Ambulance Tasmania is under more scrutiny in newly-released coronial findings into the death of an elderly Derwent Valley woman in 2017.
Valerie Bowerman refused transport to hospital after falling and hitting her head.
The 80-year-old, who'd been taking the anticoagulant warfarin, later deteriorated and was rushed to hospital but died in the days following.
Coroner Olivia McTaggart has pointed out a lack of formal guidance from AT about clinical care and transportation relating to minor head injuries.
She has recommended the service implement all recommendations arising from a Root Cause Analysis report.
"I note that a patient with capacity who is presented with professional advice regarding the need for hospital transport and the reasons why, is fully entitled to decline such advice and remain at home," said Coroner McTaggart in her findings.
"Such a patient cannot be treated or transported against their will."