A damning report into the performance of Victoria's triple-zero call service, the Emergency Services Telecommunications Authority, identified 40 "adverse" events between December 2020 and June 2022.
Within that period 33 patients died but Inspector-General for Emergency Management Tony Pearce did not rule on whether the events contributed to their deaths, leaving that judgement to the state coroner.
When the report was released on Saturday, Emergency Services Minister Jaclyn Symes offered an apology on behalf of the government to the families of those who died.
Premier Daniel Andrews has not acknowledged the report or faced questions on the subject, with his deputy Jacinta Allan reiterating the government's apology on Monday.
She wouldn't be drawn on findings the government was made aware of the call-taking service's "precarious" financial position as early as 2015 and that its funding model didn't allow for its response to be rapidly scaled up when COVID-19 hit.
"(The authority) met its benchmark every year prior to the pandemic," she told reporters on Monday.
"There is no doubt that the pandemic placed huge pressure on the organisation, on call-takers."
Ninety per cent of ambulance calls are supposed to be answered within five seconds, but figures blew out to "completely unacceptable" levels after Victoria moved away from lockdowns in October 2021.
At its worst point during the first Omicron wave, only 39 per cent of calls for an ambulance in January were being answered within the five-second target and one caller waited more than 76 minutes.
The Andrews government in May vowed to recruit and train almost 400 extra call-takers and about 150 have already started, helping to lift the ambulance call response rate to 86.2 per cent within five seconds throughout June.
Opposition Leader Matthew Guy said the premier owes an explanation to the 33 families who lost loved ones during the triple-zero system failings.
"At the moment, all he's done is give them silence," he said.
The state coroner is reviewing evidence from several cases to determine how many will form part of an investigation into the deaths, a spokeswoman confirmed on Monday.
Victorian Ambulance Union Secretary Danny Hill said lessons must be learned to ensure the triple-zero system isn't overwhelmed in future.
"Training up 400 people might completely solve the problem for a period of time but something could happen in five or 10 years," he told AAP.
"If you don't have a funding model that consistently sees ongoing recruitment occur, then you will end up in a similar position."
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