Melbourne woman dies of caffeine overdose, coroner rules

A woman may still be alive if 80 per cent of Melbourne ambulances were not ramped at hospitals the night she called triple-0, the coroner says.

A Melbourne woman died of a caffeine overdose, alone in her apartment waiting more than seven hours for an ambulance, the coroner has found.

The coroner said the backlog of ambulances ramping at Melbourne hospitals and issues with the triple-0 triage system were factors in the death, and she intended her findings to “highlight the very real potential human consequences of ambulance ramping in Victoria”.

Biomedical science student Christina Lackmann died in her Caulfield North home in April 2021.

The 32-year-old died after taking caffeine tablets, Coroner Catherine Fitzgerald said in a ruling delivered this month.

“The available evidence does not establish the precise time that Christina ingested the caffeine, or the quantity ingested,” Ms Fitzgerald said.

Christina Lackmann was about to finish her bachelor’s degree and hoped to continue studying. Picture: 7News

“In the absence of this information, I am not able to reach a definitive conclusion as to whether her death was preventable with earlier ambulance attendance.”

Eighty per cent of Melbourne’s metro ambulances were ramped at hospitals when Ms Lackmann called triple-0, the coroner said.

In her decision, Ms Fitzgerald detailed Ms Lackmann had previously attempted to take her own life with an overdose of caffeine tablets in 2015, but sought medical help.

She had been struggling with depression since her father’s death by a sudden heart attack, and she had a history of anorexia nervosa and gastrointestinal issues.

In the months before she died, Ms Lackmann was working on the final semester of her science degree and hoped to continue onto honours.

Just before 8pm on April 21, 2021, Ms Lackmann called triple-0, reporting she felt sick, numb all over, dizzy and she could not get up from the floor. The operator triaged the call as a non-urgent case of dizziness and vertigo.

This classification meant Ms Lackmann’s call was suitable to be transferred to a paramedic or nurse, but none of these secondary medical professionals were available to take a call.

Melbourne had been out of a Covid-19 lockdown for more than two months at the time Christina Lackmann died. Picture: NewsWire / David Geraghty

The triple-0 operator told Ms Lackmann to keep by the phone, or call triple-0 again if things change.

Ms Lackmann said it may be difficult for paramedics to get into her secure apartment building.

“I can’t get up,” she said.

“Please hurry.”

The operator told Ms Lackmann help had been organised. Less than 30 minutes later one of the nurse or paramedic secondary carers called Ms Lackmann, but her phone went unanswered. Text messages and 13 more calls got no response.

Ms Lackmann’s mother would later question why the unanswered calls did not trigger a welfare check from another agency.

Ambulance Victoria’s internal systems flagged Ms Lackmann’s location as an area where there were ambulances available.

Eighty-four minutes after her call to triple-0, Ms Lackmann’s case was bumped up to code two to “to improve the likelihood” an ambulance would be dispatched, the Coroner said.

Immediately after this upgrade, and Advanced Life Support paramedic was assigned to Ms Lackmann’s case, but the ambulance was diverted to a higher priority job. A similar diversion happened again about three and a half hours later, at 1.46am.

Just after 2am an ambulance was dispatched. The paramedic arrived at 2.23am, and was hindered from getting inside until a neighbour helped. The paramedics climbed up from a neighbour’s balcony and could see Ms Lackmann lying unconscious; her dog was agitated and barking, and paramedics called police for help.

Christina Lackmann died of a caffeine overdose following a series of ambulance delays. Picture: 7News

Police arrived, secured the dog, and paramedics got into the apartment “shortly before 3am, a total of seven hours and 11 minutes since Christina’s triple-0 call”. Paramedics saw she had been dead for a prolonged period.

An email to Ms Lackmann showed 90 200mg caffeine tablets had been delivered to her apartment that day, but neither the tablets nor packaging were ever found.

The autopsy found caffeine levels in her blood at very high to potentially fatal levels. A caffeine overdose can lead to seizures and fatal heart arrhythmias.

A toxicologist told the coronial inquest levels of caffeine so high could not be achieved from drinking coffee.

Overdoses are “largely preventable when treating clinicians know what they are treating,” the Coroner said.

The toxicologist said if Ms Lackmann had been in hospital immediately after calling triple-0 and told doctors what she took, she likely would have survived with treatment.

However, the Coroner could not say when Ms Lackmann took the tablets, so could not rule on the effect of the ambulance delays.

Ambulance Victoria carried out an analysis of the incident after Ms Lackmann’s death.

There was an “excessive and unacceptable” delay in ambulance response times that night, the report found. Also, at the time there was no standard process for Ambulance Victoria call takers to request a welfare check from another agency.

The report made seven recommendations for change; by May 2025, Ambulance Victoria had made all seven changes.

However, the Coroner said had Ms Lackmann known an ambulance was not on its way, she may have been empowered to seek other help.

“I am satisfied that Christina’s death was the consequence of the ingestion of caffeine tablets,” the Coroner said.

“However, I am not satisfied to the requisite standard that Christina intended to take her own life, although this remains a distinct possibility.”

Originally published as Melbourne woman dies of caffeine overdose, coroner rules