Dear Mr Cox

Prevention of future deaths report touching on the death of Mr Lachlan Charles Campbell

I am writing on behalf of South Western Ambulance Service NHS Foundation Trust (thereafter referred to as the SWAST) in response to a Regulation 28 report to prevent future deaths, issued in relation to death of Mr Lachlan Charles Campbell. Our thoughts are with Mr Campbell’s family, and we send them our sincere condolences.

In your regulation 28 report the principle concern you identified was in relation to information sharing between South Western Ambulance Service and Devon & Cornwall Police. This was illustrated by six issues that were revealed during the course of the evidence presented at inquest, I will address these in turn:

A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours.

As a part of training in relation to Right Care, Right Person, police officers are trained to dial 999 from the scene of incidents in which such medical support is needed. Any officers who ask the police control room to call an ambulance will be prompted to dial 999 themselves, unless there is a reason why they cannot. This enables SWAST to obtain information directly from the scene, conduct an accurate triage and advise police officers directly. In Mr Campbell’s case this would have also ensured that a triage was undertaken as soon as possible and a response category assigned, thereby eliminating the confusion as to whether an ambulance had been requested and also eliminating the resulting delay in an initial triage being undertaken.

The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate.

Both the police and SWAST control room staff are trained to ensure that they have asked for and received accurate information in the course of any calls held with one another. In the future this will ensure that that SWAST have a contact number for the scene of the incident.

Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.)

Due to the dynamic and constantly changing nature of call triage and ambulance service resource allocation it is not currently possible to provide any caller, including police officers, with an accurate ETA for responding resources. However, SWAST is investigating the potential to create a more accurate system and to this end has commissioned a new report from the Data Analytics and Information Team for “longest current waiting call in defined area by category” (or similar) with the intention that this information can lead to the development of a system that will be able to provide a longest estimated wait time for the area in which a call originated. Whilst this will have its limitations it will be more accurate than a snapshot ETA and provide the caller with an idea of demand in the area which they can factor into any decision making as to whether to convey the patient themselves. Unfortunately, this process is in its infancy and as such the potential development of any such system will take a significant amount of time before it is in a position to be used operationally.

In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached.

As stated above police officers are trained to dial 999 from the scene of incidents in which medical support is needed. This enables SWAST to discuss the ongoing plan with the officers on scene and thereby factor any such decisions into consideration of whether a call should be upgraded or an alternative pathway considered. In Mr Campbell’s case this may potentially have resulted in a clinician prioritising a call response, though it is unclear what effect such an upgrade would have had on the time an ambulance resource would have taken to arrive on scene.

Trust Headquarters Abbey Court Eagle Way Exeter Devon EX2 7HY

Tel: 01392 261500 Website: www.swast.nhs.uk

In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options.

We understand that Devon and Cornwall Police will be responding to this point.

The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial?

SWAST is working in collaboration with NHS England and system partners to improve system delays.

To assist with handover delays, a handover Standard Operating Procedure (SOP) was developed during November 2021 and introduced in late 2021. This has been reviewed and updated, including review against the agreed standards being undertaken with the acute Trust (RCHT) during December 2023/January 2024. The SOP supports robust management of delays, using four handover escalation levels. Local teams have worked with each hospital to agree the actions that they will take place at each level. The triggers for escalation have also been locally agreed, to allow a more responsive, tailored approach. The new approach includes an agreed area to implement an immediate handover for a patient where the Trust is unable to respond to an outstanding local Category 1 call within a reasonable timeframe.

SWAST continues to work closely with hospitals to improve the situation. In many cases, local operations teams meet with their local EDs on a daily basis. The regional NHSE team has set resolving delays as a key priority and SWAST were actively engaged in the NHSE Ambulance Handovers task and finish group over summer 2024. During 2024 they also developed a new tier of county level senior meetings between hospitals, commissioners, NHSE and SWAST. These meetings have provided a valuable opportunity for SWASFT to be part of the ICS conversations involved in the work to reduce delays. In addition to the above, there are number of actions taking place locally and across the Southwest, in terms of SWASFT, actions include:

• Maintaining a strong ‘Hear and Treat’ position, with onward referral, where appropriate, to other services such as NHS 111 or self-care.
• Maximising ‘See and Treat’ which again minimises the numbers of patients being transferred to ED, beyond which is necessary.
• Providing Hospital Ambulance Liaison Officer (HALO) cover in both the Royal Cornwall Hospital Trust and University Hospital Plymouth Trust Emergency Departments to support patient safety and crew welfare, promoting handover expedition and availability of crews to respond to patients within the community.
• The Trust’s Operations Delivery Centre minimise unavailability of resources, as much as possible, to increase the resources available to respond to patients.
• SWASFT continue to celebrate the use of the Care Co-ordination Hub in Cornwall and have co-located one of our specialists with a view to further optimise appropriate conveyance to ED. This was enhanced by the single point of access going live on 11 November 2024.
• Dynamic internal Mutual aid is utilised where possible (utilising Private Ambulance Provider resources on duty) to support areas of the Trust under most pressure. In effect this means moving some resources from one area to another to support response to patients in the pressurised area.
• The implementation of ‘Timely Handover Process’ - A process to instigate rapid handover if not undertaken within 90 minutes of arrival. This process went live at RCHT in February 2025 and we are already seeing sustained improvements in the average handover times.

SWAST is committed to collaborating with its emergency service colleagues and system partners in order to improve inter service communication which will in turn lead to greater information sharing during an incident and enable cross service strategic incident planning to occur more effectively, thereby reducing the likelihood of a situation like Mr Campbell’s occurring in the future.

