On Saturday,Alisha’s mother,Jasmin Hussein,said the report had made her relive the grief and trauma of that night but had also offered her the acknowledgment she needed on her path to closure.

“I always knew that if they’d come on time she would have pulled through but just to get that confirmation it feels like you go through the whole thing all over again,” she said.

“Alisha did used to joke ‘one day I’m going to be famous,I’m going to be known’. And if only she knew that she’s actually one of the reasons that things have changed.

“It’s so shattering. I can’t bring her back. But at least this gives her some justice. I no longer see her as a statistic anymore because her death has been acknowledged.”

The coroner is now considering whether to conduct a group investigation into a cluster of deaths linked to the emergency call delays. Four cases were initially set to be investigated separately,but a larger number are now under review.

Pearce said on Saturday there were missed opportunities and failures in the state’s emergency communication system,but he did not find fault with the “vital and skillful work of call takers”.

He said the delays were overwhelmingly caused by the pandemic’s impact on the workforce,increased demand and also a number of Victorians calling triple-zero for help in non-emergency situations.

Emergency Service Minister Jaclyn Symes said that any call delay was unacceptable,but insisted things had improved.

“This review will be upsetting to many people,particularly those that have lost loved ones. But I do want to assure those people … our efforts in this regard is off the back of their stories,their experiences and[we will] ensure that no one has a similar experience to them in future.”

Addressing the families and friends of those who had lost their lives,Symes said:“I am of course deeply sorry for your trauma and your grief.”

Symes said the past two years had also been challenging for health services and emergency responders.

Opposition emergency services spokesman Brad Battin said the triple-zero system was broken.

He branded Premier Daniel Andrews a “coward” for releasing the report on the same day as two AFL finals and for not fronting the media. “Today will open up wounds for families,” he said.

Battin also accused the report’s author of failing to look into staff cuts as a reason for the delays and criticised the report for not recommending that ESTA staff receive training to take calls for different emergencies.

Hill said it was frustrating that it took a statewide healthcare crisis for the government to accept the union’s demand for a safe minimum staffing model and sustainable funding at the triple-zero authority.

“Even with the perfect model,the pandemic and that spike in calls … would have had a detrimental effect on ESTA. But we could have reduced the severity of it,” he said.

“ESTA call takers actually provide lifesaving advice to bystanders about how to perform CPR,and that can save the patient’s life. When that doesn’t happen promptly,sometimes by the time the paramedics arrive there’s no hope of a successful resuscitation.”

Hill said paramedics had told him that ESTA’s performance had improved after recent funding increases.

In a second report released on Saturday morning,Pearce found Victoria’s level of preparedness for public health emergencies had not been assessed before the pandemic.

He found that the Victorian government’s ability to support residents was “inhibited by a lack of leadership” from the federal government.

“The control and co-ordination powers and functions in major public health emergencies are not clear,create conflict in the line of control and make it difficult for individuals to exercise the full extent of their statutory roles,” Pearce said.

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