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Finding into death of Nick Panagiotopoulos

Deceased

Nick Panagiotopoulos

Demographics

47y, male

Coroner

Coroner Catherine Fitzgerald

Date of death

2021-10-16

Finding date

2026-04-30

Cause of death

Acute myocardial infarction due to thrombotic occlusion of the right coronary artery and coronary artery atherosclerosis

AI-generated summary

Nick Panagiotopoulos, a 47-year-old man, suffered a fatal acute myocardial infarction (heart attack) on 16 October 2021 at home in Preston, Victoria. His family made five calls to Triple Zero (000) requesting emergency ambulance assistance, but experienced severe delays of more than 16 minutes before the first call was answered by an ambulance call-taker. During this critical period, Nick suffered cardiac arrest. Although paramedics ultimately arrived, he was in asystolic cardiac arrest with virtually no chance of survival. Expert evidence indicated that if emergency services had been dispatched promptly—within seconds to a few minutes of his first call—Nick's chance of survival would have been 'almost a hundred per cent' or at minimum 'good'. The delays were attributable to the Emergency Services Telecommunications Authority (ESTA) being overwhelmed during the COVID-19 pandemic. Despite having forecasted increased ambulance demand from March 2020, ESTA failed to proactively recruit additional call-takers and only escalated concerns in October 2021 when the crisis became entrenched. The coroner found that ESTA should have requested urgent government funding for staff recruitment from March 2020 onwards, and that Nick's death was preventable.

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Specialties

cardiologyemergency medicineparamedicine

Error types

systemdelayprocedural

Clinical conditions

acute myocardial infarctioncoronary artery atherosclerosiscardiac arrestasystolic arresthypertensionhypercholesterolaemiahypertriglyceridaemia

Contributing factors

  • Delay in ambulance call-taker answer (16+ minutes)
  • Delay in emergency ambulance dispatch
  • Delayed commencement of CPR instructions by ambulance call-taker
  • COVID-19 pandemic-related surge in ambulance call demand
  • ESTA workforce shortages and inadequate staffing
  • ESTA failure to proactively recruit additional ambulance call-takers despite forecasting increased demand from March 2020
  • IGEM's reactive rather than protective monitoring of performance standards
  • Unclear escalation pathways between ESTA and government

Coroner's recommendations

  1. That the Minister for Emergency Services considers reviewing the nature of the assurance role of the Inspector General of Emergency Management relating to its monitoring of performance standards applicable to Triple Zero Victoria, to assess whether this monitoring is sufficiently protective in nature, whether it adds sufficient value, and whether it is in accordance with best practice in emergency management.
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