Headline: Coroner Finds Emergency Call System Failure Contributed to Preventable Death
Lead Summary
A coronial inquest has found that a 47-year-old father of three died from a cardiac arrest that was "treatable and survivable," but was lost due to a systemic failure in Victoria's emergency call system.
The Incident
On October 16, 2021, Nick Panagiotopoulos, a civil engineer, suffered a cardiac arrest at his home. Despite his family calling Triple Zero multiple times, the emergency line was not answered promptly.
- The first call was placed, but the Emergency Services Telecommunications Authority (ESTA) did not answer for 16 minutes and 5 seconds.
- An ambulance was then dispatched, arriving approximately 4 minutes later.
- By the time paramedics arrived, Panagiotopoulos was not breathing and had no pulse.
The Coroner's Findings
Coroner Catherine Fitzgerald determined that the cardiac arrest was treatable and would have been survivable had ESTA answered the calls in time.
The report revealed that ESTA's emergency ambulance call answering system "effectively failed" for an 18-month period, from December 2020 to August 2022.
"The crisis was foreseeable," the coroner stated, noting that ESTA had received repeated warnings about increasing call volumes and staff shortages, particularly during the COVID-19 pandemic.
The system failed to meet the 90% compliance standard for answering calls within five seconds. The coroner criticized ESTA for failing to act on available forecasting data that predicted the higher demand.
Personal Impact & Official Response
The widow, Belinda Nicolazzo, stated that the death was "obviously avoidable." She expressed that the family continues to experience deep grief from the loss.
- A Victorian government spokesman expressed condolences and confirmed that the government is reviewing the findings.
- An autopsy listed the official cause of death as acute myocardial infarction (heart attack).
Broader Context
The coronial findings noted that ESTA’s performance benchmark non-compliance "drifted uncorrected," eventually leading to a crisis requiring government intervention. This case is one of several deaths reported by media that have been linked to delays in the Triple Zero system.