An elderly widow discovered dead in her home in suburban Hobart twice refused treatment from paramedics in the two days beforehand.
Feryne Gaylene Hunter, 75, suffered a tracheostomy blockage and was found lifeless in bed by a nurse on the morning of September 13, 2017.
Mrs Hunter, who had a history of coughing up blood clots, had been visited by nurses, paramedics and police over successive days.
In findings published on Wednesday, Coroner Olivia McTaggart said nothing could have reasonably been done by health professionals to prevent Mrs Hunter's death and all parties acted lawfully.
However, she recommended Ambulance Tasmania rewrite its refusal of treatment and transport policy, describing it as "confusing".
Ms McTaggart said simple and clear guidance should be given to paramedics on how to deal with issues relating to patient capacity, consent and refusal of treatment.
Mrs Hunter had been visited by nurses three times a week for six years after a throat infection forced her to have a tracheostomy in 2007.
An ambulance was called to her house on September 11 by a visiting nurse who noted she was having trouble breathing.
Mrs Hunter refused to be transported to hospital but agreed to make a GP appointment the next day.
Paramedic notes indicate she was told of the risks associated with staying home and had capacity to refuse treatment.
The following day Mrs Hunter was visited by police who were accidentally called to her house at night by a man whose phone was erroneously linked to the address.
When officers arrived, they saw Mrs Hunter hunched over on stairs inside and breathing heavily.
They called an ambulance but Mrs Hunter told them to "all go away", refusing to consent to paramedic treatment and telling them she was fine
She denied having chest pain, with medical notes indicating her speech was clear and continuous, leaving paramedics satisfied she had the capacity to refuse treatment.
Mrs Hunter was found dead the next morning.
"I cannot speculate why Mrs Hunter did not wish to accept medical treatment ... but I am satisfied that she had the ability to call for assistance when she required it," Ms McTaggart wrote.
Ms McTaggart noted ambulance paramedics who arrived on the 12th had "no ground lawfully" to do anything other than what they did.
"They were presented with a situation whereby Mrs Hunter persistently refused to be clinically assessed," she wrote.
"(She) was able to coherently communicate those wishes to them.
"On the evidence, the best medical care was to transport Mrs Hunter to hospital for treatment.
"However, in light of her refusal of assessment and treatment, this course would not have been lawful."
Ms McTaggart wrote Ambulance Tasmania had identified that the refusal of treatment and transport policy provided limited advice as to how paramedics should manage situations like Mrs Hunter's.
Ambulance Tasmania has been contacted for comment.
Australian Associated Press