A patient at Sunshine Hospital receiving treatment for asthma during last year's crisis. Credit:Justin McManus "It is tragic, nine people have passed away as a result of this but were it not for the way the agencies worked within the system and responded on the night I think that figure could have been a lot higher," Mr Pearce said. The report showed additional resources had been put on during the crisis, but that limited communication between agencies hampered the spread of information and emergency response plans were not fully activated. The crisis, which began on the evening of November 21, was being managed remotely, and the State Emergency Management Centre and Ambulance Emergency Operations Centre had not been activated. Because formal emergency incident arrangements were not in place on November 21, "this hampered the overall response to the event, including the timely development and distribution of appropriate messaging to the community," the report states.

Four of the nine people who died in last year's thunderstorm asthma epidemic: Hope Carnevali (left), Omar Moujalled, Apollo Papadopoulos, and Clarence Leo. The freak weather event caused thousands of Victorians to experience respiratory problems that required urgent medical care. Grieving families have been critical of services for not alerting them to ambulance delays and failing to advise them to drive loved ones to the hospital, rather than wait for paramedics. The report reveals escalating calls to triple zero reached 510 in the hour to 7pm. The longest wait for a call to be answered was four minutes and nine seconds at 6.49pm. The peak demand for ambulances was during the 15 minutes from 7pm, when 201 calls came in. Hospitals were also experiencing a surge at emergency departments, double what they would normally see.

Two hours into the crisis, Ambulance Victoria had a backlog of 150 jobs, nearly 100 of which were Code 1. But it was another 45 minutes before it released the first alert to the public, a tweet advising people with asthma to follow their asthma plan after a "a rise in breathing probs tonight following the weather." A second and final tweet at 10.08pm said there was "high demand" for ambulances due to breathing issues and to only call 000 in an emergency. It was not until 11am on Tuesday that the state's Chief Health Officer declared a public health emergency, activating Victoria's emergency incident management structure. By then the the surge had passed. The family of 20-year-old law student Hope Carnevali, who died while waiting for paramedics, have called for real time information about ambulance delays to be available during emergencies.

"The standard response can't just be, 'an ambulance has been dispatched.' What is that? Five minutes or 40 minutes? That's the situation we found ourselves in … knowing that things could have been different," said Hope's aunt, Melissa Carnevali.

Hope drew her last breath on her front lawn while family members waited 30 minutes for an ambulance. "When three calls were made and the ambulance operator is advising you to keep her where she was, that the ambulance is just around the corner, that's who you trust," Ms Carnevali said. "But if there is an emergency and the time is going to blow out then you can make your own decision. It would be empowering to have that information, particularly when you're at your most vulnerable and you are totally reliant on what someone on the other end of the phone is saying to you." Shuayb​ Talic​, a friend of Greenvale high-school student Omar Moujalled, who died on the way to hospital, said the government's top priority should be a warning system for people who suffer from asthma so they can prepare for, and manage, an attack.



"They have warnings for natural disasters, they need something like this for asthma," Mr Talic said. Health minister Jill Hennessy has flagged a major overhaul of how the health department manages and escalates emergencies, pledging $1 million for pollen monitoring and research. "We've got to make sure that we get the right systems, have the right resources, the right messages put in place to better predict, better prepare and better respond to similar events in the future," Ms Hennessy said. "Our health system is one of the best in the country and responds very well but in this circumstance where we had an unprecedented event that had such a rapid onset where people were not quite sure what was occurring with such extraordinary numbers, there are many lessons to be learnt." She said Ambulance Victoria was "reflecting on" whether families should have been told to drive to the hospital as part of its own internal review.

Opposition health spokeswoman Mary Wooldridge said despite the best efforts of emergency services personnel, Victorians were "let down by a poorly co-ordinated response and inadequate leadership." Loading A celebration for Hope's 21st birthday is going ahead later this month and the family have asked for donations to be made to Asthma Australia in lieu of gifts. The Inspector-General's final report is due in April.