Ambulance Victoria's "tone deaf" response cost the life of a domestic violence victim whose triple-zero call was downgraded and ambulance cancelled, a coroner says.
An ambulance was available just 700m from Kylie Cay when her triple-zero call was downgraded from urgent to non-urgent early on June 21, 2016.
The 44-year-old mother-of-three was found dead at her Port Fairy home by family members the following afternoon.
Deputy State Coroner Caitlin English on Tuesday found it was highly likely the death could have been prevented if an ambulance had arrived or if a taxi to hospital was arranged.
Ambulance Victoria's missed opportunities to save Ms Cay's life with its "tone deaf" response, the coroner said.
The woman's partner, Justin Turner, dragged her by the hair, attacked her with a hammer, and stomped on her ribs and legs when he couldn't find his cigarettes on June 18.
Ms Cay crawled into the backyard and took shelter in a dog kennel before going to hospital.
She was discharged on June 20. A CT scan failed to pick up her ruptured spleen that ultimately led to her death.
She went to the home of Turner's mother, who called an ambulance early the next morning because Ms Cay was deteriorating.
The call initially was 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 her description of abdominal and shoulder pain.
The fact she was a domestic violence victim was not considered relevant, and the operator didn't actively listen and lacked empathy, the coroner found.
Ms Cay 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.
Had she been calling to describe injuries from a car accident, she would not have been so quickly dismissed, Ms English concluded.
The woman was told she could attend hospital herself, but said she did she not have the means to get there.
A taxi was discussed but not ordered.
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 again apologised for its failings and said it had made significant changes to how it dealt with triple-zero calls since 2016.
The ambulance workers who dealt with Ms Cay's triple-zero call are still employed.
Turner was jailed in 2017 for a maximum of 12 years for manslaughter.
He'd been released from prison on a community correction order before killing Ms Cay.
The coroner pointed to several red flags missed by Corrections Victoria, but said these could not be linked to the woman's death.
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