Nick Panagiotopoulos’ death could have been preventable, coroner finds

When Nick Panagiotopoulos began to feel sharp pains in his chest, he did what so many other Australians do in an emergency. He called triple zero.

But calls from the 47-year-old father-of-three, and then more desperate calls by his family members and a neighbour, were not answered by an ambulance call-taker at the state’s Emergency Services Telecommunications Authority.

A coronial inquest into the civil engineer’s death on October 16, 2021, would later be told that calls for an ambulance should be answered within five seconds, but the time between Nick first calling triple zero and ESTA eventually answering one of the calls and dispatching an ambulance was 16 minutes and five seconds.

Last week, Victorian Coroner Catherine Fitzgerald handed down her findings into the death of the beloved father, husband and civil engineer, determining that his cardiac arrest would have been “treatable and survivable” if ESTA had answered the calls in time.

“The crisis in emergency ambulance call answering, which occurred as result of the COVID-19 pandemic, was unprecedented, but it was not unforeseeable,” Fitzgerald wrote.

“In Nick’s case, the system that was designed to save him failed, and his death could have been prevented.”

Fitzgerald was scathing in her findings and said the system of emergency ambulance call taking in Victoria “effectively failed” for an 18-month period, leaving thousands of callers waiting unacceptable lengths of time.

“ESTA’s non-compliance drifted uncorrected, and foreseeably, into a crisis which exceeded Victorian resources and required large-scale government intervention to resolve,” she wrote.

“All the while, public safety was put at risk.”

Once dispatched, it took paramedics only about four minutes to reach Nick. But by the time they arrived, he was not breathing and had no pulse, despite relentless CPR efforts from his wife, Belinda, and their neighbour.

The day Nick died, Belinda Panagiotopoulos said her world tilted on its axis.

The coronial findings this week were only further proof of what she already knew.

“It made me think yet again, it’s so shocking what we endured that day,” she told this masthead.

“It makes your present and your future feel like it all bends in on itself because Nick’s death was so obviously avoidable.

“It makes your present and your future feel like it all bends in on itself because Nick’s death was so obviously avoidable.”

Belinda Panagiotopoulos

“It takes you right back to that moment … to have faith in a system, in an emergency … what you believe you should be entitled to living in Australia, and for it to fail so terribly.”

An autopsy later found Nick’s cause of death was acute myocardial infarction, commonly known as a heart attack.

Following Nick’s death, this masthead revealed a series of other deaths linked to persistent triple-zero delays, including toddlers involved in drownings, where in one case it took almost six minutes for the call to connect, and another where several calls never connected.

Fitzgerald said the state’s emergency ambulance call-answer performance first dropped below the 90 per cent compliance standard in December 2020, and ESTA did not achieve compliance with the performance standard again until August 2022.

“The utility of the ambulance call answer performance standard as a measure to ensure ESTA’s service delivery, and ensure public safety, was largely rendered worthless,” she wrote.

“It should have acted as a warning bell prompting urgent action.”

Fitzgerald noted that it was known in early 2020 – at the beginning of the coronavirus pandemic – that more call-taking staff would be required.

“ESTA had forecasting and modelling which anticipated increases in call volume and a decrease in available staff,” she wrote.

“It is extraordinary that there was an 18-month period during which ESTA simply could not meet its monthly performance benchmark for ambulance call answer speed, even accounting for the COVID-19 context.”

Belinda noted what struck her while reading the findings was the coroner’s compassion, which she said was met by ESTA’s “bureaucratic coldness”.

“There has been such a lack of decency throughout it all,” she said.

“The findings bring to light the devastation we continue to live with. Nick was a good man. He was a beautiful man. We have three beautiful daughters. We have had to adopt a sense of stoicism to try and move forward with our lives.”

More than four years have passed since Nick’s death and Belinda said the pain was still raw.

“We just try to appreciate life,” she said. “We are very tight unit. They continue to say we had the best dad. We didn’t have him for a long time, but geez, he was the best one.”

A Victorian government spokesman said the government was reviewing the findings.

“Our thoughts are with Mr Panagiotopoulos’ family and friends, who continue to live with the loss of a loved one,” he said.

He said the government had invested more than $600 million since 2022 to strengthen the service. And on Saturday morning, the government announced the state budget had allocated an extra $101.9 million to upgrade Triple Zero Victoria’s telephone infrastructure.

Triple Zero Victoria chief executive David Clayton said the organisation was also carefully considering the coroner’s findings.

“In 2021, during the pandemic, our organisation did not meet the standard of service the community rightly expects,” he said.

“Unprecedented demand far exceeded our capacity, and change was essential. With new leadership in October 2021, we commenced urgent and significant action to improve our service for the community.”

He said this included recruiting and training more call takers and implementing critical operational and structural changes.

In her report, Fitzgerald recommended Minister for Emergency Services Vicki Ward review the Inspector-General for Emergency Management’s assurance role to determine if its monitoring of Triple Zero Victoria is sufficiently protective, adds enough value, and aligns with best practices.

She acknowledged the grief of families who lost loved ones and the toll on the operators and call-takers who stayed on the phone with distressed members of the community who were facing unacceptably long delays.

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