State emergency services made "little to no preparations" in the lead up to deadly flooding, despite severe weather warnings for heavy rain and fast-moving waters.
Mary Allford, Trevor Foster and Peter Watson died in separate incidents in June 2016 after several hundreds of millimetres of rain fell in parts of Tasmania.
Mrs Allford, 76, drowned in her home in Latrobe in the state's northwest on the night of June 5 when it was inundated by the rising Mersey River.
The grandmother and her husband Noel had gone to bed "without concern" after watching the news and an AFL game.
Mr Allford woke just after midnight to find rising waters in his room after Mary, who was bed-ridden and incapacitated, called out.
He called triple zero as well as their son Mark, who lived nearby but wasn't able to get through the flooding to help.
Three police officers tried in vain to reach the pair using an inflatable boat, a 16-tonne front-end loader and by attempting to wade through water.
Mr Allford shifted his wife to a mattress as the flooding rose but they became separated when a fridge moved by the water blocked a doorway.
Mr Allford was plucked to safety by a helicopter in the morning. His wife's body was found inside the house the next day.
In findings published on Friday, coroner Simon Cooper was critical of the "poor" SES response in the northwest.
The SES incident controller overseeing the region did "nothing" to respond to the unfolding event despite adequate information being available.
"Unfortunately, it is apparent that little to no preparation was made by the SES in the northwest ... despite severe weather warnings for heavy rain, flash flooding and flood watches and warnings in the area," Mr Cooper said.
No evacuation warnings were issued by the SES to media for Latrobe or the northwest coast until June 6.
"By that time Mrs Allford was dead and it was too late to evacuate Latrobe," Mr Cooper said.
The SES at the time didn't have enough staff to respond to the floods and was poorly equipped to be the lead agency.
Mr Cooper made no formal recommendations, noting the SES had since merged with the Tasmania Fire Service and made significant improvements to how warnings were issued.
An SES spokeswoman said since 2016 the service had implemented a statewide system to streamline warnings and now operates a Hobart control centre.
"Our thoughts remain with Mrs Allford's loved ones, as well as the loved ones of Mr Foster and Mr Watson, at this difficult time," she said.
Mr Cooper praised the bravery of constables Mark Johnston, Adam Filler and Dean Wotherspoon for trying to save the Allfords at considerable personal risk.
Mr Foster, 83, died after being swept away from his property on June 6 when the Ouse River in central Tasmania broke its banks.
In the early hours of the next morning, Mr Watson was killed after driving his delivery van into flood waters in the state's north.
