The 16 minutes and five seconds that probably cost Nick his life

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A Preston father of three who died of a heart attack would have had a good chance of surviving if not for a shocking delay connecting to Victoria’s triple-zero service, the coroner’s court has heard.

Nick Panagiotopoulos, a civil engineer adored by his wife and daughters, began to feel unwell after assisting his neighbours with a concreting job in the early afternoon of October 16, 2021.

Nick Panagiotopoulos could have survived his heart attack if a triple zero call had gone through when it was supposed to.Credit: Wayne Taylor

But a call by the 47-year-old for an ambulance, and then calls by his wife Belinda and neighbours, could not be connected to the Emergency Services Telecommunications Authority (ESTA), which manages dispatches of the state’s ambulance, fire and police services.

Calls for an ambulance should be answered within five seconds. The time between Panagiotopoulos first calling triple zero and ESTA eventually answering one of the calls was 16 minutes and five seconds.

An Age report from December 2021 about Panagiotopoulos’ death led Inspector-General for Emergency Management Tony Pearce to announce a major review into the failings of the triple-zero system. Yet answering delays at ESTA – since renamed Triple Zero Victoria – persisted months after, and dozens more Victorians died following significant triple-zero connection delays.

It only took paramedics about four minutes to reach Panagiotopoulos once they were dispatched, but by the time they arrived he was not breathing and had no pulse, despite CPR efforts from Belinda and their neighbour.

Nick, pictured with wife Belinda, died while waiting for an ambulance. His death is the earliest linked to ESTA answering delays.

Shortly after, the paramedics noticed Panagiotopoulos was in asystolic cardiac arrest, which means his heart had stopped beating. An autopsy found that his cause of death was acute myocardial infarction, otherwise known as a heart attack.

Associate Professor and cardiologist Nicholas Cox argued the delays before reaching a triple-zero call taker “were contributory to Nick’s death”.

“It is foreseeable that Nick’s likelihood of survival with appropriate treatment of his myocardial infarct by defibrillation would have been high,” said Cox’s evidence, presented to the hearing on Friday overseen by coroner Catherine Fitzgerald.

“If paramedics were in attendance prior to Nick’s cardiac arrest, his chance of survival would have been good. Paramedics, had they witnessed Nick’s cardiac arrest, would have been able to commence CPR immediately, then assess and perform defibrillation within [one to two] minutes of loss of cardiac output.

“The likelihood of success of defibrillation in this situation would have been high.”

Following Panagiotopoulos’ death, investigations by this masthead revealed a cluster of other deaths linked to persistent triple-zero delays, including toddlers involved in drowning incidents, where in one case it took more than six minutes for the call to connect, and another where multiple calls never connected.

The later report by Pearce found 33 deaths in Victoria between July 2021 and the end of May 2022 that followed notable delays in answering emergency calls and “agency command and control issues”.

The coroner’s court has repeatedly declined to confirm exactly how many of these cases it is investigating, but it was revealed on Friday that the triple-zero cases would be dealt with in individual inquiries rather than as a cluster.

The barrister assisting the coroner, Georgina Coughlan, KC, said the coroner was overseeing “a number of cases where issues similar to those arising in Mr Panagiotopoulos’ case have also arisen”.

“Although there is some similarity in the issues arising, the circumstances of each case remain quite distinct.”

The upcoming inquest, due to be held later this year, will hear from Pearce and two representatives from ESTA, yet to be named. It will examine the management of triple-zero calls in the case, whether they contributed to Panagiotopoulos’ death, and whether the tragedy was preventable.

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