Overview

• Paramedics reached Christina Lackmann’s Caulfield North apartment seven hours and 11 minutes after her April 2021 emergency call, by which time she was found dead from a caffeine overdose.
• Coroner Catherine Fitzgerald described the response time as ‘unacceptable’ and identified failures in the triple-zero triage system alongside widespread ambulance ramping at Melbourne hospitals.
• Toxicology reports showed caffeine concentrations in Lackmann’s blood far exceeded levels achievable through coffee consumption and pointed to a delivery of high-dose caffeine tablets on the day of her call.
• The inquest noted that Lackmann’s call was initially classified as a non-urgent Code 3 case, preventing immediate clinical assessment that might have revealed her ingestion of caffeine tablets.
• Following Fitzgerald’s ruling, Ambulance Victoria conducted an internal review and has implemented procedural changes aimed at reducing ramping and improving real-time clinical triage.