The woman had been a resident of the aged care facility for about seven months after her Alzheimer's and other medical issues saw her deteriorate rapidly.

Her condition worsened to the point that her children agreed to begin palliative care. She was placed on high doses of morphine to manage her increasing pain.

The woman’s three children, the coroner found, provided around-the-clock dedicated care and expressed deep love and loyalty to their mother. One of her daughters described their mother in court as a “strong woman, an unbelievable nurse, an incredible mother (and grandmother) who gave up everything to raise her three children”.

On July 30, 2016, the woman passed away. Her children had taken turns staying with her throughout the days and nights preceding and a nurse reported observing the “death rattle” in the woman’s breathing as she came closer to death.

On the day she died, her son and one daughter went home in the morning, while the other daughter played a DVD of her sister’s wedding for the nurses, carers and residents to remember their mother as she was before dementia took hold.

Immediately after the DVD was finished, an enrolled nurse decided to check on the woman in her room.

In the room, a sliding door opening to a courtyard was slightly open, and she could not see the sick woman in her bed.

She checked again and realised the woman was completely covered by the doona, whereas she had not been earlier. The woman was not breathing.

Calling for the registered nurse on duty to confirm the woman had died, the enrolled nurse went to the hallway and saw one of the woman’s daughters approaching.

“She gauged that [the daughter] could tell by the look on her face that [the daughter] knew her mother had passed away,” the coroner found.

The enrolled nurse gave evidence that the daughter entered the bedroom and said: “[The brother] said that if we covered her head she would go quicker and she would …”

The nurse told the inquest she knew the daughter was trying to say the word "asphyxiate". The daughter later denied saying such a thing.

“[The nurse} was alarmed by [the daughter’s] response as it was completely unprompted and [the daughter] had not been advised that her mother had been found with bedclothes covering her head,” the coroner found.

The facility manager wrote up notes later that day stating that the nurse had been so “unsettled” about the conversation she had not been able to complete her own notes.

The coroner found that for a patient in such a poor state, having the doona pulled over her head could have potentially accelerated her death.

The coroner was notified about the death by the woman’s treating physician, who was also alarmed by the situation after a conversation she had with the woman’s first daughter earlier about a “blue needle”.

In her notes a few days before the woman’s death, the doctor wrote about the “family asking for the blue needle - declined”. She told the inquest she “knew she was being requested to euthanise [the woman]”.

The doctor agreed it was possible but unlikely the woman could have pulled the doona over her own head.

Queensland Police began an investigation into the death, questioning the woman’s two daughters and son.

The daughter who had spoken to the nurse denied pulling the doona over their mother’s head, and denied mentioning anything about taking such a step or discussing it with her brother.

Her brother, who had earlier entered his mother’s room from the courtyard through the sliding door, also denied such a step.

After investigating, police determined that “all avenues of the investigation” had been exhausted and while the death had initially been deemed suspicious, they were unable to prove any suspicious behaviour contributed to the woman’s death.

Police finally determined that “no offence can be proven and ... it is unlikely an offence has occurred”.

The coroner found there was insufficient evidence to determine who pulled the doona over the woman’s head, or if it had hastened or caused her death.

The coroner also asked most of the inquest’s witnesses for their opinion on the use of CCTV in aged care facilities.

The woman’s children agreed CCTV inside their mother’s bedroom could have provided immediate clarity on what had happened, but the son raised questions about privacy.

Staff at the facility were not comfortable about having cameras in residents’ rooms because of privacy issues.

The police investigator also agreed CCTV would have helped.

The coroner did not make recommendations on the use of CCTV footage in aged care facilities, but directed a copy of the inquest be submitted to the Royal Commission into Aged Care Quality and Safety.

The coroner ruled the final cause of death as “undetermined” and offered her “sincerest condolences” to the women’s children and their wider family.