Roman Barr

Ms Linda Lee 
Acting Coroner 
Coroners Area of Coventry 
Manor House Drive 
Coventry 
CV1 2ND 

13 May 2026 

Dear HM Acting Coroner, Linda Lee, 

Regulation 28 Report following the death of Mr Roman Louis BARR  

Thank you for bringing the Regulation 28 Report to our attention following the 
inquest into the death of Mr Roman Louis BARR who died on 14 December 2023 
after suffering an asthma attack. Mr Barr died at University Hospital Coventry after 
being brought to the hospital by his parents. We acknowledge the concerns you 
have raised and appreciate the opportunity to respond.  

We would like to express our sincere condolences to Mr Barr’s family and loved 
ones following his death in such tragic circumstances.  

We note your Regulation 28 report was addressed to multiple organisations. This 
response is prepared solely on behalf of the Care Quality Commission (CQC) as far 
as I am able and relates to the role of CQC and our regulatory work with those 
organisations we regulate. 

We have noted the matters of concerns listed below in respect of those 
organisations involved in his care: 

1.  Limited awareness of salbutamol overuse 

Evidence showed that patients and families may not appreciate the clinical 
significance of increased use of the blue (salbutamol) inhaler or its association 
with poorly controlled asthma. 

2.  Identification and follow-up of reliever overuse 

Evidence showed that excessive or repeated requests for salbutamol inhalers 
may not be reliably identified within existing systems, and there may be no 
consistent process for follow-up when such patterns occur, meaning deteriorating 
asthma may go unrecognised. 

 
 
 
 
 
 
 
 
 
 
 
 
 We have given consideration to points 1 and 2 above. We note from evidence 
provided to the Coroner by Mr Barr’s GP that actions have been taken at that 
practice to consider how to more effectively monitor potential overuse of inhalers and 
ensure patients and families are aware of the risks therein.  

We note issues with overuse of asthma relieving medicine is in line with the 
Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update 
(DSU): Short-acting beta 2 agonists (SABA) (salbutamol and terbutaline): reminder 
of the risks from overuse in asthma and to be aware of changes in the SABA 
prescribing guidelines, 24 April 2025. We have written internally to our Chief 
, CBE, 
Inspector of Primary Care and Community Services, 
to ask her to remind colleagues and the wider community in primary care to ensure 
assessment of general practices includes reference to the MHRA DSU when 
conducting our regulatory work.  

3.  Ambulance handover delays affecting emergency availability 

Prolonged ambulance handover times at local hospitals were a significant factor 
in no ambulance being available at the time help was sought, reducing 
emergency response capacity during periods of high demand. 

We have given consideration to point 3 above. In inspections of NHS Ambulance 
Services across England in recent years, we have had cause to take enforcement 
action where ambulance services are unable to meet response times for those 
patients who are critically unwell – typically those, as with Mr Barr, who would meet 
the category 1 or 2 threshold for requiring an emergency ambulance in a mean 
average time of 7 or 18 minutes or less respectively.  

This includes taking regulatory action taken against West Midlands Ambulance 
Service (WMAS) in 2023 (as referred to in the coroner’s bundle p53 and p54 points 
7.4.4 and 7.4.5), although with recognition of how the delays in handing over 
patients at NHS emergency departments was the critical factor in not releasing 
ambulances back into the community. Since that action was taken, there has been a 
steady and welcomed improvement in the response times of WMAS. When we 
inspected and published our inspection report, the response time for category 2 
incidents at WMAS (which are the largest category of ambulance incidents) was 48 
minutes and 12 seconds. The 90th centile 40-minute response time was 110 
minutes and 46 seconds. In the latest NHS Statistical Data report (March 2026) 
WMAS attended category 2 patients in 19 minutes and 30 seconds (mean average) 
and 38 minutes and 34 seconds (90th centile).  

