South Western Ambulance Service NHS Foundation Trust
NHS / Health Body
Action Taken
Police officers are being trained to dial 999 from the scene for medical support, and SWAST has implemented a new communication pathway to improve inter-agency information sharing. SWAST is implementing a Timely Handover Process at RCHT to instigate rapid handover if not undertaken within 90 minutes of arrival. (AI summary)
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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.
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.