Nick Panagiotopoulos’ death could have been preventable, coroner finds

When Nick Panagiotopoulos started feeling sharp pains in his chest, he did what many other Australians do in an emergency. He called triple zero.

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

The judicial inquest into the civil engineer’s death on October 16, 2021 was later told ambulance calls were supposed to 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 said to be 16 minutes and five seconds.

Last week, Victoria Coroner Catherine Fitzgerald conveyed his findings Regarding the death of the beloved father, husband and civil engineer, he determined that the heart attack would have been “treatable and survivable” if ESTA had responded to calls in a timely manner.

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

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

Fitzgerald was harsh in his findings, saying the emergency ambulance call-taking system in Victoria had “effectively failed” over an 18-month period, causing thousands of callers to wait for unacceptable lengths of time.

“ESTA’s non-compliance has spiraled uncorrected and predictably into a crisis that has overwhelmed Victorian resources and required large-scale government intervention to resolve,” he wrote.

“Meanwhile, public safety has been compromised.”

It took only four minutes for paramedics to reach Nick after he was dispatched. But when they arrived, he was not breathing and had no pulse, despite the continuous artificial respiration efforts of his wife Belinda and neighbors.

The day Nick died, Belinda Panagiotopoulos said her world revolved around its own axis.

This week’s forensic findings were just further proof of what he already knew.

He told this imprint: “This made me think again; what we experienced that day is so shocking.”

“It makes your present and your future feel like everything is happening on its own because Nick’s death was so clearly preventable.

“It makes your present and future feel like everything is happening on its own because Nick’s death was so clearly preventable.”

Belinda Panagiotopoulos

“It takes you back to that moment… believing in a system, believing in an emergency… what you believed was your right to live in Australia, and having it fail horribly.”

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

Following Nick’s death, this imprint revealed a number of other deaths linked to persistent triple zero delays; these include young children involved in drownings; in one case it took almost six minutes for the call to be connected, and in another many calls were not connected at all.

The province’s emergency ambulance call-and-response performance first fell below the 90 percent compliance standard in December 2020, and ESTA did not regain compliance with the performance standard until August 2022, Fitzgerald said.

“The utility of ESTA’s ambulance call response performance standard as a measure to ensure service delivery and public safety has been largely devalued,” he wrote.

“It should have served as a warning bell calling for immediate action.”

Fitzgerald noted that it was known in early 2020, at the beginning of the coronavirus pandemic, that more call-answering personnel would be needed.

“ESTA had forecasting and modeling that predicted an increase in call volume and a decrease in available staff,” he wrote.

“It is extraordinary that there was an 18-month period in which ESTA failed to meet its monthly performance benchmark for ambulance call response speed, even taking into account the COVID-19 context.”

Belinda stated that what impressed her when reading the findings was the coroner’s compassion, which was met with the “bureaucratic coldness” of ESTA.

“There was a huge lack of civility in everything,” he said.

“The findings bring to light the devastation we continue to experience. Nick was a good man. He was a beautiful man. We have three beautiful daughters. We have had to embrace grit to try to move forward with our lives.”

It’s been more than four years since Nick’s death and Belinda said the pain is still fresh.

“We’re just trying to understand the value of life,” he said. “We’re such a tight team. They keep saying we have the best dad. We haven’t had him in a long time, but God, he was the best.”

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

“Our thoughts are with the family and friends of Mr. Panagiotopoulos as they 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. On Saturday morning the government announced the state budget allocated an extra $101.9 million to upgrade Triple Zero Victoria’s telephone infrastructure.

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

“During the pandemic period in 2021, our organization could not meet the service standard that society rightfully expected,” he said.

“Unprecedented demand far exceeded our capacity, and change was essential. With new leadership in October 2021, we initiated immediate and significant actions to improve our service to the community.”

This includes hiring and training more call takers and implementing critical operational and structural changes, he said.

In his report, Fitzgerald recommended Emergency Services Minister Vicki Ward review the assurance role of the Inspector General of Emergency Management to determine whether Triple Zero Victoria monitoring is sufficiently protective, adds sufficient value and is consistent with best practice.

He acknowledged the pain of families who lost loved ones and the burden on operators and call takers who were left on the phone with distressed members of the community who faced unacceptably long delays.

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