We have also taken regulatory actions against NHS trusts where the emergency 
departments are not taking handover from ambulance crews in safe and responsive 
times. Equally this was with recognition of how delays in getting people discharged 
home who were waiting in the same trusts’ hospital wards without criteria to reside 
was the critical factor in not having beds to admit patients who required them in an 

 
 unplanned emergency. We have also written extensively on this point in the CQC 
State of Care reports in recent years. 

4.  Risks when families transport critically unwell patients 

The absence of an available ambulance for several hours resulted in the family 
transporting Roman to hospital themselves, exposing both him and his family to 
significant risk during a time-critical medical emergency. 

5.  Clarity of NHS Pathways triage wording 

Evidence showed that a key NHS Pathways question used during triage was not 
understood by the caller and did not elicit clinically significant information. This 
raises a concern that, given the reliance on scripted triage systems, such scripts 
may not always use wording that is easily understood by lay callers in distress. 

We have given consideration to points 4 and 5 above. We have had further 
conversations with WMAS about the guidance and advice given to patients by its 
NHS Pathways system or the script used in times of crisis when vehicles to attend 
are not available. We asked whether there was guidance given to families and 
friends who have either been advised or have opted to take the patient directly to 
hospital.  

The director for the emergency operations centres advised that following previous 
cases heard by the coroner, WMAS has changed the script used since the case in 
question here and now says and asks: 

“The Ambulance Service Is Under Significant Pressure, And We Don't Have An 
Ambulance Available To Respond To (You /The Patient). It May Be A Number of 
Hours Before One Is Available. Is There Any Way You Can Arrange To Safely (Make 
Your Own Way / Take The Patient) To A Hospital Emergency Department?” 

If the answer is “yes” then the caller is provided with instructions as to what to do if 
the patient deteriorates and asked to ensure they have a mobile phone with them. 

Also, following a review by NHS Pathways of the triage system for severe 
asthmatics, the process has changed. WMAS state that should the case of Mr Barr 
present today in exactly the same way the case would be prioritised as a category 1. 
Mr Barr’s case was classified at the time as a category 2. In order to trigger a 
category 1 response, the system required 2 positive answers, one of which was “is 
the patient a deathly colour?” This question would have required a positive answer 
(coupled with a positive answer to one of the other key questions) but now only 1 
positive answer is needed.  

Furthermore, your Prevention of Future Death report does state how: “A 
recommendation made during the subsequent review to amend this NHS Pathways 
wording was not accepted by those responsible for the system’s content.” (p2 
section 4 CIRCUMSTANCES OF THE DEATH). I have been informed by WMAS 
that: “The West Midlands Ambulance Service have requested that a category 1 
emergency ambulance can be received for acute asthma with fighting for breath and 

 
 confusion/agitation/drowsiness alone. This would mean removal of the second 
discriminator of "deathly colour" to identify clinical shock. Removal of this triage 
question would increase the number of those reaching a category 1 emergency 
ambulance and represent an uplift from the category 2 emergency ambulance. This 
would then align the pathway with that of the British Thoracic Society’s definition of 
life-threatening asthma. NHS Pathways subsequently accepted our recommendation 
and removed the need for “deathly colour” to be identified to reach a category 1 for 
life threatening asthma.” 

I trust that the considered response provided, alongside the actions undertaken by 
the Care Quality Commission, offers the necessary assurance in accordance with 
our regulatory responsibilities. We will continue to monitor registered healthcare 
providers against compliance with regulatory standards to ensure that learning from 
this case is embedded into practice. We remain committed to supporting 
improvements in patient safety and care quality across all services. 

Yours sincerely 

Deputy Director of Secondary and Specialist Care 
Central Region

Our ref: 

Linda Lee, HM Acting Area Coroner, Coventry

By email: 

Dear Ms Lee 

Minister of State for Health (Secondary Care) 

39 Victoria Street 
London 
SW1H 0EU 

20 April 2026 

Thank you for the Regulation 28 report of 4th March 2026 sent to the Secretary of State / the 
Department of Health and Social Care about the death of Roman Louie Barr. I am replying 
as the Minister with responsibility for Health.  

