Overview

• Christina Lackmann, a 32-year-old biomedical science student, called triple zero in April 2021 reporting dizziness and numbness after taking caffeine tablets, but paramedics did not reach her for more than seven hours.
• Coroner Catherine Fitzgerald’s June 2025 ruling found that misclassification of her case and failure to transfer her call to a health practitioner amounted to an “unacceptable” wait that likely proved fatal.
• Post-mortem toxicology showed blood caffeine levels far exceeding what could be ingested through coffee, confirming a lethal overdose from tablets delivered to her apartment the same day.
• The inquest highlighted that roughly 80 percent of Ambulance Victoria’s fleet was unavailable due to hospital ramping, forcing paramedics to wait to off-load patients at emergency departments.
• In response to the coroner’s seven recommendations, Ambulance Victoria has implemented procedural changes and is collaborating with health authorities to improve triage and reduce ambulance ramping.