One Victorian police officer has been sacked and three others disciplined over the death of a man in police custody who was ignored in his cell and then left in the rain.

Gong Ling Tang, 53, was arrested and taken to the Dandenong Police Station to "dry out" after his wife reported he was drunk and had breached a court order.

Mr Tang was placed in a cell but, unbeknown to the five officers on duty, had cirrhosis of the liver and was bleeding internally.

An inquest into his death heard officers ignored Mr Tang "making loud moaning noises and observed blood splatter on the cell wall, and could see blood on his mouth".

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But they thought "he was just being difficult and trying to avoid questioning".

Despite him being observed as "clearly distressed", one officer also said "it is not uncommon for people in custody to exaggerate a medical condition for the purpose of early release or what they perceive will be sympathetic treatment by police".

The officers did not respond to Mr Tang's complaints.

Closed circuit vision of the police station released by the Coroners Court showed Mr Tang crawling from his cell on the ground.

Warning: Video below contains footage that some people may find distressing.

A Mandarin interpreter called to the police station told the inquest she saw Mr Tang "crawling out of that cell door like a dog with blood in his mouth".

Mr Tang was taken outside and left on the ground in the rain.

He died in hospital the next morning.

It was the interpreter who blew the whistle on his treatment by police leading up to his death.

"The vision is extraordinary," said deputy state coroner Iain West, in his finding released on Tuesday.

"No police officer offered or felt compelled to offer Mr Tang any assistance.

"This is confounding and deeply distressing to witness."

Sorry, this video has expired Gong Ling Tang crawls from his cell in the Dandenong Police Station.

Victoria Police 'deeply regrets' circumstances of death

Coinciding with the inquest finding, Victoria Police released a statement expressing its deep regret over Mr Tang's death.

One officer has been sacked from the force.

Three others were found guilty of disgraceful and improper conduct and demoted or placed on a good behaviour bond.

They have also taken a pay cut and been ordered to perform community service or pay a $2,000 fine to the Blue Ribbon Foundation.

"Victoria Police deeply regrets the circumstances in which Mr Tang died," the statement said.

"We again offer his friends and family our sincere condolences.

"This is a matter we have taken very seriously. Police members had a duty of care to Mr Tang on the night he died, and were found wanting."

Another officer has since retired.

Mr West said the five female officers on duty - Leading Senior Constable Fiona Jones, Kate Jackson, Leading Senior Constable Meghan Whitehead, Leading Senior Constable Kaye Price and Senior Constable Kate Griffiths - "have expressed little or no responsibility for any of the decisions made or actions taken on 12 May, 2010".

All declined to give evidence, choosing to exercise their privilege against self-incrimination.

"(Senior Constable) Jones says that she has no specific training to undertake the situation she was facing, but at the same time she was an experienced watch house keeper," Mr West said.

"Ms Jackson says her role was subordinate and she was the most junior officer on duty.

"(Leading Senior Constable) Whitehead said her appointment was only recent, she relied on the experience of Senior Constable Jones.

"(Senior Constable) Griffiths and (Leading Senior Constable) Price said that they relied on the watch house keeper (and others) in whose custody Mr Tang had been in for some hours before they arrived."

'Many failings' on the night of Tang's death

Mr West said the officers' attitude was in stark contrast to their Chief Commissioner, Ken Lay, who described their treatment of Mr Tang as "grossly lacking in care and compassion... its unacceptability is patent".

Mr Lay also described the officers' approach as "a laissez-faire, disinterested attitude, inconsistent with the obligations of a serving member of the Victoria Police".

"The statements of the members and the Chief Commissioner of Police stand in stark contrast," Mr West said.

"I make the comment that, whilst incarcerating citizens may become routine for police officers, there is no such thing as a minor deprivation of liberty - particularly for the offence of drunk in a public place.

"In my view there was no particular expertise required to have provided the proper care and management of Mr Tang.

"There were many failings at the Dandenong Police Station in relation to Mr Tang's incarceration on 12 May 2010."

The coroner also said there was no need for Victoria Police to wait until the inquiry was finished to take action against the offending officers.

"I consider that Victoria Police should as soon as possible consider whether any disciplinary action should be taken in relation to the actions of police," he said.

"It is not appropriate that those issues be postponed pending the coronial process."

Mr West recommended investigators of such incidents record an interview with officers "involved in any incident involving a death associated with police contact as soon as possible".

He also recommended the Victorian Department of Justice provide an independent, legally trained person to observe the interviews.

That recommendation echoes similar coronial advice given more than three years ago at the finding into the death of teenager Tyler Cassidy, who was shot dead by police.

At the finding of another police shooting death on Monday, another coroner also endorsed the recommendation, and noted that it was yet to be acted upon.

Tang's family will never forgive officers involved

Mr Tang's widow, Hai Troung, did not want to speak publicly but in a statement she said her former husband's death was "the most horrible experience a family could go through".

"Devastated": Mr Tang's widow, Hai Troung, said she had suffered four years of grief ( ABC News )

"My daughter, my sisters and I have suffered four-and-a-half years of grief, not only because of my husband's death but because of the inhuman way he was treated," she said.

"It was devastating to have the world see my husband crawl out of a cell without a hand to help, to be treated like a dog.

"The coroner found that more competent, diligent and compassionate police officers would have preserved my husband's welfare and dignity.

"My daughter and I miss him terribly, and I shall never forgive those police officers for the way my husband was treated."

Ms Troung also thanked Mr Tang's interpreter, for speaking out about his treatment.

"I doubt these horrible events would have surfaced without her courage," she said.