Firstly, I would like to say how saddened I was to read of the circumstances of  Roman’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.  

The  report  raises  concerns  over 
the  continued  pressure  caused  by  prolonged 
ambulance  handover  times  at  local  hospitals  which  reduced  emergency  capacity  to 
respond 
the  community,  risk  of  patient’s  family  transporting  Roman  to  hospital 
themselves and clarity of NHS Pathways triage wording. NHS England will reply separately 
on other concerns in your report.  

in 

DHSC and NHSE actions  

Improving handover and ambulance responses 

the  Department  of  Health  and  Social  Care  recognise 

NHS  England  and 
the 
ongoing pressures across urgent and emergency care,  including ambulance services. To 
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 10-Year Health Plan for England: Fit for the Future (July 2025). These set 
out key system priorities: 

•
•
•
•

reducing ambulance response times
eliminating handover delays over 45 minutes and ending corridor care
improving hospital flow and discharge
expanding urgent care access across primary, community, and mental health settings

Over £450m of capital investment last year supported expansions to urgent and emergency 
care capacity, including new and expanded Same Day Emergency Care (SDEC) and Urgent 
Treatment  Centres  (UTCs),  connected  care  records  for  ambulance  services,  and  nearly 

 1000 replacement ambulances by March 2026. The plans committed to shifting focus from 
treatment to prevention, reducing pressure on urgent and emergency care.  

To ensure timely patient care and release ambulances back into the community, the plan 
mandated  the  “Release  to  Rescue”  approach  which  will  be  continually  implemented 
across  all  trusts.    This  requires  the  handover  process  to  begin  at  30  minutes  and  be 
completed  by  45  minutes.  There  is  significant  progress  still  to  be  made  on  this 
commitment,  the  most recent  performance  figures  show  that  average  handover  time 
in 
the  West  Midlands  Ambulance  Service  was  54  minutes  and  30  seconds.  NHSE 
continues  to  work  with  the  most  challenged  trusts,  with  the  Medium-term  Planning 
Framework  (2026/27–2028/29)  setting  further  ambitions  for  acute  and  ambulance 
collaboration  to  further  improve  performance, including  progress  toward  the  15-minute 
handover  standard  and  reducing  pressure  in  hospitals.  Risks  associated  with  long 
for  ambulances  are  regularly  discussed  at  national  forums  to 
community  waits 
support  shared  understanding  and  coordinated  action across the urgent and emergency 
care system. 

NHSE also published new national clinical standards, including Model ED and The Model 
Acute Pathway, which is supporting more consistent, high-quality care and improved flow 
through hospitals, supporting improved performance and reducing pressure in hospitals.  

Conveyance to hospital 

In  a  medical  emergency—where  a  life  is  at  risk  or  someone  is  seriously  ill  or  injured—
patients  should call  999  for  an  ambulance rather  than  transport  themselves.  However,  I 
appreciate  that  in  this  circumstance,  Roman’s  family  felt  they  could  not  wait  for  an 
ambulance.  This  represented  a  significant  risk  to  Roman  and  his  family,  and  they  were 
involved  in  a  collision  while  transporting  Roman  to  hospital.  Continued  improvements  in 
handover and ambulance response times, alongside regular review of triage processes will 
reduce  the  risk  that  patients  and  their  families  feel  they  need  to  convey  themselves 
to hospital.  

