to, or rejected, the crucial and undisputed medical opinions provided to the inquest.

Instead, she accepted and added to the evidence of drunken witness Roy Bramwell, whose account suggests Sergeant Hurley punched Doomadgee.

While that mistake by Ms Clements presumably had great influence on the final decision by Ms Clare not to prosecute, it should not have done so.

What would be put to a jury in a criminal trial is the evidence of witnesses, not the coroner's incorrect conclusions and findings.

In rejecting a prosecution of Sergeant Hurley, it is apparent that Ms Clare has rejected or given little weight to evidence that Doomadgee died through an act of violence and not, as she described it, "a terrible accident".

As Ms Clare pointed out in her reasons for not laying any charges over the death, two autopsies were conducted on Doomadgee.

"From them we know that neither kicks nor punches are likely to have caused Mr Doomadgee's death. On the evidence, the fall is the only satisfactory explanation for the injuries identified by the doctors," she said.

That is absolutely true. It was even admitted by Sergeant Hurley under cross-examination that he "must have" fallen on Doomadgee, who was on his back on the concrete floor of the Palm Island watchhouse following a "scuffle" between them.

This is the key to whether Doomadgee was killed, or died by accident.

It would be simple, on evidence provided to the coroner by police at the scene, to establish that Sergeant Hurley landed on top of Doomadgee, and the result was a shirtful of broken ribs and a cleaved liver.

It would be open to the jury to decide whether that "landing on Doomadgee" was a deliberate and malicious act by Sergeant Hurley, or an accident.

It has to be conceded that a jury would take a lot of convincing that it was deliberate. However, if it was an accident - which would seem a reasonable explanation given that the men were grappling in a police station - then why did Sergeant Hurley give a different account about it on four occasions, including under oath?

One of the key pieces of testimony during the inquest came from Mr Bramwell.

At the precise time that Sergeant Hurley and Doomadgee were struggling and entering the rear of the police premises, Mr Bramwell was sitting on a chair in the adjoining front-office section.

He was very drunk and was wanted for questioning over two serious assaults committed on women that morning.

His evidence was that he did not rise from the chair, but made his observations from a restricted position. At the crucial time when Doomadgee was on the floor, there was a metal filing cabinet obscuring all but Sergeant Hurley's upper body.

Mr Bramwell said he saw Hurley's elbow rising and falling, at the same time as he was calling out, "Do you want more, Mr Doomadgee, do you want more?"

The inference was that Sergeant Hurley was punching the man on the ground.

In fact, the autopsy revealed a trauma injury to Doomadgee's right eye and forehead that, according to Sergeant Hurley, was not there when he was arrested.

In her findings, Ms Clements said she was satisfied with Mr Bramwell's account, "together with the immediately preceding sequence of events, that Senior Sergeant Hurley lost his temper and hit Mulrunji after falling on the floor".

She found Sergeant Hurley fell on Doomadgee's left side.

"I do not necessarily conclude that this force was to Mulrunji's head as stated by Mr Bramwell ... it is open on Bramwell's evidence that the force was applied to Mulrunji's body rather than his head," she found.

"This is also consistent with the medical evidence of the injuries that caused Mulrunji's death. It is also most likely that it was at this time that Mulrunji suffered the injury to his right eye.

"After this occurred, I find there was no further resistance or indeed any speech or response from Mulrunji. I conclude that these actions of Senior Sergeant Hurley caused the fatal injuries."

Ms Clements clearly attributes the cause of death to punches delivered by Sergeant Hurley.

The submission by Mr Boe, the solicitor for the Palm Island Council, said in regard to that issue: "Once Hurley got Mulrunji into the station there were further assaults inflicted upon Mulrunji by Hurley. During this interaction, Mulrunji received the fatal injury in his abdominal region.

"The most likely explanation for such an injury is that a knee, elbow or a closed fist was used with considerable deliberate force by Hurley whilst Mulrunji was on the ground. Following this altercation, Mulrunji appeared lifeless and was unconscious. Hurley was the only person who had been involved in any physical interaction with Mulrunji, from the point of arrest to when he was rendered unconscious."

Counsel assisting the coroner, Mark Plunkett, said in his final submissions: "In the re-enactment by Hurley (the day following the death of Doomadgee), he told the investigating police that he had tried to pick upthe deceased and demonstrated a picking-up movement with his elbows going up and using words to the effect, 'Get up, Mr Doomadgee'.

"One would be forgiven for thinking that an opportunity may have been afforded to Hurley to groom his version to explain innocently what Roy Bramwell said he saw."

On four separate occasions Sergeant Hurley denied that his body landed on a prostrate Doomadgee, saying on each occasion that he fell to the left of the man.

Counsel representing the Doomadgee family, Peter Callaghan, wrote in his final submission: "It must have been Hurley's view that Mulrunji had been resisting arrest and, indeed, assaulted a police officer. He then decided to apply his own sense of fairness.

"Correct legislative procedure would have seen Mulrunji charged with 'resist police' and 'assault police'. We know he was not. In Hurley's eyes there was no need. Summary justice was administered to Mulrunji as he lay on the floor of the police station."

Mr Callaghan said Mr Bramwell's view was "slightly obscured by a filing cabinet, but it must be conceded that even if Bramwell had seen everything, his account of events ... could never be completely accepted".

Mr Callaghan said the police video showed Doomadgee writhing in pain while he slowly died as a result of internal bleeding.

"The video depicts (Sergeant Michael) Leafe giving the body of Mulrunji a kick. This was an arousal technique. CPR, of course, was not an option.

"Hurley knew that Mulrunji had gone from being outspoken, active and resistant, to being lifeless and silent. He did nothing to find out why this was so."

Mr Callaghan accused Sergeant Hurley of lying about the death to Doomadgee's partner, Tracey Twaddle, and of challenging her as to whether he had told her certain things.

Ms Clare has had all transcripts, including medical evidence, since the coronial findings were delivered on September 27.

When she announced her decision last week not to lay any charges against Sergeant Hurley, Ms Clare said the evidence was not capable of proving he was criminally responsible for Doomadgee's death.

"I have carefully reviewed all of the evidence available to me. I have pursued further lines of inquiry and received additional evidence," she said.

Ms Clare has refused to reveal the "further lines of inquiry" she pursued or the nature of the "additional evidence" she received that was not available to the coroner.

It is difficult for any objective assessment of the evidence - as distinct from the coroner's findings - to appreciate how Ms Clare arrived at the conclusion that Doomadgee's death was "a terrible, terrible accident".

Given yesterday's belated decision by the Queensland Government to order a review of Ms Clare's recommendations, those questions might yet be for a jury to consider.