It remains unclear whether an elderly woman given the wrong medication at a Canberra aged care home died because of the mix-up.
Coroner James Lawton this week handed down his findings following an inquest into the death of Viola Diana Clarke, who lived at the Goodwin Village aged care facility in Ainslie.
The findings say that on February 9, 2016, a carer accidentally gave the 89-year-old another resident's medication.
The error was detected almost immediately and the care home followed protocols to notify Mrs Clarke's family and doctor.
But the condition of Mrs Clarke, who was already suffering from a number of health issues, worsened the next day.
She was admitted to hospital and died on February 20, 2016, with the cause of death determined to be aspiration pneumonia.
Aspiration pneumonia is a lung infection that develops when a person inhales, or aspirates, something into the airways or lungs instead of swallowing it.
Mr Lawton said he could not make a finding about exactly what had caused Mrs Clarke to develop the infection, noting that there had not been a post-mortem examination.
It was also unclear when or how many times Mrs Clarke had breathed in a foreign object in order to trigger aspiration pneumonia.
It could have occurred before she was given the wrong medication, after she was given the wrong medication but before being taken to hospital, or even after she was admitted to hospital.
"Ultimately I am unable to be comfortably satisfied that the erroneously given medication caused or contributed to the aspiration that led to Mrs Clarke developing aspiration pneumonia," Mr Lawton said.
"... [I] cannot be comfortably satisfied that the aspiration occurred during the time period in which the medication would have had an effect upon Mrs Clarke."
The coroner said no matters of public safety had arisen as a result of the inquest.
He did, however, make recommendations about the need to make the aged care industry an attractive option for graduate nurses, with demand for care set to consistently increase as the population grows and ages.