Triage wording 

NHS  Ambulance  Services  in  England  must  process  999  calls  through  a  nationally 
approved clinical triage system. NHS England currently approves two systems in England 
for  primary  999  assessments;  NHS  Pathways  and  Medical  Priority  Dispatch  System 
(MPDS).  This ensures that there is a degree of consistency and standardisation in 999 call 
handling.  

is 

triage 

The  primary  purpose  of 
(e.g. 
unconsciousness,  difficulty  breathing,  chest  pain)  and  assign  a  response  priority.  The 
outcome  (disposition) reached  following  the  initial  assessment  must  be  mapped  to 
approved,  contracted standards.  These  outcomes  are  mapped  to  the  various  categories 
(Categories  1  to  5)  set  out  within  the  NHS  Constitution  and  ambulance  service  999 
contracts.  

identify  priority  symptoms 

to  quickly 

that 
The  NHS  Pathways  Licence  Agreement  with  provider  services  mandates 
Health Advisors  (call handlers)  are  supported  by  round  the  clock  ready access  to  clinical 
support through  the  “Complex  Call”  process.  The  Complex  Call  process  provides  Heath 
Advisors  with  a  clear  process  to  ask  for  help  or  transfer  the  call  to  a  clinician  – 
supported  by 
the  introduced  motto  of  “If  in  doubt,  shout”.  The  recognition  and 
management of complex calls is comprehensively taught in the initial training period for 

 Health Advisors. It is tested at the end of this period, prior to live call-taking, and is 
repeatedly reinforced through Continuous Quality Improvement (CQI) and mandatory call 
audits. 

The  safety  of  the  clinical  triage  process  endpoints  resulting  from  NHS  111  or  999 
assessments using NHS Pathways is overseen by the National Clinical Assurance Group 
(NCAG),  an  independent  intercollegiate  group  hosted  by  the  Academy  of  Medical  Royal 
Colleges  (AoMRC).  Alongside  this  independent  oversight,  NHS  Pathways  ensures  its 
clinical  content  and  assessment  protocols  are  consistent  with 
latest  advice 
from  respected  bodies  that  provide  evidence  and  guidance  for  clinical  practice  in  the 
UK.  This includes  latest  guidelines  from  organisations  including  NICE  (National  Institute 
for  Health  and  Care  Excellence),  the  Resuscitation  Council  UK  and  the  UK  Sepsis 
Trust,  amongst others. 

the 

Within NHS England, the mapping of triage outcomes to response categories is undertaken 
and  reviewed  regularly  by  an  expert  group  which  makes  recommendations  to  the  NHS 
England Emergency Call Prioritisation Advisory Group (ECPAG) for implementation across 
all NHS ambulance service providers.  

This provides a governance framework to ensure appropriate prioritisation, equity of access 
and uniformity of response across the English Ambulance Services. As such, services 
will follow standardised key questions / scripts to ensure consistency of responses. The 
group will regularly review evidence to change triage questions.   

"Asthma: 

guidance 

On the concerns you raised on monitoring of reliever overuse, to support implementation 
asthma 
of  NICE’s 
management", published  November  27,  2024,  NHS  England  has  been  engaging  with 
health  system partners to coordinate resources and implementation efforts to make sure 
that  patients  are  on  the  appropriate  treatment  regimen  and  are  using  their  inhaler 
(preventer  or  reliever)  at the  right  time,  with  the  right  technique.  The  over-prescribing  of 
reliever  inhalers  amongst  people  with  asthma  has  seen  a  steady  fall  over  the  past  few 
years.  

diagnosis,  monitoring 

chronic 

and 

I hope this response is helpful. Thank you for bringing these concerns to my attention.  

MINISTER OF STATE FOR HEALTH

Ms Linda Lee 
Acting Area Coroner for Coventry 
Coroner’s Service 
Cheylesmore Manor House 
Manor House Drive 
Coventry  
CV1 2ND 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

20th April 2026  

Dear Coroner, 

Re:  Regulation  28  Report  to  Prevent  Future  Deaths  –  Roman  Louie  Barr  who 
died on 14th December 2023.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  4th 
March 2026 concerning the death of Roman Louie Barr on 14th December 2023. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my  deep condolences to  Roman’s  family  and  loved ones.  NHS England  is 
keen to assure the family and yourself that the concerns raised about Roman’s care 
have been listened to and reflected upon.   

