Dorothy Hoyberg
14 Jan 2026 · Coroner Melanie Lee · Inner North London
This report repeats 4 earlier warnings. See the linked reports.
The coroner's concerns
1. inadequate welfare monitoring of patient
“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 [the deceased] 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 [the deceased] 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 [the deceased] within two hours but it took five and half.”
2. systemic capacity shortfall in ambulance services
“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.”
3. operational pressure level REAP Level 4
“LAS are currently operating at REAP Level 4.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
This report
“Demand outstripped capacity. An ambulance should have reached [the deceased] within two hours but it took five and half.”
Closely relatedConfidence 0.90 · high
Earlier report
“The ambulance service was called again at 23.45 hours and the call was again coded as a Category 3 call.”
This report
“An ambulance should have reached [the deceased] within two hours but it took five and half.”
Identical hazardConfidence 0.90 · high
Earlier report
“notwithstanding the national target for Category 3 999 calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes.”
This report
“Multiple attempts were made to find an ambulance resource for [the deceased] but LAS were unable to meet targets for Category 3 patients and were struggling to meet targets for Category 2 patients.”
Identical hazardConfidence 0.90 · high
Earlier report
“SCAS has been at REAP 3 or above for 90% of this time period. They have been constantly at REAP 4 since 9 October 2024.”
This report
“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.”