Overview

• The inquest found Christina Lackmann, 32, died from a fatal caffeine overdose after calling triple zero for dizziness and numbness on April 20, 2021.
• Despite 14 callback attempts and a text message, paramedics did not reach her Caulfield North apartment until seven hours and 11 minutes later.
• Coroner Catherine Fitzgerald ruled that categorising her case as non-urgent and widespread ambulance ramping made the delay unacceptable.
• Toxicological analysis showed her caffeine levels were too high to result from coffee, with tablets delivered to her home the day she called emergency services.
• Following the ruling, Ambulance Victoria has revised its triage procedures, and the health department is targeting reduced hospital offload times.