Unprecedented demand led to Victoria's triple-zero call system being overwhelmed and no amount of extra funding would have stopped it, Premier Daniel Andrews insists.
A report by the state's Inspector-General for Emergency Management was released on Saturday and found 33 people died following adverse events linked to ambulance call delays and other issues.
It prompted two senior ministers to publicly apologise on behalf of the Victorian government but Mr Andrews went a step further on Tuesday during his first public appearance in three days.
"I offer my deepest condolences and sympathies and my personal apology ... to anybody who has been touched by this virus and particularly those who have lost a loved one," he told reporters in Frankston.
The Victorian government was aware of the Emergency Service Telecommunications Authority's (ESTA) precarious financial position as early as 2015, and ad hoc supplementary funding limited its ability to recruit to meet demand.
"These financial constraints proved to be the main cause of ESTA's inability to develop capacity to meet the scenarios that were played out in the COVID-19 Delta and Omicron waves," the report said.
But Mr Andrews said the pandemic was no ordinary surge event and the triple-zero system still would been overwhelmed even if the government had tipped in more money earlier.
"Nothing in that model would avoid the system being overwhelmed by the thousands of additional calls for day after day after day," he said.
"Many things have been overwhelmed in recent years, and it's incredibly challenging and tragic.
"And that's why we send not only our best wishes and our sincere condolences and sympathies to those families, but we apologise for a system that did not meet your needs."
ESTA's benchmark is for 90 per cent of ambulance calls to be answered within five seconds.
But figures blew out to unacceptable levels after Victoria moved away from lockdowns in October 2021 and hit record lows during the first Omicron wave in January.
The Andrews government in May committed $333 million to recruit and train almost 400 extra call-takers but Inspector-General Tony Pearce has described it as a short-term fix.
"In four years' time if you don't finish the work on that model, you will be back in the same place you are now," he told The Age.
Mr Pearce's frustration is understandable but the Victorian government allocates agencies' funding four years in advance, Mr Andrews said.
"He wants to see what happens in the fifth, sixth and 10th year. I'm giving him and all Victorians a commitment that we'll see this through," he added.
Opposition Leader Matthew Guy said the premier's apology dripped with insincerity, given it was accompanied by a government announcement about the official opening of the Frankston Public Surgical Centre.
"What we wanted was the system fixed. We wanted this system fixed in 2015 when he got the first report," he said.
The opposition has criticised the timing of the report's release but Mr Andrews denied the government was attempting to bury it amid the AFL finals.
"Every day in September is about football," the premier said.
"If it had been released on Monday, Tuesday, Wednesday of this week then you would be putting it to me that it had been sat on."
