Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0115, written 28 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Feb 2025 |
|---|---|
| Reference | 2025-0115 |
| Deceased | Lachlan Campbell |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Alcohol, drug and medication related deaths · Emergency services related deaths (2019 onwards) · Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Information Classification: CONTROLLED
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
, MP, Secretary of State for Health & Social Care.
1 CORONER
I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall
and the Isles of Scilly.
2 CORONER’S LEGAL POWERS
3
I make this report under paragraph 7, Schedule 5, of the Coroners and
Justice Act 2009 and regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013.
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.
4 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?
1
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.
5 CORONER’S CONCERNS
During the course of these inquests, the evidence has revealed matters
giving rise to concern. In my opinion there is a risk that future deaths will
occur unless action is taken. In the circumstances it is my statutory duty
to report to you.
The MATTERS OF CONCERN are as follows.
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,
2
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
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.
who works in the patient
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,
3
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.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe you have the power to take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 26 April. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise, you must explain
why no action is proposed.
8 COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:
- The family of Mr Campbell
-
- The Chief Constable of Devon & Cornwall police.
- SWAST.
and
, the two former police officers
I am also under a duty to send the Chief Coroner a copy of your
response.
The Chief Coroner may publish either or both in a complete or redacted
or summary form. He may send a copy of this report to any person who
he believes may find it useful or of interest.
I have sent copies of this letter to
& Isles of Scilly ICB,
and
avoidance of any doubt, I do NOT require replies from them, but I felt they
would find it helpful to be sighted on this exchange.
, Medical Director at Royal Cornwall Hospital. For the
, Chief Executive Cornwall Council
, Chief Executive Cornwall
You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the
Chief Coroner.
[DATE] [SIGNED BY CORONER]
9
28.2.25
4
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 25 April 2025 Our ref: HM Coroner Andrew Cox Cornwall Coroner’s Service Pydar House Pydar Street Truro Cornwall TR1 1XU By email: 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. Yours sincerely, MINISTER OF STATE FOR HEALTH
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