Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0019, written 14 Jan 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Jan 2026 |
|---|---|
| Reference | 2026-0019 |
| Deceased | Dorothy Hoyberg |
| Coroner | Melanie Lee |
| Coroner area | Inner North London |
| Category | Alcohol, drug and medication related deaths · Emergency services related deaths (2019 onwards) |
| Organisation named | London Ambulance Service NHS 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: Prevention of Future Deaths report
Dorothy Margaret Hoyberg (died 19 June 2025)
THIS REPORT IS BEING SENT TO:
1. Secretary of State for Health & Social Care
1
CORONER
I am: Melanie Sarah Lee
Assistant Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and The Coroners (Investigations)
Regulations 2013, regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 26 June 2025 an investigation was commenced into the death of
Dorothy Margaret Hoyberg age 70 years. The investigation concluded
at the end of the inquest on 12 January 2026. I made a determination at
inquest that Dorothy’s death was drug related.
4
CIRCUMSTANCES OF THE DEATH
On 19 June 2025 Dorothy Margaret Hoyberg called 999 for the first
time at 08:08 hours. She reported a one week history of a gastric bug
and worsening severe pain in the top of her leg since the previous day.
A Category 5 disposition was reached and she was advised to call the
NHS 111 service. Dorothy did call 111 at 08:27, reporting lower back
pain radiating into her groin which was now affecting her breathing.
They triaged her as requiring a Category 3 face to face response within
2 hours. This was sent electronically to the LAS dispatch team at 09:24.
Dorothy’s call was reviewed by a paramedic at 09:28 who confirmed
the need for a Category 3 ambulance within 2 hours.
On that day LAS were operating at REAP Level 4 (extreme pressure).
Multiple attempts were made to find an ambulance resource but LAS
were unable to meet targets for Category 3 patients and were
1
struggling to meet targets for Category 2 patients. A welfare call back
was made at 10:06 hours. At 10:22 a neighbour called 999 at Dorothy’s
request. He reported her moaning and groaning which he heard again,
along with a commotion, at 13:00 hours. A welfare call was made at
10:25 when Dorothy advised worsening abdominal pain going into her
leg. The call was re-triaged but the disposition remained a Category 3
ambulance. There is nothing to suggest any errors in the Category 3
disposition. Ongoing attempts were made to find a resource. At 12:25
the last welfare check was made. After this, the demand on LAS was
so high that there was no capacity to make any further call backs.
At 14:40 a double crewed ambulance was dispatched and arrived at
Dorothy’s home at 15:03. On arrival, they found Dorothy deceased. At
post-mortem, the cause of her leg and abdominal pain could not be
ascertained but toxicology revealed elevated levels of morphine and
methadone. Dorothy was known to have a long standing history of
substance misuse or though as far as her family were aware, she had
been stable on methadone for some time.
5
CORONER’S CONCERNS
During the course of the inquest, the evidence 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.
On 19 June 2025 London Ambulance Service (LAS) were operating at
REAP Level 4 (extreme pressure) and by 9am that day, targets were
being breached. Multiple attempts were made to find an ambulance
resource for Dorothy but LAS were unable to meet targets for Category
3 patients and were struggling to meet targets for Category 2 patients.
Welfare calls were made to Dorothy until 12:25 at which point the
demand on LAS was so high that there was no capacity to make any
further welfare calls. Ideally welfare calls should have been made at least
every 30 minutes but it was necessary for LAS to prioritise demand and
deploy clinicians where they were most needed. Demand outstripped
capacity. An ambulance should have reached Dorothy within two hours
but it took five and half.
I heard evidence that this is a pan-London problem, and it does not
appear to be restricted to London. The demand on ambulance services
is increasing and the number of patients requiring their services is
increasing. Ambulance services are under extreme pressure and this is
causing a systems challenge and long delays for patients.
LAS are currently operating at REAP Level 4.
2
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 that your organisation has 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 11 March 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 following.
• Family of Dorothy Hoyberg
• London Ambulance Service
• HHJ Alexia Durran, the Chief Coroner of England & Wales
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 other 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.
