Delays caused by Victoria’s triple-zero system leading to ‘dire outcomes’ for ambulance patients, review finds

·4-min read
<span>Photograph: Luis Ascui/AAP</span>
Photograph: Luis Ascui/AAP

Investigation follows the deaths of at least 12 people kept waiting after emergency calls weren’t answered on time


Victoria’s crisis-riddled triple-zero system lacks agility to respond to emergencies and is besieged by a risk-averse culture, leading to “dire outcomes” for patients awaiting ambulances, according to an independent review of the service.

The review, by former police chief Graham Ashton, found the state’s Emergency Services Telecommunications Authority (ESTA) operates like a “corporate entity” rather than an emergency management service.

Its release follows reports of at least 12 deaths – including four children – since October after triple-zero operators either failed to pick up or answer the call within the service’s benchmark times.

Related: ‘Health system in distress’: how ambulance ramping became a major problem

ESTA takes call for all of Victoria’s emergency services. The investigation found simple time-critical decisions had to be escalated through multiple levels of ESTA’s leadership until it reached “a person who felt empowered to make a decision.”

“This type of delay is an example that typifies a culture not consistent with ESTA’s mission,” the report says.

It concluded that failures in the system often had “dire outcomes”, with the pandemic pushing ESTA’s workforce “to its limits.”

With a workforce pool of only 800 operational staff and a lack of flexibility in enterprise agreements, ESTA was unable to boost capacity during times of unprecedented demand, such as storms in 2021 and peak Covid periods, the review found.

The Victorian Ambulance Union’s secretary, Danny Hill, said the report aligned with paramedics’ concerns about the service.

“It’s been our biggest complaint that ESTA has been … almost like a satellite surrounding the rest of the emergency services planet and sort of doing its own thing,” he said.

The report recommended the service be integrated into the Department of Justice and Community Safety from next year and undergo a rebrand to become “Triple Zero Victoria” to signify faster call-taking as its primary responsibility.

A new board of advisers will also be created, which will include members of Ambulance Victoria and Victoria police to draw on their emergency services expertise.

The Andrews government said it supported “in principle” all of the report’s recommendations and noted five were already under way. It said work on the remaining 15 recommendations would begin immediately, with call-taking and technology recommendations the most pressing elements of the report.

The report also warned that low staff morale – due to the challenging and confronting nature of the role and pandemic pressures – would affect the service’s ability to boost recruitment to meet demand if left unresolved.

Staff told the review the leadership team did not understand their issues, with Covid-19 and negative media coverage of the service exacerbating staff wellbeing concerns.

“The reactive nature of service delivery means that there is a focus on ‘keeping the lights on’, rather than proactive improvement or innovation,” the report found.

A separate review by the inspector general for emergency management will probe the unprecedented call volume the service faced during Covid.

The Victorian opposition has for weeks accused the Andrews government of keeping the report secret after it was received in March. Last week, the premier, Daniel Andrews, was pressed by reporters on whether he had read the full report but labelled the opposition’s attacks a “political game”.

The emergency services minister, Jaclyn Symes, said the government would work with ESTA, emergency service organisations, unions and workers to ensure it got the reform right.

Related: Victorian government delivers a budget that’s a tale of two elections

“Victorians should have the confidence that when they call for help in an emergency, they will get it,” she said.

The review, commissioned by the government last year, was not designed to investigate individual deaths but to consider broad structural reform of the call service. It also followed reports of the call system crashing and putting patient lives at risk.

Earlier this month, the government handed down the state budget, with a $12bn health funding blitz to help repair the state’s overburdened health sector and clear deferred care that has built up over the pandemic. It included $333m for 400 extra ESTA call-takers.

In March, the government also launched a recruitment campaign to hire 120 additional call-takers as part of a $115.6m reform package.

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