Ambulance Victoria failed Port Fairy violence victim, coroner finds

An ambulance was available just 700 metres from Kylie Cay when her triple-zero call was downgraded to non-urgent early on June 21, 2016.

The 44-year-old mother-of-three was found dead from a ruptured spleen at her Port Fairy home the following afternoon.

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Deputy State Coroner Caitlin English on Tuesday found the death was preventable if an ambulance had arrived or a taxi to hospital was arranged.

The coroner said Ambulance Victoria missed opportunities to save Ms Cay's life with its "tone deaf" response.

Her partner Justin Turner had dragged her by the hair, attacked her with a hammer, and stomped on her ribs and legs when he couldn't find his cigarettes.

Ms Cay crawled into the backyard and took shelter in a dog kennel before going to hospital.

She was discharged two days after the June 18 assault. A CT scan did not pick up her ruptured spleen.

Turner's mother called an ambulance for Ms Cay as she deteriorated following her discharge.

The call was initially considered a code one, but downgraded by Ambulance Victoria on review to a code three.

The triage operator said he did not think the call was urgent in light of Ms Cay's recent hospitalisation, and the description of her symptoms as abdominal and shoulder pain.

The fact she was a domestic violence victim was not considered relevant, and the operator did not actively listen to and lacked empathy for Ms Cay.

She said she could hardly breathe and was about to lose consciousness, only to be told it wasn't a medical emergency and she needed pain relief.

The coroner concluded Ms Cay may not have been so quickly dismissed had she been been calling to describe injuries from a car accident or workplace incident, as opposed to domestic violence.

She was told to get herself to hospital. A taxi was mentioned but not ordered.

The call dropped out and Ms Cay walked home, where she was found dead.

Her family said her life was cut short by Ambulance Victoria's "inability to take family violence seriously".

"She was a kind and compassionate mother who would go out of her way to help others," the family said in a statement.

"Sadly, her caring nature resulted in the biggest mistake of her life, trying to rehabilitate a partner who was beyond help. She was brutally assaulted by a coward.

"She perished at her home, knowing that help would not arrive. She died in isolation and in pain, begging for assistance while a free ambulance remained parked 700m away."

Ambulance Victoria expressed its sympathies to the family and said it had made significant changes since 2016. It confirmed the workers who dealt with Ms Cay's triple-zero call were still employed.

Ms English made six recommendations including an internal review to ensure Ambulance Victoria staff were trained in responding to patients experiencing family violence.

A transcript of the call between Ms Cay and the triage operator should be used to teach staff about active and empathetic listening, the coroner said.

Turner was jailed in 2017 for up to 12 years after pleading guilty to manslaughter.

He was on a community correction order for previous violence offences when he killed Ms Cay.

Turned breached that order 18 times.

Corrections Victoria was urged to bring in an electronic case management system so it could better track compliance with court orders.

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