The long-awaited report into the Emergency Services Telecommunications Authority, led by former Victoria Police chief commissioner Graham Ashton, was released by the state government on Thursday.
The damning 80-page review, commissioned last year after reports of the call system crashing, found "continued and systematic underperformance".
"Over its short history the number of times when the system has failed continues to grow, often with dire outcomes," Mr Ashton found.
"Equally, the increasing frequency of complex major emergencies and the impact of the COVID-19 pandemic continues to push ESTA's CTD (call taking and dispatch) workforce to its limits."
Since October at least 12 Victorians have died while waiting for an ambulance, but the report found problems with ESTA pre-date the pandemic.
It noted a lack of rostering flexibility in enterprise agreements for its roughly 800 operational staff played a part in its failure to meet surge demand events such as major storms in 2021 and peak periods of the pandemic.
Emergency service organisations told the review they were concerned with ESTA's capability, service delivery and unresponsiveness to their needs.
One ESO said its request for a change has been unfulfilled for more than 10 years.
Interim ESTA chief executive and former Victoria Police assistant commissioner Stephen Leane said the call-taking body was not seen as an "equal" among emergency services during his time in the force.
"ESTA is the frontline of the frontline ... it is the tip of the spear," he said.
Mr Ashton found the ESTA call service has faced recruitment and retention problems along with fixed-term funding for many years, eroding its capability and capacity.
He made 20 recommendations, including moving ESTA into the Department of Justice and Community Safety and rebadging it as Triple Zero Victoria, which the government says it will do.
The government has accepted all recommendations in principal - of which five are in train - after committing to hiring and training 400 ESTA staff as part of a $333 million state budget pledge this month.
However, there is no firm timeline for their implementation.
"We really want to get this right. We need to take the time," Emergency Services Minister Jaclyn Symes told reporters.
Ms Symes was handed the Ashton report in March and admitted the timing of the report's release, two days before the federal election, may look "cynical".
But she said the Victorian government finalised its response earlier on Thursday and did not wish to further delay the report's public release.
Opposition health spokeswoman Georgie Crozier accused the Andrews government of seeking to use the cover of the federal election campaign to "hide" the report.
"These issues were identified years ago. They should have been and could have been fixed years ago," she said.
A separate review into the performance of ESTA during COVID-related surges last year is due to be handed to the government in August.
KEY RECOMMENDATIONS:
* The Emergency Services Telecommunications Authority to become part of the Department of Justice and Community Safety.
* The ESTA board and advisory committee are disbanded and replaced with a new board of advisers.
* Creation of a dedicated fixed-term position to specifically lead cultural reform at ESTA during this transition.
* ESTA should be rebranded Triple Zero Victoria.
* ESTA, in partnership with emergency service organisations, commission an independent review of ESTA training standards to ensure they are fit for purpose.
* ESTA should use live monitoring of call data to alert ESOs to potential large-scale emergencies.
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