Liliane Bowden: Prevention of future deaths report – 2025-0569
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Date of report: 11/11/2025
Ref: 2025-0570
Deceased name: Liliane Bowden
Coroner name: Henry Charles
Coroner Area: Hampshire, Portsmouth and Southampton
Category: Emergency services related deaths (2019 onwards)
This report is being sent to: SCAS Legal Services
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1 SCAS Legal Services | |
| 1 | CORONER I am Henry CHARLES, HM Assistant Coroner for the coroner area of Hampshire, Portsmouth and Southampton |
| 2 | CORONER’S LEGAL POWERS 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. |
| 3 | INVESTIGATION and INQUEST On 26 September 2024 I commenced an investigation into the death of Liliane Andree BOWDEN aged 90. The investigation concluded at the end of the inquest on 24 October 2025. The conclusion of the inquest was that: On 26 September 2024 I commenced an investigation into the death of Liliane Andree BOWDEN aged 90. The investigation concluded at the end of the inquest on 24 October 2025. A narrative conclusion was reached, set out in the circumstances of death, below. |
| 4 | CIRCUMSTANCES OF THE DEATH On 23rd September 2024 Mrs Liliane Andree Bowden sadly died at Oak View Care home, 47-49 Beach Road, Hayling Island, Hampshire by reason of bronchopneumonia. She had suffered from vascular dementia and on 10th and 11th September 2024 had suffered falls. Although bronchopneumonia was the direct cause of death the contributions of the vascular dementia and, latterly, the falls, were very substantial. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) During the course of the inquest evidence revealed matters giving rise to concern, relating to ambulance delay on a callout just under two weeks prior to Liliane Andree Bowden’s death. It is right to immediately acknowledge that the ambulance service, South Central Ambulance Service, provided me with a detailed explanation. In this instance the initial call was at 11.40 with a second call at 13.29, a third call at 15.53 and a fourth call (seeking an estimated time of arrival of the ambulance) at 17.29. Liliane, 90, had fallen. Category 3 was called at around,13.29, category 3 was confirmed at around 16.26. A specialist paramedic was at the deceased’s bedside at 17.35 and an ambulance was requested at 18.00. At that time there was demand on the ambulance service (the Enhanced Patient Safety Procedure had been in place from 23.15 the previous night until 11.35 on the day of the call) and there were significant hospital handover delays at hospital: apparently the call centre log records up to 25 ambulances held outside hospital waiting to hand over patients that afternoon, at 18.10 there were 8 ambulances at hospital waiting to hand over patients, one of which had been waiting for 4 hours and 40’ to hand over their patient. It was estimated that an ambulance would not be available for seven hours. In the event an ambulance eventually arrived at 23.30. The response timeframe for a category 3 call is for at least 9 out of 10 calls to be within 120’. It follows that although the Enhanced Patient Safety Procedure was activated the previous night, following deactivation of the Enhanced Patient Safety Procedure a large contingent of ambulances was taken out of action for substantial periods by handover issues. Quite apart from a repetition of such circumstances potentially affecting category 1 and 2 calls, there must be significant risk in the case of an elderly and/or vulnerable person in Category 3 having an extended wait, particularly if there has been a head injury, as is often the case. 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. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 January 06, 2026. 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 [REDACTED] I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. 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. |
| 9 | Dated: 11/11/2025 Henry CHARLES HM Assistant Coroner for Hampshire, Portsmouth and Southampton |