This report is a compilation of the Legal and Social Issues Committee’s investigations, evidence gathering and research during an inquiry into the core issues impacting the management and functions of Ambulance Victoria. Ambulance Victoria is the emergency and non‑emergency ambulance service provider in Victoria, Australia. It is a statutory authority.

The report finds that the evidence presented is stark: Ambulance Victoria is an organisation in crisis. It makes 52 findings and 21 recommendations.

Key findings

• A toxic culture continues to thrive – marked by bullying, harassment, nepotism and reprisals against those who challenge authority.
• Leadership has misused complaints processes against its own staff, creating deep and widespread distrust.
• Governance failures run deep. A lack of paramedicine expertise on the Board has contributed to poor decision‑making.
• Excessive workloads are pushing paramedics to breaking point. Regional staff are particularly vulnerable, isolated from adequate support.
• The Triple Zero triage system, overly risk‑averse, is contributing to resource misallocation, while ambulance ramping continues to undermine patient outcomes.
• Over the last decade Ambulance Victoria’s staffing levels of qualified ambulance officers has grown faster than Victoria’s population.