Source · Prevention of Future Deaths

Lachlan Campbell

Ref: 2025-0115 Date: 28 Feb 2025 Coroner: Andrew Cox Area: Cornwall and the Isles of Scilly Responses identified: 1 / 1 View PDF

Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, which an expert stated would have prevented their death.

Date 28 Feb 2025

56-day deadline 25 Apr 2025 est.

Responses identified 1 of 1

Alcohol, drug and medication related deaths Emergency services related deaths (2019 onwards) Police related deaths

Coroner's concerns

AI summary

Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, which an expert stated would have prevented their death.

View full coroner's concerns

1) Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital

Mr Campbell had a history of recreational drug misuse with previous non-intentional overdoses. On 31/10/22, he travelled by train from St Austell to St Erth to visit a friend. While with his friend, it is understood he took drugs as he then became unconscious/fell asleep. His friend took him back to the railway station to catch the last train back to St Austell. At approximately 00:15 on 1/11/22, a bus driver saw Lachlan outside the train station. He was on his knees, bent forwards with his head on the ground in what was described as a ‘prayer position.’ A concern for welfare call was made to the emergency services. A police response was delayed, understandably, owing to a higher priority call being received in relation to an incident of potential domestic violence to which the Officers were diverted. The Officers arrived with Lachlan shortly after 01:00. At 01:42, a request was made for an ambulance. This resulted in a Category 2 disposal requiring an attendance within an average of 18 minutes with 90% of incidents to be attended upon within 40 minutes. The Officers left Lachlan at the scene understanding that an ambulance would arrive shortly. They had initially wondered if Lachlan was the male involved in the incident of Domestic Violence but once it was recognised he was not and that the suspect was still at large, Information Classification: CONTROLLED there was a concern to apprehend the suspect to safeguard the female victim. After a downpour, Officers returned to the scene shortly before 05:00 to find Lachlan in much the same position but now soaked through. They discussed their options and the risk of hypothermia. A chasing call was made to the ambulance service and it was identified there were still 13 Category 2 or higher cases ahead of them. No ETA was provided. The Officers decided to watch Lachlan from their car. At approximately 06:00, his breathing became agonal. The outstanding call was upgraded to Category 1. An ambulance crew arrived on scene at 06:15 just over 4.5 hours after the first call against a target time of 18 minutes. The situation could not be retrieved and resuscitation efforts were abandoned as futile at 07:45. An expert, Professor Lyon, opined that had Lachlan been conveyed to hospital in a timely manner, his death would have been avoided. At inquest, the jury heard from who works in the patient safety team at South West Ambulance Service Trust. She told us: On 31 October 2022, there were over 730 hours of ambulance time lost to handovers that were over the 15 minute target at RCHT, Derriford Hospital and North Devon District Hospital (NDDH). This is equivalent to approximately 66 DCA ambulance shifts lost to delays (based on a standard 11 hour shift). At RCHT, the average handover time per patient was one hour, 55 minutes and 57 seconds. At Derriford, the average handover was seven hours, five minutes and four seconds. At NDDH, the average handover was two hours, 12 minutes and 27 seconds. These events happened some time ago and I wanted to know if the situation had improved in the meantime. I was advised that in January 2025, the average handover time per patient at Royal Cornwall Hospital was just under 2 hours 15 minutes, in other words, the situation has worsened. This gives rise to an obvious concern and it is in these circumstances that I write to you.

May I also take the opportunity to bring to your attention that I have written Preventing Future Death (PFD) reports with the same concerns to two previous Ministers. I am aware some of my colleagues have additionally written with the same concerns.

Included in the Reply to my first PFD was a response from , the Chief Executive of the local ICB (to whom this is copied) which set out, most helpfully, a plan of action over the coming years to relieve the current pressures. It is entirely a matter for you how you choose to reply to this report but you may feel an update from Ms Shields would be informative.

2) Information Sharing There is a concern also about how information was shared between the police and ambulance service. Both police officers said that, had they been aware of the extent of ambulance delays, Information Classification: CONTROLLED they may have considered other options, notably, conveying Lachlan to hospital in a police car. I am writing separately to SWAST and Devon & Cornwall Police in this regard and your reply does not need to address this concern.

Responses

1 respondent

Department of Health and Social Care Central Government

25 Apr 2025 PDF

Action Planned

The government acknowledges concerns around emergency service pressures and is working with NHS England to address them, with a focus on ambulance response times and handover delays; the upcoming 10-Year Health Plan will set out radical reforms for the NHS and address these issues. (AI summary)

View full response

Dear Mr Cox,

Thank you for the Regulation 28 report of 28 February sent to the Secretary of State about the death of Lachlan Campbell. I am replying as the Minister with responsibility for urgent and emergency care.

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Campbell’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.

