A report by Inspector-General for Emergency Management Tony Pearce linked 33 deaths to ambulance call delays, but did not say whether faster intervention would have prevented them.
It found the Victorian government was aware of the Emergency Service Telecommunications Authority's (ESTA) precarious financial position as early as 2015 and had not settled on a sustainable funding model despite 10 years of work.
Premier Daniel Andrews has argued the extent the system was overwhelmed was not foreseeable but Mr Pearce said ESTA forecasts accurately predicted demand for the Delta and Omicron COVID-19 waves.
"The numbers they arrived at were very, very close," he told ABC Radio Melbourne on Wednesday.
"The problem they had was that their funding base was one that allows them to resource on a year-to-year basis for their business as usual. What it doesn't do is provide them with enough capacity to ramp up when they get a large surge event."
ESTA's benchmark is for 90 per cent of ambulance calls to be answered within five seconds but figures blew out after Victoria moved away from lockdowns last year.
It took an average of 90 seconds to answer ambulance calls in Victoria in October, compared to the national average of 13 seconds.
When COVID-19 cases skyrocketed in January, the national average rose to 15 seconds and spiked to 118 seconds in Victoria.
NSW's ambulance service recruited call-takers aggressively in mid-2020 but ESTA's ad-hoc supplementary funding curtailed its ability to hire and train enough staff to meet demand, the report found.
Mr Pearce said the authority lacked confidence to "spend money and deal with consequences" later, unlike Ambulance Victoria.
The Victorian government committed $333 million to recruit and train almost 400 extra call-takers in May.
Treasurer Tim Pallas said ESTA had previously received every dollar it requested.
"Victoria made choices and, quite frankly, the choice that we made at that time was to fund the request that was made in that particular year," Mr Pallas said.
Former ESTA chair Roger Leeming said the board requested an extra $20 million in 2015.
He said he was subsequently pressured to resign by a department head and the former emergency services minister.
"We got the money and then the instruction to sack ... me and the longest-serving members of the board," he told Melbourne radio station 3AW.
Opposition emergency services spokesman Brad Battin accused the Andrews government of forcing out board members to replace them with Labor mates.
"If they had have acted in 2015 or 2016 when these reports came through, rather than forcing the resignation of the man standing up for Victorians, we would have had better outcomes during the COVID crisis," he said.
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