Ambulance Tasmania intensive care paramedic Damian Michael Crump was 36 when he took drugs from the service's Hobart headquarters and fatally overdosed in December 2016.
He had a long history of mental illness and unresolved psychological issues, which were unrelated to his work, Coroner Olivia McTaggart found.
However, he was regularly inappropriate at work - "alarmingly so" in the weeks before his death - and Ambulance Tasmania management never properly called him to account for his behaviour, Ms McTaggart said.
Instead, it would be dismissed with: "That's just Crumpy!"
"Further, it was known amongst his colleagues and some managers of his longstanding intention to die by suicide before the age of 40 years," the coroner said.
"This was not taken further as a welfare issue, despite his deteriorating mental state.
"The coronial investigation highlighted severe resourcing deficits in the organisation, inadequate management of staff and a culture of tolerating unacceptable behaviour."
Mr Crump died after a lengthy history of stealing dangerous drugs from his employer, but Ambulance Tasmania lacked any processes to ensure an internal investigation over the thefts progressed, Ms McTaggart found.
He was never formally identified as the person responsible.
Nine days before Mr Crump's death, he became frustrated and angry after the ambulance he was in got bogged in a ditch.
He abused his manager and drove to a station rather than headquarters, ignoring her direction.
Ambulance Tasmania had numerous opportunities to properly deal with his behaviour, Ms McTaggart said.
"Appropriate intervention may have uncovered his addiction and thefts at that time," the coroner said.
"Because of the unfeasibly large workload of (Ambulance Tasmania) managers and their lack of adequate training, there was no proper auditing of medication and there were no pathways to deal with Mr Crump's behaviour or welfare.
"He was therefore able to remain at work and able to keep stealing schedule 8 medications from the drug store."
The coroner noted Ambulance Tasmania had considerably improved how it handled medication and developed comprehensive strategies for management and welfare.
The organisation had also taken significant steps to change its culture since Mr Crump's death.
Ms McTaggart recommended Ambulance Tasmania roll out random drug and alcohol testing for employees as a matter of priority, and regularly review its policies relating to how drugs were managed, stored and accounted for.
Among her total 13 recommendations, she also urged Ambulance Tasmania to make regular psychological assessments mandatory for employees, and continue to try to cut down on workloads.
Ambulance Tasmania chief executive Jordan Emery gave condolences to Mr Crump's family, and said the organisation would carefully consider the coroner's report and recommendations.
He pointed to significant changes since 2016 to Ambulance Tasmania's medication management systems, support and mental health resources, and education and guidance for managers.
"There has also been a considerable focus on improving our culture and psychological safety in the workplace and we have actions and goals that we are progressing," Mr Emery said.
"While many changes have already been implemented, the work is far from over and we are committed to reviewing any additional recommendations to continue strengthening Ambulance Tasmania."
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