Inspector-General for Emergency Management Tony Pearce’s report found that the Emergency Services Telecommunications Authority (ESTA) call answer speed had “fallen below community and government expectations”,with one Victorian forced to wait more than 70 minutes for their emergency call to be answered in January.
Emergency Services Minister Jaclyn Symes has held a press conference about the results of an inquiry into ESTA
Pearce identified 40 “potential adverse events” between December 2020 and May 2022 associated with answering delays,command decisions and resourcing issues.
“Tragically,33 people did not survive these emergencies. This does not necessarily mean that call answer delay was a contributing factor,because in some cases no amount of rapid intervention would have saved the patient,” Pearce said.
“What it does mean is that due to these call answer delays,the community waited longer to receive important first-aid advice,and paramedics had less time to apply advanced treatment in time to make a difference to the patient’s outcome.”
The report found the COVID-19 pandemic had strained Victoria’s health system – particularly ESTA – and caused answer times to blow out from the five-second target to,in some cases,more than 10 minutes.
Pearce found the number of calls answered within the five-second target “was consistently under the 90 per cent benchmark”.
In September 2021,ESTA’s statewide call answer speed performance dropped to 67.8 per cent,before sliding to its lowest point in January 2022,when it only answered 39 per cent of calls in five seconds.
On January 14,2022,ESTA received more than 2500 calls,with 139 people forced to wait more than 10 minutes for a responder to answer.
One waited more than 76 minutes for their call to be answered that day.
Ambulance Union state secretary Danny Hill said the report “pulled no punches” in describing the service’s lack of funding and staff and ill-preparedness for the pandemic.
Paramedics were in “absolute disbelief” that some severely unwell patients had to wait more than 20 minutes for their calls to be answered,he said.
The review confirmed that ESTA’s delays also clogged the national emergency call system because.
“Prior to the COVID-19 pandemic,ESTA had typically been compliant with the monthly call answer performance benchmark,” the report says.
By the end of the 2020-21 financial year,ESTA had answered 884,962 emergency ambulance calls,which was 53,201 more than the previous year. “That equates to 146 additional[triple-zero] calls for ambulances in Victoria every day,” the report says.
It coincided with a surge in COVID cases,an increase in the number of Victorians with sudden,serious illnesses linked to delays in check-ups and medical appointments and the suspension of elective surgeries.
“There is a strong statistical correlation between emergency ambulance call demand via triple-zero and the numbers of newly diagnosed COVID-19 cases in Victoria five days prior,” the report says.
,although a leaked report from Ambulance Victoria last month revealed that of patients,including 357 in cardiac arrest,could have been hurt as ambulance calls took too long to be answered.
In March,The Age and Nine’s60 Minutes revealed that were among the Victorians who died after urgent calls for an ambulance were never answered or were picked up too late.
Alisha Hussein,14,pictured with her mother,Jasmin,died after suffering an asthma attack and waiting over 15 minutes for a triple-zero call to be picked up.Supplied
Among them was,who died after her mother was forced to drive her to hospital as they waited more than 15 minutes for their triple-zero call to connect to an ESTA operator. Two toddlers also died following significant call connection waits after drownings.
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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