9
DATE SIGNED BY ASSISTANT CORONER
14 January 2026
3
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 HM Coroner Melanie Sarah Lee Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 09 March 2025 Dear Ms Lee, Thank you for the Regulation 28 report of 14th January, 2026 sent to the Secretary of State / the Department of Health and Social Care about the death of Dorothy Margaret Hoyberg. I am replying as the Minister with responsibility for Care. Firstly, I would like to say how saddened I was to read of the circumstances of Dorothy’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. In preparing this response, my officials have made enquiries with NHS England and the Care Quality Commission to ensure I can address your concerns. NHS England and the Department of Health and Social Care recognise the significant pressures across urgent and emergency care services, including ambulance services. I recognise that this falls below the standards that patients need, expect and deserve. The Government is committed to turning this around and setting out clear actions which improve the quality and responsiveness of ambulance services. To prioritise and improve the quality and timeliness of patient care, the Department of Health and Social Care and NHS England published the 2025/26 Urgent and Emergency Care Plan (June 2025) and the 10Year Health Plan for England: Fit for the Future (July 2025). The Urgent and Emergency Care Plan commits to reducing mean ambulance response times for Category 2 patients by over 14%, to 30 minutes and improving the clinical validation of Category 3 and 4 calls. To achieve this, we recognise we will need to make improvements to patient flow through the whole system, and the plan outlines a set of priority actions to support systems to maximise patient flow, including: • continuing to reduce wait times for patients requiring an ambulance • eliminating prolonged handover delays, ensuring no hospital handover exceeds 45 minutes improving timeliness of care in hospitals • tackling delays in patient discharge • • expanding access to urgent care in primary, community, and mental health settings More than £370 million of capital funding has been allocated nationally to support implementation, including £250 million of capital budget to continue the expansion of co- located urgent treatment centres and same day emergency care, and £75 million capital funding for new ambulances. The 10 Year Plan for England also sets a clear trajectory towards shifting from treatment to prevention, reducing overall demand for urgent care. NHS England actions NHS England continues to work closely with commissioners, Integrated Care Boards, acute providers, and ambulance services, including London Ambulance Service, to support delivery of stretching but achievable plans aligned with operational priorities. The risks associated with community waits for ambulances have been discussed at national forums to support shared understanding and coordinated action across urgent and emergency care pathways on measures such as implementing the 45-minute maximum handover requirement; expanding urgent community care provision; reducing length of stay; and supporting timely patient discharge. These measures are designed to maintain patient flow, reduce emergency department crowding and facilitate prompt ambulance handovers. In 2025/26, all ambulance services received national growth funding to support activity levels and incentivise service improvement. Performance improvements have been observed in LAS, between January 2025 and January 2026: • • • • the average Category 1 response time improved from 07:20 to 07:02, the 90th centile Category 1 response time improved from 12:42 to 12:01, the average Category 2 response time improved from 35:28 to 32:23, the 90th centile Category 2 response time improved from 01:18:25 to 01:09:43, In October 2025, NHS England published the Medium-Term Planning Framework – Delivering Change Together 2026/27 to 2028/29. This framework sets out further ambitions for ambulance response times, including improving average Category 2 response times to 25 minutes in 2026/27, and achieving by the end of 2028/29 the constitutional standard of an 18minute average Category 2 response time, with 90% of calls responded to within 40 minutes. London Ambulance Service Trust Actions The LAS has introduced multiple processes to mitigate the issue of hospital handover delay for example: directing crews conveying patients towards hospitals with greater capacity and cohorting patients at hospitals (two or three staff taking responsibility for additional patients, so that other crews can become available for calls more quickly) where necessary. The Trust is currently in the middle of its five-year strategy (2023-2028). This strategy aims to forge closer links between Primary and Acute care sectors and Local Authorities, ensuring the right care is provided at the right time, including the development and referral to alternative care pathways avoiding the need to convey to hospital when appropriate. It is intended to align with the priorities of these organisations to improve the care, health and wellbeing of the populations served, focusing on outcomes and quality. The LAS recognises the risk to patient safety caused by response delays and is committed to reducing delays. The LAS maintains a performance recovery plan, which is regularly updated in response to changes in the demand profile and system pressures. This includes the implementation of dedicated clinical support linked to dispatch to identify incidents where allocation of a clinical resource may need to be prioritised. Care Quality Commission Actions The Care quality Commission (CQC) are sorry to hear of the death of Ms Hoyberg. CQC have added discussion of this Regulation 28 report to the agenda for the next quarterly engagement meeting with the trust for discussion and follow up of any action taken by the trust. CQC have quarterly engagement meetings with London Ambulance Service NHS Trust. The CQC have noted to me that the Trust are proactive and transparent in their engagement with them, reaching out to the local inspection team when they become aware of any inspections of urgent and emergency care departments to share information about partnership working. CQC have a key named contact at the Trust. CQC are aware of the pressures ambulance trusts across the country are experiencing. As reported in their 2024/25 State of Care Report, demand for ambulances grew 2.2% in comparison with 2023/24 data. We recognise that in an emergency, waiting a long time can be extremely frustrating and distressing for people, and can potentially affect their outcomes 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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