The inquest into the death of mixed martial arts fighter Joao Carvalho in Dublin has returned a verdict of misadventure and recommended the endorsement of a national governing body for MMA.
It also recommended that all medical partners engage nationally qualified paramedics and in the short-term MMA should adopt safety standards used in professional boxing.
The cause of death was acute subdural hemorrhage due to blunt force trauma to the head, with aspiration of gastric contents as a contributory factor.
The 28-year-old Portuguese man died at Beaumont Hospital on 11 April 2016, two days after a fight at the National Stadium.
The inquest first heard from Mr Carvalho's brother, Alexandre, who said he saw doctors turn off the life-support machine.
State Pathologist Marie Cassidy said that Mr Carvalho died as a result of bleeding inside the skull caused by head injuries.
Mr Carvalho's opponent, Charlie Ward, who won the bout, told the inquest it was a close fight with plenty of back and forth. He said it was difficult, but all fights were difficult.
He said that after the fight Mr Carvalho asked for a photo with him and Conor McGregor.
Referee Marius Domasat said Joao was conscious throughout the bout and afterwards looked tired and disappointed, but well.
He said given the chance he would not change the way he refereed the fight.
The inquest heard how Joao Carvalho had walked out of the octagon in the National Stadium after his fight.
A garda witness said video evidence showed Mr Carvalho had received 41 blows to the head.
Dr Ishmael Khan one of the three doctors on duty at the event said that by the end of the fight he wanted both men brought to hospital for assessment.
Initially, the fighters went into a small medical room at the stadium. A short time later, Mr Carvalho became drowsy and started vomiting.
There was difficulty getting him to a waiting Red Cross ambulance because the narrow hall outside the medical room was blocked with people.
In the ambulance, Mr Carvalho ended up on the floor. It headed initially for Beaumont Hospital, but diverted to the Mater Hospital.
Mr Carvalho's airway had become blocked and he needed resuscitation.
When the Mater Hospital was ready to transfer him to Beaumont Hospital, the original ambulance had left and he was brought in another one.
An operation there failed to save his life.
The inquest heard from neurosurgeon and Safe MMA Ireland co-founder Professor Daniel Healy, who said he contacted the promoter Cesar Silva with safety concerns before the fatal fight.
"Mr Silva indicated there was a limited budget for the event and the safety standards required were not possible," Prof Healy said.