Liliane Andree BOWDEN · Prevention of Future Deaths report

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.

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.

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.