Ambulance ramping — its "very real potential human consequences"

On 13 June 2025, in the Coroners Court of Victoria, Coroner Catherine Fitzgerald handed down her findings into the 2021 death of 32-year-old Christina Lackmann. Lackmann, who called 000 at 7.49 pm on Wednesday, 21 April 2021, was found dead in her apartment by attending paramedics shortly before 3 am the next day — a total of 7 hours and 11 minutes since her 000 call.

Before her 000 call ended, Lackmann said, “Please hurry”, the call-taker advising Lackmann that her condition had been assessed, and that help had been organised. No resuscitation was attempted on arrival — paramedics having assessed that she had been deceased for a prolonged period.

Lackmann’s death was determined to be the consequence of the ingestion of caffeine tablets, and as the precise time that Lackmann ingested the caffeine was not able to be established — or the quantity ingested — the corner wrote: “I am not able to reach a definitive conclusion as to whether her death was preventable with earlier ambulance attendance”.

However, the coroner does comment: “As acknowledged by Ambulance Victoria [AV], the delay in ambulance assistance reaching Christina was unacceptable, and a result of a confluence of factors.” Following Lackmann’s death, AV reported her case to Safer Care Victoria as a ‘sentinel event’ — a type of serious incident that is wholly preventable and has caused serious harm to, or the death of, a patient — and a Root Cause Analysis (RCA) was undertaken in accordance with its statutory obligations.

The findings of this RCA raised a number of systemic issues of concern both during and following Lackmann’s 000 call.

The RCA’s findings

The RCA findings included that:

• There were excessive and unacceptable delays in ambulance response times, with ramping impacting 80% of AV’s metropolitan fleet;
• No standard process was in place at the time of the 000 call to enable AV to trigger a welfare check from another agency, or to provide any other non-ambulance response to a 000 caller who did not respond to attempted telephone contact — in all, a total of 14 call-backs were attempted;
• Emergency Services Telecommunications Authority (ESTA) scripts in place at the time did not adequately describe the situation to the patient — namely the type of response that Lackmann would receive, including that an ambulance would not be immediately dispatched. In particular, the advice (as per ESTA scripts) given to Lackmann that “help [was] being organised” — which left Lackmann (whose call was classified as a ‘Code 3’, which meant it was deemed suitable to be first transferred to the AV Referral Service for secondary triage) unable to make any subsequent decisions in relation to seeking further assistance; and
• An inability to provide a warm transfer to an AV Referral Service Triage Practitioner from the ESTA call-taker constituted a missed opportunity to establish a connection between the patient and a health practitioner and affected the ability to elicit further pertinent clinical information from the patient. A connection that, potentially, would have allowed for the transfer of important clinical information, which would have enabled a different prioritisation of response.

Coroner’s assessment

The coroner sought an update from AV regarding any changes made as a result of the RCA findings. To which, in a 21 May 2025 statement, Acting Director of Patient Safety and Experience David Allan is said to have reported that all seven RCA recommendations have been implemented. Such implementation included updating exit scripts used by ambulance call-takers to include the expected time of ambulance arrival and updated ESTA workflows to require earlier SMS messaging when attempting call-backs to a 000 caller.

On the former, the coroner said: “Reflecting on Christina’s case, I consider that the updated exit scripts […] may have assisted by alerting Christina to the possibility that an ambulance might be delayed, potentially empowering her to seek other help.” While on the latter, the RCA had deemed the policy of completing three unanswered phone calls to the patient before sending an SMS informing them that the incoming calls were from AV as suboptimal.

“I note the efforts of Ambulance Victoria and the Department of Health to address the problem of ambulance ramping and improve the triage and dispatch system,” Fitzgerald said in her comment. “However, considering the reported statistics regarding the percentage of patients transferred from the ambulance to the ED within the percentage target, and the average ambulance clearance time target, there is clearly more work to be done.

“I note the ongoing Inquiry into Ambulance Victoria being undertaken by the Legislative Council Legal and Social Issues Committee. The Committee, which will soon be holding public hearings,” Fitzgerald added. “I have determined to make this finding available to the Committee to highlight the very real potential human consequences of ambulance ramping in Victoria, as it may assist in informing the work of the Committee on this important issue.

“I convey my sincere condolences to Christina’s family for their loss.”

Fitzgerald’s finding is available to read here, via the Coroners Court of Victoria website.

Information on the Inquiry into Ambulance Victoria is available here, via the Parliament of Victoria website.

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