More than 30 people died after the pandemic overloaded Victoria’s triple-zero call service and caused delays, an independent review has found.
In one case, someone waited for more than 76 minutes for their emergency call to be answered, as the pandemic placed “unprecedented demand” on the system.
Victoria’s inspector general for emergency management, Tony Pearce, identified 40 potential adverse events as the Emergency Services Telecommunications Authority (Esta), which runs the service, was swamped during the pandemic. Thirty-three people died.
“Victorians expect that when they call triple zero (000), their call will be answered promptly,” he wrote.
“The current benchmark for Esta’s speed of call answer for emergency ambulance is that within a calendar month, Esta answers 90% of such calls within five seconds.
“Despite its careful planning and best endeavours Esta’s call answer speed performance for emergency ambulance via 000 has fallen below community and government expectations and performance benchmarks during the pandemic.”
In some cases, calls were queued for 15 minutes and longer.
Esta “simply did not have sufficient ambulance call-takers to meet incredible demand”, the review found, and fewer than 70% of triple-zero calls were answered within five seconds during the pandemic.
Esta did not have the funding to recruit more staff, and “missed an opportunity” to seek urgent government funding in 2020.
The situation was exacerbated by employees getting sick with Covid themselves.
When Victoria’s lockdowns ended and restrictions were eased at the end of 2021, demand on the system increased. By January 2022, as the Omicron variant spread, just 39% of calls were answered in the benchmark time.
“On 14 January, 2022, Esta received 2,501 calls, with 139 calls waiting more than ten minutes for Esta to answer, with the longest waiting over 76 minutes,” the review found. “Over the six months from October 2021 to March 2022, Esta reported the lowest emergency ambulance call answer performance in its history.”
“Thousands of callers each month waited more than one minute for Esta to answer their emergency call.”
Pearce said he did not make any findings about whether faster intervention would have stopped those deaths – that will be a matter for the coroner.
“I therefore apologise to the families and friends of those 33 people, if their expectations of this report are not met concerning the circumstances of their loved ones’ emergencies,” he said.
There were “missed opportunities and failings” in the system, Pearce said on Saturday, but he found “no fault at all” by the dispatchers and call-takers, who have needed mental health support because of the crisis.
Pearce’s recommendations included a revision of Esta’s funding, better resourcing, more transparency, and better education for the public about when to call triple zero.
He said his review should be read in conjunction with a separate one, released by former police chief Graham Ashton in May. The Ashton review followed reports of at least 12 deaths, including children, when operators either took too long or failed to pick up emergency calls altogether.
The Victorian government has accepted the findings and supports all the recommendations.
The emergency services minister, Jaclyn Symes, said the government would continue to reform the system with more resources, better training and stronger governance. “Vast improvements” had already been made, she said, adding that “the Esta today is not the same as the Esta six months ago”.
“This review will be upsetting to many people, particularly those who have lost loved ones,” Symes said.
“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, and [we hope] no one has a similar experience in the future.
“Any call delay has been unacceptable.”
Symes was questioned over the decision to release the review on the weekend, and asked why the premier, Daniel Andrews, was not present at the press conference.
She said she had released the review at the first opportunity, and that she had already briefed the premier on its contents.