The report raises concerns over emergency service pressures, including ambulance response times and handover delays, and information sharing between police and ambulance emergency services. I recognise the concerns raised with health and care delivery in the region, which align with representations from local members of parliament. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand that the South Western Ambulance Service NHS Foundation Trust is also writing to you separately to address the matters of concern you have raised for them which include the issues with information sharing.

The Government is clear that patients should expect and receive the highest standard of service and care from the NHS. The Government also accepts that the NHS’s urgent and emergency care performance has been below the high standards that patients should expect in recent years.

We have been honest about the challenges facing the NHS and we are serious about tackling the issues; however we must be clear that there are no quick fixes.

To start with, in the Autumn Budget, the Government announced an extra £22.6 billion in day-to-day spending in 2025/26 for the NHS compared to 2023/24, to help deliver 40,000 extra appointments a week and cut NHS waiting times. An additional £3.1bn further capital investment over 2 years will provide the highest real-terms capital budget since before 2010.

We recognise that investment alone won’t be enough and are determined that it must go hand in hand with fundamental reform. On 5 December 2024, the Government published the Plan for

Change (available here: https://www.gov.uk/government/publications/plan-for-change), that set the mandate for the direction of change with clear milestones in five national missions, including building an NHS that is fit for the future.

On 30 January 2025 the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care.

On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving the average Category 2 ambulance response times to no more than 30 minutes across 2025-26, and practical actions focused on reducing avoidable ambulance dispatches and conveyances. NHS England is also working with systems to reduce ambulance handover delays, working towards delivering hospital handovers within 15 minutes with joint working arrangements that ensure no handover takes longer than 45 minutes. I recognise that this will be challenging in the South West where handover delays have been much longer that this, however, I am determined that we tackle there these long delays and the outliers regionally. Nationally, in February 2025, average national handover times were 34 minutes and 39 seconds, an improvement of 31 seconds from the previous year.

In June 2025, to accompany the additional investment in the NHS, the Government will publish its 10-Year Health Plan which will set out the radical reforms for the NHS. The health plan will focus on ensuring three big reform shifts in the way our health services deliver care. First, from ‘hospital to community’ to bring care closer to where people live. Second, from ‘analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third from ‘sickness to prevention’ so people spend less time with ill-health by preventing illnesses before they happen. The reforms will support putting the NHS on a sustainable footing so it can tackle the problems of today and the future.

In addition, later in the Spring we will also set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to further improve services during 2025/26.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Report sections

Investigation and inquest

On 27 February 2025, I concluded a four-day jury inquest into the death of Lachlan Charles Campbell who died on 1 November 2022 at the age of
51.

The jury recorded the cause of death as:

1a Bronchopneumonia, hypothermia and Combined Drug Intoxication II Fatty Liver Disease

The jury recorded a narrative conclusion of a drug-related death contributed to by neglect. Responding police officers missed opportunities to provide sufficient care to Mr Campbell as they did not provide shelter, warmth or appropriate medical attention. Delays in responding services resulted in a failure to provide Mr Campbell with timely care which contributed to his death.

Circumstances of the death

The jury recorded the following:

Despite appropriate treatment by paramedics and medical professionals, Mr Campbell died in hospital due to cardiac arrest detailed in section 2 at 7:45am in Royal Cornwall Hospital, Truro. a) How is it that an ambulance has not attended Mr Campbell until 6:15am after one had been requested by police at 01:42? Operational requirements on South West Ambulance Service Trust (SWAST). Handover delays at Royal Cornwall Hospital and poor communication between police and ambulance services. b) Were the actions taken by police officers at the scene appropriate? If not, what should have been done and by when? Information Classification: CONTROLLED Actions by police officers were not appropriate. The primary survey by police officers was inadequate at first attendance. At second attendance, patient should have been conveyed to hospital. Advice should have been taken from supervisory officer. To what extent have other duties been a factor? Other duties delayed initial response but were not a factor in relation to second response. c) Are any failings gross failing? Yes, as police officers didn't provide shelter, warmth or appropriate medical attention to Mr Campbell and this amounted to serious failings. d) On a balance of probabilities had different actions been taken at a timely manner would Mr Campbell's death have been avoided? Yes, if actions had taken place such as conveying Mr Campbell to hospital at an appropriate time or more care had been taken to provide shelter and warmth as hypothermia could have been avoided.

Copies sent to

and , the two former police officersChief Constable of Devon & Cornwall policeSWAST

Similar PFD reports

Shared signals

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Report details

Reference: 2025-0115
Date of report: 28 February 2025
Coroner: Andrew Cox
Coroner area: Cornwall and the Isles of Scilly

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 25 Apr 2025 (estimated).

Sent to

Department of Health and Social Care

Part of a series

2 reports

2025-0114 All responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.