Thirty-three Victorians died after answering times for triple-zero calls blew out to "unacceptable" levels during the COVID-19 pandemic, a long-awaited report shows.
The state's emergency ambulance call-answer performance between December 1, 2020, and May 31, 2022, has been laid bare in a review by the Inspector-General for Emergency Management (IGEM) released on Saturday.
The benchmark for Victoria's triple zero call service, run by the Emergency Services Telecommunications Authority (ESTA), is for 90 per cent of ambulance calls to be answered within five seconds.
But inspector-general Tony Pearce found that the benchmark was missed, with 67.8 per cent of calls answered within five seconds in September 2021, before hitting rock bottom in January 2022 when only 39 per cent of calls were answered on time.
This means at the low point, fewer than four in 10 calls were being answered in line with the benchmark.
"During this period, the Victorian government ended the last in a series of lockdowns and began to ease restrictions from October 2021," his 150-page report says.
"This contributed to call volumes increasing significantly, with ESTA answering approximately 2800 calls a day for eight months, that is, 400 more a day than the 2020/21 mean."
ESTA reported the lowest emergency call answer performance in its history in the six months from October 2021 to March this year.
This resulted in thousands of callers each month waiting for more than a minute for ESTA to answer their emergency call.
Some calls, Mr Pearce said, were queued for "completely unacceptable" lengths of time - 10 minutes, 15 minutes, and longer.
Forty potential "adverse events" were linked to call-answer delays, agency command and control decisions, and/or ambulance resourcing issues.
Of those 40 events, 33 patients did not survive.
No findings were made on whether the performance issues may have contributed to the deaths of those 33 patients, or if faster intervention may have prevented their deaths.
That would be for the Coroner's Court to decide, Mr Pearce said.
But resourcing was a key reason why callers experienced delays, with ESTA "missing opportunities" to recruit and deploy additional call-takers during the pandemic, and particularly in 2020.
"This was for several reasons, one of which is related to the existing funding model to which ESTA is subject," Mr Pearce said.
"Another reason for shortfalls in call-takers related to the need to furlough employees affected by COVID-19 itself."
Answer times have improved since the review began in January 2022, rising to 86.2 per cent in five seconds in June this year.
"This improvement has no doubt been due to some urgent interventions by government and the committed efforts of ESTA," he said.
Mr Pearce made 42 findings and eight recommendations, all of which are being recognised by the government.
This review comes after an earlier review by former Victoria Police chief commissioner Graham Ashton into ESTA, which recommended the service be rebranded, brought under government control and its board disbanded.
Emergency Services Minister Jaclyn Symes offered her sympathies to those who had lost their loved ones during the pandemic.
"Building on significant investments and major structural reforms already underway, we are using the lessons from these reviews to prepare our system to be strong and resilient into the future," she said in a statement on Saturday.
The Victorian government has committed to recruiting and training almost 400 extra call-takers under a $333 million state budget package announced in May.
