Asthma attack death prompts review of emergency responses in Coventry
Coroner's report raises concerns about asthma management and ambulance availability
A coroner's report has been issued following the tragic death of Roman Barr from an asthma attack in Coventry on 14th December 2023, highlighting several concerns that may prevent future deaths.
The acting area coroner for Coventry, Linda Lee, outlined concerns about the emergency response and asthma management systems during Roman's critical illness.
Roman suffered an asthma attack and was taken home by his father, where he attempted to use a nebuliser, but without improvement.
Despite three calls to the ambulance service, Roman was assessed as Category 2, meaning no ambulance was available for several hours. This was due to delays in hospital handovers, significantly impacting emergency service capacity.
The report noted that clearer triage prompts, particularly regarding a patient's symptoms, could have resulted in Roman being categorised as Category 1, potentially leading to a faster ambulance response.
At one point, Roman displayed symptoms such as bluish lips, which were not clearly understood by his father during triage, resulting in crucial information not being conveyed.
Additionally, the report highlighted the risks faced by families transporting critically unwell patients themselves, as Roman suffered a cardiac arrest during the journey to the hospital. A collision involving the family vehicle led to his mother sustaining serious injuries.
The coroner further expressed concerns about salbutamol inhaler overuse. Evidence showed Roman had been using his inhaler more frequently than recommended, pointing to poorly controlled asthma. The family was reportedly unaware of the clinical significance of increased inhaler use.
Following Roman's death, his GP practice implemented measures to recognise and manage excessive inhaler use, such as automatically booking patient reviews and liaising with pharmacists.
Despite a Drug Safety Update in 2025 highlighting the risks of increased salbutamol use, the report suggests these risks are not fully appreciated by patients and healthcare providers.
The report has been sent to health authorities including the Secretary of State for Health and Social Care and NHS England, with recommendations to address the identified issues and prevent similar tragedies in the future.
The coroner has requested responses to the report by 29th April 2026, detailing actions proposed or taken to address the concerns raised.