Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0570, written 11 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Nov 2025 |
|---|---|
| Reference | 2025-0570 |
| Deceased | Liliane Bowden |
| Coroner | Henry Charles |
| Coroner area | Hampshire, Portsmouth and Southampton |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | South Central Ambulance Service NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. 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. Ambulance Service, provided me with a detailed explanation. It is right to immediately acknowledge that the ambulance service, South Central 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Henry CHARLES HM Assistant Coroner for Hampshire, Portsmouth and Southampton Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
South Central Ambulance Service NHS Trust Unit 7 & 8 Talisman Business Park Talisman Road Bicester, Oxon OX26 6HR PRIVATE AND CONFIDENTIAL Mr Henry Charles, HM Assistant Coroner for Hampshire, Portsmouth and Southampton 17th December 2025 Dear Mr Charles, I am writing to you in response to the concerns that you highlighted to the Trust following the inquest hearing into the sad death of Liliane Andree Bowden that concluded on 24th October 2025. Thank you for providing us with the opportunity to respond to your concerns. At the outset I would like to offer my personal condolences to Mrs Bowden’s family and friends. To confirm, your Regulation 28 report relates to concerns regarding delays that the ambulance service experience when ambulance crews are handing over patients at local hospital Trusts and the impact this has on our ability to respond to patients waiting in the community. Your officer confirmed that you did not issue a report to the local hospital Trust because you wanted to receive a full appraisal of the difficulties SCAS and more importantly, patients face upon arrival at Queen Alexandra Hospital. It is regretful that a Regulation 28 report was issued to this Trust when the source of the concern relates to a different organisation, and it is they who ultimately have the power to take action to resolve the concerns. Moving forward, we would be grateful if HM Coroner could write to the appropriate organisation in line with paragraph 9 of Chapter 16 of the Chief Coroner’s Bench Book. Response to concerns HM Coroner will be aware that the issue of ambulance response times being affected by hospital handover delays is not a matter that is isolated to Hampshire. In response to the problem, in January 2023 NHS England asked London hospitals to support the timely handover of patient care and the release of ambulance crews from London Ambulance Service within a maximum of 45 minutes where it is safe and appropriate to do so. South Central Ambulance Service is commissioned by 2 Integrated Care Boards (ICB); Buckinghamshire, Oxfordshire and Berkshire ICB and Hampshire and Isle of Wight ICB. In September 2024 both ICB’s agreed that they would also implement the now nationally recognised process of “Release to Respond” in their respective geographical areas. This process was fully implemented in all hospitals in Hampshire by the end of 2024 and resulted in significant improvements in our response times to patients waiting in the community. To demonstrate the impact of the “Release to Respond” process, in September 2024 our ambulance crews spent over 4,072 hours waiting longer than the 15 minute national target to handover patients at Queen Alexandra Hospital alone and over 8,224 hours at all hospitals within the geographical area we cover. By September 2025 the figure for Queen Alexandra Hospital had fallen significantly to just under 319 hours and the total for all hospitals was just over 2,538 hours. To evidence the effect the reduced wait times at hospitals, among other initiatives, has had on our ability to attend to patients in the community, despite nearly 1,000 extra incidents taking place in the month of September 2025 compared to September 2024, we reduced our Category 2 response times by over 8 minutes. HM Coroner has asked for details of difficulties the Trust experiences when arriving at Queen Alexandra Hospital. Like all the acute hospital Trusts in our area, we maintain effective working operational relationships with senior teams at Queen Alexandra Hospital and good professional relationships at all levels between our organisations, including the Chief Executives who have worked together with system partners to reduce the amount of time ambulances are delayed handing over their patients. This includes operational leaders working closely together face to face at the Emergency Department and participating in regular operational tactical calls during times of increased demand. The Trust is extremely grateful to our Acute Trust Partners for their continued willingness to work together for the benefit of our mutual patients. of Ambulance Chief Executives The SCAS and PHT CEO’s jointly presented the work our teams had carried out the excellent Association achievements in reducing handover delays. Each year we are required to submit an annual plan to NHS England on how we will deliver our services. For 2025/26, our plan included average handover times at hospitals across our geography. Each hospital was asked to sign up to the improvement and for the year to date we have delivered on or below plan across our region. There is a requirement within the next 3 years for all hospitals to reach the 15 minute handover target and have not delay over 45 minutes. We will continue to work with all hospitals to deliver these targets and we will submit our plan to NSHE in February for 26/27. showcase the to to Commissioning HM Coroner may targets we have to understand been commissioned to provide. I have enclosed a table providing details for this financial year with this letter. the response it useful find I hope that this letter has adequately addressed the concerns that you have raised. Should you wish to discuss these matters further, please contact Jennifer Saunders, Head of Legal Services at SCAS who will be able to facilitate this. Yours sincerely, Chief Executive Enc. Commissioned targets 2 Category ARP target April 25 May 25 June 25 July 25 Aug 25 Sept 25 Oct 25 Nov 25 Dec 25 Jan 26 Feb 26 March 26 00:07:00 00:08:33 00:08:52 00:08:45 00:09:04 00:08:57 00:08:52 00:08:59 00:08:48 00:08:51 00:08:47 00:08:51 00:08:35 00:15:00 00:17:58 00:18:40 00:18:23 00:19:07 00:18:51 00:18:39 00:18:55 00:18:32 00:18:37 00:18:28 00:18:37 00:18:03 00:18:00 00:26:19 00:30:32 00:28:46 00:33:32 00:31:41 00:30:21 00:32:05 00:29:37 00:30:10 00:29:16 00:30:10 00:26:44 00:40:00 00:51:00 00:59:40 00:56:02 01:05:51 01:02:02 00:59:18 01:02:51 00:57:48 00:58:55 00:57:05 00:58:55 00:51:52 02:00:00 04:25:39 05:37:39 05:07:26 06:28:54 05:57:18 05:34:30 06:04:06 05:22:09 05:31:22 05:16:10 05:31:22 04:32:52 03:00:00 05:22:51 06:43:52 06:09:52 07:41:31 07:05:59 06:40:19 07:13:38 06:26:26 06:36:47 06:19:42 06:36:47 05:30:59 Category 1 mean Category 1 90th percentile Category 2 mean Category 2 90th percentile Category 3 90th percentile Category 4 90th percentile
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