Your Report raises the following concerns:  

1.  There is limited awareness of salbutamol overuse by patients and families. 
2.  Excessive  or  repeated  requests  for  salbutamol  inhalers  may  not  be  reliably 
identified  within  existing  systems,  and  there  may  be  no  consistent  process  for 
follow-up  when  such  patterns  occur,  meaning  deteriorating  asthma  may  go 
unrecognised. 

3.  Ambulance handover delays are affecting emergency availability. 
4.  Families are exposing themselves to risk when having to transport critically unwell 

patients themselves due to ambulance shortages.  

5.  NHS  Pathways  triage  wording  may  not  be  easily  understood  by  lay  callers  in 

distress. 

Salbutamol overuse 
NICE  guidance  NG245  provides  advice  on  treatments,  self-management  and 
identifying  those  at  risk  of  poor  outcomes,  including  in  relation  to  the  salbutamol 
inhaler: 

1.14.5  Include  advice  in  self-management  programmes  on  contacting  a  healthcare 
professional for a review if asthma control deteriorates.  

1.15.1  Consider  actively  identifying  people  with  asthma  who  are  at  risk  of  poor 
outcomes and tailor care to their needs. Risk factors should include: 

• 

non-adherence to medicines 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
  
 • 

• 
• 

over-use  of  short-acting  beta2  agonist  (SABA)  inhalers  (more  than  2 
inhalers per year) 
needing 2 or more courses of oral corticosteroids per year 
2 or more visits to an emergency department or any hospital admission for 
asthma.  

It is a legal requirement that all Prescription Only Medicines are supplied with a patient 
information  leaflet.  For  inhaler  prescriptions,  these  leaflets  provide  warnings  on  the 
risks  of  increasing  the  dose  of  salbutamol  and  what  actions  to  take  if  the  medicine 
stops working. All asthma patients should be offered the opportunity of a Personalised 
Asthma  Action  Plan  and  an  annual  review  via  their  GP  practice  or  respiratory  care 
team, at which these risks can be reinforced and understanding checked.  

Symptom control and medication use, compliance and inhaler technique would usually 
be assessed at the routine annual asthma review and medication review (as per NICE 
guidance). General Practice IT systems allow the prescriber to set a maximum number 
of prescriptions before highlighting that it needs to be reviewed. 

Many local systems have issued specific reminders to their prescribers and in local 
formulary guidelines. 

Excessive or repeated requested for inhalers 

High or early repeat SABA prescribing is recognised nationally as a marker of risk and 
sub-optimal  disease  control,  rather  than  an  issue  that  can  be  addressed  through 
prescribing  controls  alone.  NHS  England’s  approach  focuses  on  using  prescribing 
data to support risk-based clinical review and pathway-level action, recognising that 
meaningful improvement requires coordinated clinical responses rather than isolated 
system interventions. 

NHS  England  is  taking  this  work  forward  through  the  Respiratory  Transformation 
Partnership, working with partners including Asthma + Lung UK to support risk-based 
identification and more consistent adoption across systems. In parallel, NHS England 
is identifying the policy levers required to support any future national framework for 
respiratory care, recognising the importance of national coherence and prioritisation 
in enabling sustainable delivery at scale. 

Although not mandatory, through the GP Quality and Outcomes Framework (QOF), 
GP practices are incentivised to record patients on a practice asthma register and offer 
an  annual  asthma  review  which  includes  an  assessment  of  asthma  control,  the 
number of exacerbations and a documented personalised action plan. However, whilst 
it is good practice and there are many examples of ways in which practices can do 
this,  there  is  no  specific  requirement  for  practices  to  identify  salbutamol  overuse  in 
individual patients.  

Community  pharmacies  are  encouraged  to  counsel  patients  when  they  dispense 
inhalers  including  salbutamol  and  whilst  it  is  good  practice,  there  is  no  specific 
requirement for them to do so. 

