The report into the 2017 death of 85-year-old Gwendoline Flynn was made after the case was referred to the ACT Coroners Court last year by her daughter Robyn.

Robyn alleged her mother's death was a result of systemic bullying and intimidation of staff at the hospital.

While Coroner Lisbeth Campbell said the findings of the report determined there was no jurisdiction to investigate the death further, serious medical issues at Calvary Hospital were raised.

"[The] report raises serious concerns about the medical treatment of Mrs Flynn," Ms Campbell said.

Mrs Flynn was admitted to hospital in April 2017 due to an infected leg ulcer, but her condition deteriorated during a weekend in May after contracting sepsis and pneumonia from one of the wards.

Despite the pleas of family members, doctors and specialists were not able to be called in on a weekend to treat Mrs Flynn.

Robyn said staff at the time told her specialists weren't able to treat her mother due to a fear of backlash and intimidation from senior staff.

While the independent report by Dr Michael O'Leary found Mrs Flynn's death in July 2017 wasn't entirely caused by her deterioration in hospital over the May weekend, the report said the 85-year-old did not receive appropriate care during her stay.

"I do not believe that appropriate consideration was given to Mrs Flynn's observed clinical deterioration," Dr O'Leary said.

"I believe that an attempt to make a diagnosis should have been made as early as on May 5, but in fact did not occur until the afternoon of May 8.

"I believe that there were unacceptable delays in the diagnosis."

Calvary Hospital said in its response to a Health Services Commission inquiry into the incident Mrs Flynn was attended by "a number of medical staff" who adjusted medications.

However, Dr O'Leary said Calvary's statement was not supported by clinical records.

The report found Mrs Flynn's deterioration warranted a response time of 30 minutes to review her condition, as per Calvary's policies, but did not occur.

Robyn said she was shocked the case wouldn't proceed further to a coronial hearing.

"It's been really devastating to not see the case progress. The whole thing has been traumatic, to be honest," she said.

"There's nowhere to go now. The coroner has done what they can. The hospital has apologised, and the health commissioner can't do anything."

Robyn also wrote a letter last year to ACT Attorney-General Gordon Ramsay, who has the authority to refer cases to the coroner, although the request was rejected.

Coroner Campbell referred the medical report to Mick Reid, the chair of the independent review into bullying and staff culture.

However, the review does not have the legislative power to investigate specific incidents.

Robyn said she hoped for a different outcome for the medical report and answers for her mother's death.

"It was really sad that mum passed away the way she did," she said.

"In order to achieve real reform, a Royal Commission type inquiry [into the ACT health system] is needed, and it needs to have the power to investigate individual matters, and it's clear the current inquiry doesn't have that power."

Calvary Hospital declined to comment, citing privacy for the family.

Do you know more? Email: andrewbrown@canberratimes.com.au