Lachlan Campbell

Assistant Chief Constable 
Police Headquarters, Middlemoor, Exeter, Devon, EX2 7HQ 

Mr Andrew Cox                                                                                             22 May 2025 
His Majesty’s Senior Coroner for                                                                                                  
Cornwall, and the Isles of Scilly 
The Coroners Court 
Pydar House  
Pydar Street 
Truro 
TR1 1XU 

Coroner’s Ref: 

Dear Sir, 

INQUEST INTO THE DEATH OF LACHLAN CHARLES CAMPBELL 

, is in receipt of the 
The Chief Constable of Devon & Cornwall Police, 
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. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 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. 

Yours faithfully  

Assistant Chief Constable - Crime, Justice and Vulnerability 
Devon& Cornwall Police

Trust Headquarters 
Abbey Court 
Eagle Way 
Exeter 
Devon 
EX2 7HY 

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

Our ref:    
Your ref: 

Private & Confidential 

20 May 2025 

Mr Andrew Cox  
HM Senior Coroner for Cornwall and the Isles of Scilly  
Pydar House  
Pydar Street  
Truro  
Cornwall 
TR1 1XU 

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. 

Yours sincerely 

Executive Medical Director