Adam Troy Shepley, 30, had been behaving in a paranoid manner when he fell from the roof of an Adelaide home after being pursued by police on October 24, 2020.
On Thursday, SA Deputy State Coroner Naomi Kereru delivered her findings from an inquest that explored whether manual restraint played a role in Mr Shepley's death, and whether there was a failure by paramedics to administer prompt medical treatment.
Mr Shepley, who had a history of paranoid and aggressive behaviour linked to drug and alcohol abuse, had left his grandmother's Salisbury North home with a large bottle of wine on October 23, 2020.
Late that night, he knocked on the door of a resident in the same suburb and told her he needed help because a car was chasing him, and he was scared.
She contacted the police, who found Mr Shepley on the woman's roof.
When they urged him to get down, Mr Shepley began jumping to neighbouring rooftops.
An officer pursued him and urged him to get down but Mr Shepley "rushed at" the officer and there was an altercation.
Mr Shepley fell from the roof and landed on the ground next to the house, where he was restrained with handcuffs after a struggle with police, and an ambulance was called.
The coroner found the officers displayed awareness of the risk to Mr Shepley's safety while he was restrained and made appropriate changes to his positioning and location when required.
But she found body-worn video showed paramedic Clarke Timmins demonstrated no sense of urgency in his approach to Mr Shepley.
"He made no proper assessment of Mr Shepley's consciousness, nor of his breathing and circulation," Ms Kereru wrote.
"There can be no reasonable explanation for a paramedic not examining an unconscious person who had fallen from a height, and who was potentially under the influence of illicit substances."
When Mr Shepley was placed on a trolley, the paramedics discovered he was not conscious or breathing, but CPR failed to revive him.
His cause of death could not be ascertained.
Mr Timmins had failed in his provision of care to Mr Shepley in three ways, the coroner found.
Ms Kereru said it was difficult to express the level of discomfort and disappointment she felt when viewing the footage of "such a casual approach to a medical situation".
"What Mr Timmins' lack of action did do was deny Mr Shepley any chance of survival," she said.
Ms Kereru found the failing in Mr Shepley's care was "that of Mr Timmins alone", and she had considered the consequences of such serious findings.
SA Ambulance Service said it was "carefully and thoroughly" considering the findings. In a statement, it said Mr Timmins retired from service in 2021.
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