The deaths of four children in a house fire in Werribee have been linked to the crisis that has engulfed Victoria’s triple-zero call agency, the true scale of which has been revealed in a damning report highlighting 33 deaths.
The long-awaited report on the performance of the Emergency Services Telecommunications Authority (ESTA), released unexpectedly by the state government on Saturday morning, identified almost double the number of deaths previously reported in connection with call-answering delays.
The Werribee house fire in November 2021.Credit: Paul Rovere
The report, by Victoria’s Inspector-General for Emergency Management, revealed 33 deaths between July 2021 and the end of May this year were linked to delays in answering emergency calls and “agency command and control issues”. All of them have been referred to the coroner.
Most emergency ambulance calls in Victoria are meant to be answered within five seconds, but there was a week in January during the Omicron wave when fewer than two in 10 calls were answered on time, and for several months at least 40 per cent of calls were met with delays.
One person waited more than 76 minutes for their call to be answered in January this year.
Inspector-General for Emergency Management Tony Pearce, the report’s author, said while in some cases no amount of rapid intervention would have saved the people who died, “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”.
One of the 40 cases highlighted as a “potential adverse event” in the report was a fire in Melbourne last year.
While the report does not identify the location of the blaze or the number of fatalities, The Sunday Age has confirmed it is the Werribee fire that killed four siblings, aged one to 10, in November.
Floral tributes and toys left outside the Werribee home after a fire killed four young siblings.Credit:Darrian Traynor
The initial triple-zero call to police was subject to several delays caused by a backlog of calls for ESTA ambulance dispatchers in Victoria.
The caller was initially unable to get through to the Telstra service charged with directing every Australian triple-zero call to either police, fire or ambulance because too many of the operators were on hold trying to connect calls for Victorian ambulances.
They waited 22 seconds listening to a pre-recorded message warning of the delays, then waited another minute for the call to be answered and dispatched to Victoria.
Following that, it took another 79 seconds before an operator at ESTA was available to answer the call. The first fire crew arrived at the scene at least 10 minutes after the initial triple-zero call. The children could not be saved.
At least 18 deaths had already been linked to the call-taking crisis at ESTA. Among them was 14-year-old Alisha Hussein, who died of an asthma attack in the back seat of her parents’ car as they waited 15 minutes for their triple-zero call to be answered.
Father-of-three Nick Panagiotopoulos, 47, died after collapsing in his Preston home with chest pain. Multiple calls to triple-zero went unanswered. His family waited 25 minutes for an ambulance to arrive, by which time it was too late.
In another case identified in the report, a caller waited 50 minutes to speak to an ESTA ambulance dispatcher after a person suffered a cardiac arrest. A person calling about an asthma attack this year waited 23 minutes to reach an ESTA call-taker.
The review confirmed that ESTA’s delays also clogged the national emergency call system because Telstra operators were “tied up for long periods on calls waiting for ESTA to answer”.
Jasmin Hussein’s daughter Alisha, 14, died during an asthma attack last October while waiting for an ambulance.Credit:Simon Schluter
“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.
“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.”
Pearce said 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”.
Tony Pearce, Inspector-General for Emergency Management.Credit:Paul Jeffers
The review found the key reason for the ESTA delays was resourcing, as the pandemic drove surges in demand and saw triple-zero staff off work sick.
“Since December 2020 – and more specifically since October 2021, when its call answer speed performance dropped below 70 per cent of [triple-zero] calls answered in five seconds – ESTA simply did not have sufficient ambulance call-takers to meet incredible demand,” the report says.
“ESTA missed opportunities to recruit and deploy additional emergency ambulance call-takers during the pandemic, particularly in 2020. This was for several reasons, one of which is related to the existing funding model to which ESTA is subject.”
But an ESTA call-taker, who is not authorised to speak publicly, told The Sunday Age it was not fair to blame the crisis on the COVID pandemic, as there had been repeated warnings of staffing issues and delays noted back in May 2019.
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.
Ambulance Union state secretary Danny Hill said 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 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.
Emergency Service Minister Jaclyn Symes acknowledged that any call delay was unacceptable, but said 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.
In a second report released on Saturday, 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.
The Victorians left waiting for ambulances
with Ashleigh McMillan
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