A doctor who misdiagnosed an Indigenous man with a drug-induced syndrome who later died has been referred to the NSW health care complaints commission.

The findings into the death of 36-year-old Kamilaroi-Dunghutti man Ricky 'Dougie' Hampson Jr were released on Tuesday, with Coroner Erin Kennedy finding his death in the aftermath of being released from Dubbo hospital was "preventable".

Mr Hampson Jnr, a father of eight, had presented to the emergency room at Dubbo Hospital with "ten out of ten" pain, and a "popping" sound in his stomach on August 14, 2021, despite having a self-confessed fear of hospitals.

He was misdiagnosed by Dr Sokol Nushaj with cannabinoid hyperemesis syndrome (CHS), a drug-related syndrome seen in long-term cannabis users, despite showing no signs of vomiting - a key indicator.

He was given droperidol - an intravenous drug used to reduce vomiting and nausea - along with morphine, but not a CT scan, and after being left overnight in the short-stay unit, was discharged the next day with paracetamol.

A day later, in the early hours of August 16, Mr Hampson Jnr died on his friends couch from two undiagnosed perforated duodenal ulcers.

Despite experiencing challenges with substance abuse in his life, Ms Kennedy said Mr Hampson Jnr faced them "head on".

"He wanted to support his family, his children, his friends…he was constantly trying to improve himself," she said.

Ms Kennedy was critical of the misdiagnosis of CHS by Dr Nushaj, arguing the lack of vomiting meant it "was not a diagnosis available" to him.

"As a result of the misdiagnosis, what followed is Dougie should not have been administered droperidol…which further masked his pain…rendering later clinical assessments unreliable," Ms Kennedy said.

Dr Nushaj had previously told the hearing that "cognitive bias" led him to misdiagnose Mr Hampson Jr with CHS after a busy night overseeing the emergency department during the COVID-19 pandemic.

Practising emergency physician, Associate Professor Anna Holdgate, told the inquiry the misdiagnosis of CHS was "made without any justification," and the administration of droperidol was below the peer professional standard.

Dr Holdgate said at the time that early diagnosis and treatment of Mr Hampton Jnr would have likely allowed him to "survive…and live a normal life".

As a result, Ms Kennedy recommended a referral of Dr Nushaj to the health care complaints commission to decide on whether he engaged in unfair medical conduct.

Ms Kennedy said she was satisfied that Mr Hampson Jnr's Aboriginality, a key focus during some of the evidence at the inquiry, didn't play a conscious role in his treatment.

However, she argued that whilst there was no specific racial bias - conscious or unconscious - during the treatment of Mr Hampson Jnr, no real attention was given to his Aboriginality.

"Recognition should be given to that fact," Ms Kennedy said, and argued the concept of 'colour blind treatment' of patients didn't work when First Nations people continue to have such disproportionate outcomes.

She noted that "some steps have been taken" at Dubbo Hospital, but that "more needs to be done", and recommended the Western NSW local health district (LHD) consider implementing a First Nations advisory group with local ACCHOs to be regularly consulted.

Ms Kennedy also called for Dubbo Hospital to have face-to-face engagement with First Nations people, as well as specific training to better treat Indigenous people in the catchment area.

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