The story of the breakdown of Victoria’s triple-zero ambulance system is complicated. This has been exploited by those wanting to seed confusion about what went wrong and how it could have been avoided.

They’ll say ambulance services across the nation are struggling to get to people on time during the pandemic. That’s true and that’s also threatening lives, but it has little to do with the issue at hand.

Victorians have endured long waits for ambulances through triple-zero delays.
Victorians have endured long waits for ambulances through triple-zero delays.Credit:Wayne Taylor

The problem is tens of thousands of triple-zero calls in Victoria were not answered when they should have been.

When Victorians called because a loved one was critically ill or injured, there was no one free at the Emergency Services Telecommunications Authority (ESTA) to answer them. Seconds stretched into minutes and there still was no answer.

Many Victorian callers were instead stuck on the line with a person from a national Telstra call centre, untrained to give advice, and, in any event, not allowed to. They certainly couldn’t dispatch an ambulance.

When the system is working as it should, our encounters with these people should be fleeting and forgettable.

They ask us whether we want police, fire or ambulance, as well as our state and town, and then transfer us to the right service. But many thousands of Victorians waited more than a minute to be transferred because ESTA was too short-staffed.

Telstra call takers described how they could only say vaguely reassuring things, urging people not to disconnect.

“I had this woman where some member of the family was screaming ‘they need an ambulance’, ‘she’s not breathing’ [and] ‘she’s dying’,” one of the call takers told us this year. “You still hear those voices in your head.”

The Telstra call takers have reported delays getting through to services across the nation at different times. NSW Ambulance was previously a major source of delayed calls.

When I was speaking to the Telstra workers in March this year, one reported they experienced waits of about six or seven minutes to connect to NSW Ambulance one day that month. They said long delays had not typically been a recent issue for the service, but on this particular day, the delays persisted for hours.

But – and this is crucial because it goes to whether this crisis in Victoria could and should have been prevented – the data shows that while ESTA’s ambulance call performance dramatically declined when the COVID-19 Delta outbreak hit, it appears other states managed largely to weather the pandemic storm without a major collapse of call-taking performance.

This was highlighted in the Inspector-General for Emergency Management report that found that while nationwide it was taking on average 15 seconds for emergency ambulance calls to be transferred to emergency services in January, it took almost two minutes on average for the Victorian calls to be answered.

Inspector-General for Emergency Management Tony Pearce has been clear on what he considers to be the source of ESTA’s inability to answer ambulance calls on time. He blames its inadequate funding and a broken funding model, which had been highlighted to the government often over many years, but not acted upon.

The report also says ESTA missed an opportunity to seek money from the Victorian government in early to mid-2020 to prepare for increased pandemic demand. In comparison, it said NSW Ambulance had a relationship with its state’s health department which allowed it to aggressively recruit in June and July 2020.

“These financial constraints proved to be the main cause of ESTA’s inability to develop capacity to meet the scenarios that were played out in the COVID-19 Delta and Omicron waves,” Pearce wrote.

ESTA is meant to answer 90 per cent of emergency ambulance calls within five seconds.

It slipped below that target about December 2020, many months before the first death associated with triple-zero performance in spring the next year. Performance declined rapidly from August 2021, to a low in January when fewer than 40 per cent of calls were answered on time.

We know ESTA requested callers be diverted to a voice announcement warning ambulance lines are “extremely busy” on at least 153 occasions from October to March this year. This was a measure designed for sudden natural disasters. In comparison, the announcement was requested just twice in NSW and never in Western Australia, according to those state’s services.

For almost as long as we have been reporting on the story, the government has been keen to elevate the role of the pandemic in what has occurred, often noting ESTA’s targets were being met for years beforehand.

On Tuesday, Premier Daniel Andrews said he offered his “personal apology and my deepest sympathies to all of those families [impacted by the delays] and indeed all families who have lost somebody because of this global pandemic”.

He also claimed that ESTA would still have been overwhelmed, even if the government had delivered funding earlier.

The idea that the pandemic is to blame for what happened at ESTA, and that the overwhelming of the system was unavoidable, ignores the findings of the inspector-general’s report and doesn’t explain the comparative resilience of other states’ triple-zero ambulance services.

It also overlooks the fact that after millions in funding for the extra staff, the problem has been fixed. Last month, 92.8 per cent of calls were answered in time, but here we are still in a pandemic, with call demand still high.

If we don’t accept what went wrong, how can we ensure it won’t happen again?

We know seconds can count. When a toddler drowned in November it took almost six minutes for the triple-zero call to connect. There was a delay of more than five minutes in the case of a man in his 40s who had a fatal chainsaw accident. There are at least 31 other deaths that have been highlighted because there were problems, mostly related to delays.

Yes, it will be up for the coroner to try to determine if they might still be alive today if calls were picked up faster. What we can now say is that families should never have been left to ask “what if?”

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