Dear Sir,

INQUEST INTO THE DEATH OF LACHLAN CHARLES CAMPBELL

The Chief Constable of Devon & Cornwall Police, , is in receipt of the report dated 28 February 2025 that you have authored in relation to the above inquest in accordance with Regulation 28 of The Coroners (Investigations) Regulations 2013. For the remainder of this correspondence I will refer to this report as “the Regulation 28 report”.

The Chief Constable has asked me to respond to the concerns that you have raised in that report, on the basis that the issues of concern fall within my remit as the Assistant Chief Constable for the Devon & Cornwall Police portfolio for Crime, Justice and Vulnerability. I have also had operational oversight of the Devon & Cornwall Police response to Lachlan’s death for the majority of the period since he died. Accordingly, please treat this correspondence as the Chief Constable’s formal response to the Regulation 28 report.

Firstly, I want to express my sincere condolences on behalf of the Chief Constable, myself, and all in Devon & Cornwall Police, to Lachlan’s friends and family for their loss. This is a truly tragic case that should have been avoided.

Secondly, I want to thank you, both for the opportunity to respond to the concerns raised by you in the Regulation 28 report, and for the generous extension of time that you have afforded to us to provide this response. This has allowed us to give your concerns serious and thorough attention, and I am pleased to be able to report that we have been able to use the time to collaborate with the South West Ambulance Service Trust (SWAST) in respect of the Regulation 28 report, to seek to reassure you in respect of the concerns that you have raised as much as possible.

Assistant Chief Constable

Police Headquarters, Middlemoor, Exeter, Devon, EX2 7HQ

I will use the remainder of this correspondence to respond to each of the concerns that you have raised at point 2 of box 5 of the Regulation 28 report, adopting the same wording for what I hope will be your ease of reference.

“a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours.”; and

“b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate.”

I intend to respond to these points together as I believe that relatively recent changes to Devon & Cornwall Police working practices will address both points.

I understand that you are aware of the Right Care, Right Person (RCRP) initiative. By way of brief reminder, RCRP is an agreement between Devon & Cornwall Police, SWAST, and other relevant partners (most notably, healthcare providers) that sets out to ensure that individuals in need of medical attention are seen by the right professional as soon as possible. RCRP is relevant for the purposes of this inquest as it has seen Devon & Cornwall Police amend their working practices in areas that relate to the circumstances of the police’s involvement in the events preceding Lachlan’s death.

Specifically, there is now a triage process within the Devon & Cornwall Police control room which is used to assess which is the most appropriate agency to deal with an incident of concern that is reported to us. Following Lachlan’s death, we have included reports in relation to potentially drunk and incapable individuals in this triage process, in order to assess which such cases are for the police to address, and which should be addressed by another agency.

As a part of RCRP, if our police officers come across or attend an incident in respect of which they deem that there is a requirement for additional medical support, they are trained to telephone 999 from the scene. This is to seek to ensure that the 999 operator can liaise directly with the person who has the patient with them and can offer appropriate treatment, as well as allocating a resource to attend.

If our officers call for an ambulance through the police control room, they are asked if there is a reason they cannot do this themselves (such as the need to commence CPR, or other environmental factors). Police control room and SWAST personnel are trained to record all relevant information when contacting or otherwise liaising with SWAST.

“c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes, but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.)”

We understand that the SWAST will be addressing the issue of the ETA and target time with you directly in their response to the Regulation 28 report.

Ordinarily officers are not encouraged to use police vehicles to transport individuals in need of pressing medical attention to hospital. Our position is that the primary service for this must be SWAST as they are better equipped to manage the individual in question in transit, and / or to treat an individual when their condition declines. Police officers are trained in the use of the National Decision Model, which empowers them to risk assess specific scenarios, and (using this) as a last resort are able to make the decision to transport patients themselves to help save life if they consider this appropriate. This is an individual decision by the officer involved. This possibility continues to be reinforced during Devon & Cornwall Police first aid training.

“d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached.”

Devon and Cornwall Police understand that SWAST will factor police presence at a scene of someone needing medical attention into their triage / risk assessment process when determining whether to attend such an incident. If our officers are called to an urgent or potentially life-threatening incident, then they could be redeployed. Accordingly, Devon & Cornwall Police’s position is that this possibility should be factored into the aforementioned SWAST triage / risk assessment process.

The potential for redeployment is particularly acute given the relatively large geographic areas of Devon and Cornwall. Our officers are trained to carefully consider the risk of each situation and liaise with our control room in relation to redeployment decisions. If affected officers redeployed, our control room personnel are trained to ensure that SWAST are notified of the deployment.

“e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options.”

It is Devon & Cornwall Police’s expectation that our officers communicate any concerns of this type to their supervising officer (a sergeant, in the present case) at the time. Sergeants are able to make a decision to redeploy other police resources, including in liaison with an inspector and / or the Force Incident Manager (the officer in the control room who is responsible for overseeing the initial force response to incidents) as appropriate. In extreme circumstances, a more senior officer can be contacted by the control room for assistance and support in respect of redeployment. The Assistant Chief Constable with responsibility for local policing in Devon & Cornwall Police has reiterated this expectation in recent messaging to frontline personnel.

“f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (e.g. stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial?”

Devon & Cornwall Police would welcome any such provision, or indeed any initiative, which would allow police personnel to handover the care of a patient to medical professional as quickly as possible to both ensure that the patient is getting the right care, and the police personnel are returning to policing duties, as swiftly as possible. We would support any work in this area in order to maintain or improve our capacity to respond to policing incidents.

Conclusion

I hope that this response provides you with sufficient reassurance that Devon & Cornwall Police have taken the concerns raised by you in the Regulation 28 report seriously. Please do make contact with me if I can assist you with any of the contents of this correspondence.