An independent investigation has found at least 33 people died after delays with Victoria's triple-0 call taking system.
The Inspector-General for Emergency Management, Tony Pearce, reviewed emergency calls from December 2020 to May 2022.
He's released two reports into delays in answering calls by the state's emergency telephone service, ESTA and the way the organisation handled the pandemic.
Mr Pearce said he found there was an inadequate number of call takers employed by ESTA but also a large number of calls during the pandemic for non-life threatening cases.
He said adverse events began to occur from September 2021 and he identified 40 cases of seriously ill and injured patients whose calls were delayed.
Thirty-three of those died.
"It's not possible for me to conclude as to whether or not the call answer delay impacted upon the final outcome for those individuals. Only the coroner can do that," he said.
"The fact that the system was just not able to cope with what it was being presented with was the worst finding for me."
"To the families and friends of the people that are involved in these terrible events, I apologise.
"And I apologise if the expectations of the report are not going to meet each individual's desires to know individually what happened for their loved one."
He has recommended a revision of ESTA's long-term funding to ensure it will be adequately resourced in the future and better community education about when to call triple-zero.
Mr Pearce said he found no fault with ESTA call takers and dispatchers who he said also suffering during the unfolding situation.
His reports noted the number of triple-0 calls almost doubled from an average of around 2,200 a day before the pandemic to nearly 4,000 at the peak of the Omicron surge.
But from September 2021 the time it was taking ESTA to answer emergency calls significantly declined to 67.8 per cent before sliding to its lowest point in January 2022, when it only answered 38 per cent of calls within the five-second target.
Mr Pearce found at times it was more than 10 minutes.
"Significant declines in ESTA's emergency ambulance triple-0 answer times were identified from December 2020 with the most significant degradation correlating with increasing peaks during the COVID-19 pandemic surge," Mr Pearce said.
"Ambulance call activity increased beyond historical highs and emergency calls queued for unacceptable lengths."
The Victorian Ambulance Union has previously said understaffing had contributed significantly to what it describes as an alarming number of people being harmed by triple-zero delays.
The Victorian government said paramedics responded to more than 93,000 Code 1 call-outs in January 2022 quarter, breaking the record set in the previous quarter.
It said ESTA's call-taking performance is now at 92.8 per cent of all calls answered within five seconds, exceeding the benchmark for the first time since October 2021.
Minister apologies to grieving families
It said it's invested more than $333 million to meet demand including bringing on more than 400 extra staff and providing more support to frontline workers.
Emergency Services Minister Jaclyn Symes said the state government accepted all the recommendations of the reviews and had already invested more than $333 million to ensure ESTA can meet future increases in calls, including employing more than 400 extra staff.
"During the last two years, we have faced unprecedented demand on our health system and of course our call taking system has not been immune to this," Ms Symes said.
She again expressed her sympathies to all Victorians who've lost ones during the pandemic.
"This review will be upsetting to many people, particularly those who have lost loved ones but I do want to assure those people, and I've spoken to many of them, that our efforts in this regard is off the back of their stories, their experiences."
"I am, of course, deeply sorry for the loss, your trauma, your grief. It's driven me every day to work very hard to secure the funding from government that ESTA has required to ensure that Victorians have a system they rely on."
Ms Symes paid tribute to ESTA's call-takers who she said were dedicated and committed to "help Victorians get the help they need, when they need it".
In May, the state government announced the triple-0 service would be renamed and its board disbanded because of blow-outs in waiting times for critically ill patients and staff shortages.
State opposition Emergency Services Spokesman Brad Battin criticised the government for releasing the reports on a weekend.
"How dare the Andrews Labor government want to hide a report behind the AFL finals that is about 33 people dying under his watch in this state," he said.
'They’re an amazing workforce'
For 40 years on the police beat, Stephen Leane worked closely with emergency call dispatchers and receivers as he responded to calls around Victoria.
But he said he did not realise just how special the workers were until he stepped into the role of interim CEO at ESTA in October 2021.
Mr Leane said he walked into a crisis.
Unions were calling for the CEO and board executives to be sacked and Mr Leane said staff, under enormous pressure from the media, were disenfranchised with management.
“They took every line in every newspaper heading and every news bulletin around ESTA not answering calls as personally," Mr Leane said.
Mr Leane said the organisation has had to arrange for a lot of mental health support for its workers.
“They’re an amazing workforce,” he said.
“They’ve carried this burden, no matter who they are."
"They’ve carried this burden all the way through the pandemic and they’re so pleased to come out the other side.”
Mr Leane said he was confident Victoria would not experience more significant triple-0 delays like those seen when Victoria was recording tens of thousands of new daily COVID-19 cases.
"The enormous delays we had in January were [due to] Omicron and I think we forget a little bit about what January was like," he said.
He revealed 20 per cent of ESTA's staff were furloughed at the height of the Omicron wave due to personal and family illnesses.
"We're in a much better position today to deal with that sort of surge if we got it," he said.
"But if the community got that sort of surge I think no matter what industry, no matter what health sector you're in, what emergency service you're in, we're all going to struggle if we hit something like that again."
Mr Pearce revealed he and his staff at the Office of the Inspector-General for Emergency Management had also been affected by the calls they had to study for the reviews.
"You've probably heard the term 'vicarious trauma'. It does traumatise our people," Mr Pearce said.
"Those who've had to sit through those calls — and they don't just listen to them once; they listen to them multiple times to be able to clarify particular issues and correlate what they're hearing with other data sources — that's a very, very difficult job for them.
"And this one, because it's been so large has been extremely difficult."
Editor's note (6/10/22): The original headline on this article referred to "fatal ambulance delays". This was incorrect. The Inspector-General of Emergency Management found 33 people died after their calls to triple-0 were delayed, but could not conclude whether or not the call delay impacted on the final outcome. The Inspector-General also noted that "in some cases no amount of rapid intervention would have saved the patient".
