Kathleen Bain Henderson, 85, died in May 2019 after travelling to and from a Canberra community centre on a bus modified by Transport Canberra for the not-for-profit organisation Communities@Work.

Coronial inquest findings, published on Friday, show the bus stopped outside her home before the driver got out to retrieve Mrs Henderson's walker from the back of the vehicle.

Midway there, he heard what Coroner Glenn Theakston described as "a loud noise".

The man turned around to see Mrs Henderson lying unconscious on her concrete driveway, with her legs in the bus stairwell.

Two passengers later told police the 85-year-old had stood up from a seat opposite the side door and taken a step backwards.

She then fell out through the door, which had opened automatically upon arrival at her home.

The bus driver called an ambulance and Mrs Henderson was taken to Canberra Hospital, where she died without ever regaining consciousness.

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Mr Theakston said Communities@Work had "quickly and appropriately" accepted recommendations from WorkSafe ACT following the incident.

The not-for-profit implemented six protocols including that bus doors on its service no longer open automatically on arrival at destinations.

Drivers and signage are also now used to remind passengers to stay seated until the driver is ready to help them get off the bus.

In his findings, Mr Theakston said Mrs Henderson's family had expressed concern about the elevated seat the 85-year-old had been sitting on, as well as a step between it and the stairwell.

"It appears that only one seat in the bus is elevated in that manner," the coroner said.

"The family submitted that the door being open and the presence of that step contributed directly to Mrs Henderson's fall, the severity of the injury she suffered, and ultimately her death."

Mr Theakston said the evidence was not clear enough for him to make a finding about whether the step contributed to the fall.

"However, the presence of that step, so close to the stairwell and an open door, must create the risk that any fall due to that step could result in a fall through the open bus door," he wrote.

"In the above circumstances, I find that a matter of public safety does arise.

"The use of the seat, located on an elevated step adjacent to the opening side door of the bus, represents a serious risk to passengers with mobility issues."

Mr Theakston accordingly recommended that Communities@Work and Transport Canberra and City Services conduct joint, periodic assessments to address risks associated with the relevant bus service.

"In the first instance, that should include the risk of passengers falling due to existence of the step and the passenger door," he wrote in his findings.

"The two organisations should also jointly consider and implement any necessary controls to mitigate those risks.

"Such controls may, for example, involve the adoption of protocols by Communities@Work and modifications to the bus by Transport Canberra and City Services."

Communities@Work chief executive officer Lee Maiden told The Canberra Times the not-for-profit remained deeply saddened by the death of Mrs Henderson.

"Mrs Henderson had been involved in community activities for many years and always brought humour and passion to the groups she was involved with. She is missed," Ms Maiden said.

Ms Maiden said the not-for-profit would adopt Mr Theakston's recommendation "so that we can continue to deliver safe and quality services for our community".

An ACT government spokeswoman said Transport Canberra and City Services was procuring an independent risk assessment "to ensure all risks associated with the delivery of community transport services are identified and appropriate actions put in place".

"It is expected that this assessment will be delivered in the next six weeks," she said.

The spokeswoman said the directorate would also continue to work closely with the Community Transport Working Group, of which Communities@Work is a member.

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