Dorothy Hoyberg
PFD Report
All Responded
Ref: 2026-0019
All 1 response received
· Deadline: 11 Mar 2026
Response Status
Responses
1 of 1
56-Day Deadline
11 Mar 2026
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
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. In my opinion there is a risk that future deaths will occur unless action is taken.
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. In my opinion there is a risk that future deaths will occur unless action is taken.
Responses
The Department of Health and Social Care acknowledges ambulance service pressures and refers to the 2025/26 Urgent and Emergency Care Plan and the 10-Year Health Plan, which commit to reducing ambulance response times. The London Ambulance Service maintains a performance recovery plan, including implementing dedicated clinical support linked to dispatch to prioritise incidents.
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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.
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.
Report Sections
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.
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 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.
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 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.
Copies Sent To
London Ambulance Service
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.