 
 
 Ambulance shortages and risks for families transporting patients  

NHS England recognises the ongoing pressures across urgent and emergency care, 
including ambulance services. To 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  10-Year  Health  Plan  for 
England:  Fit  for  the  Future  (July  2025).   These  plans  set  out  key  system  priorities: 
reducing ambulance response times,  eliminating handover  delays  over  45  minutes, 
ending corridor care, improving hospital flow and discharge and expanding urgent care 
access across primary, community, and mental health settings. Over £370 million in 
national  capital  funding  supports  these  improvements.  The  plans  also  commit  to 
shifting  focus  from  treatment  to  prevention,  reducing  pressure  on  urgent  and 
emergency care. 

To ensure timely patient care and release of ambulances back into the community, the 
2025/26  Urgent  and  Emergency  Care  Plan  mandates  the  “Release  to  Rescue” 
approach.   The  “Release  to  Rescue”  approach  will  be  triggered  once  a  handover 
reaches 30 minutes and means that all ambulances must complete their handover and 
leave the hospital site at 45 minutes. NHS England continues to work with ICBs, acute 
trusts,  and  ambulance  services  to  deliver  the  45-minute  maximum  handover 
requirement,  strengthen  urgent  community  care,  and  improve  hospital  flow  and 
discharge. Risks associated with long community waits for ambulances are regularly 
discussed at national forums to support shared understanding and coordinated action 
across the urgent and emergency care system. 

The Medium-Term Planning Framework (2026/27–2028/29) sets further ambitions for 
acute  and  ambulance  collaboration,  including  progress  toward  the  15-minute 
handover standard. 

In 2022, NHS England reminded ambulance services that clinicians should use a risk 
assessment  to  decide  whether  a  patient  can  be  advised  to  make  their  own  way  to 
hospital, typically for Category 3, lower acuity patients. 

For higher-category patients, the arrangement of an ambulance remains the standard 
response  and  priority.  Only  in  exceptional  circumstances,  after  a  remote  clinical 
assessment has been completed, which determines that it is clinically appropriate, and 
that a timely resource is not available, may a clinician advise a higher-category patient 
to make their own way to hospital. This decision must be recorded on the electronic 
patient record. Clinicians should use Service Finder (directory of services) to identify 
the  most  appropriate  service  and  communicate  this  to  the  patient.   Non-clinical  call 
handlers must not make this decision, although they may record when a caller chooses 
to make their own way to hospital. 

NHS Pathways  

NHS  Pathways  is  the  Clinical  Decision  Support  System  (CDSS)  used  for  remote 
clinical  assessment  (triage)  in  urgent  and  emergency  care.  In  use  since  2005,  it 

 
 
 underpins  all  NHS  111  services  and  more  than  half  of  England’s  999  telephony 
systems.  The  tool  also  supports  online  triage,  in-person  and  enhanced  clinical 
assessments via modules such as the NHS Pathways Clinical Consultation Support 
(PaCCS) system. 

The safety of NHS Pathways triage outcomes - known as "dispositions" - is overseen 
by  the  National  Clinical  Assurance  Group  (NCAG),  an  independent  intercollegiate 
body  hosted  by  the  Academy  of  Medical  Royal  Colleges.  Alongside  this  external 
scrutiny, NHS Pathways aligns its content with up-to-date national clinical guidance, 
including NICE (National Institute for Health and Care Excellence), UK Resuscitation 
Council and UK Sepsis Trust. 

The  system  supports  over  2.5  million  triage  assessments  each  month  across 
telephone, digital, and face-to-face settings. 

NHS  Pathways  follows  a  structured  clinical  hierarchy.  Serious  and  potentially  life-
threatening  symptoms  are  assessed  first  to  ensure  rapid  escalation  -  such  as 
dispatching an ambulance or involving a clinician. The assessment then progresses 
to less urgent symptoms, identifying the most appropriate level of care. The tool is not 
diagnostic.  Instead,  it  works  by  systematically  ruling  out  more  serious  causes  of 
symptoms to ensure safe, efficient triage. Relevant history is gathered where clinically 
necessary to minimise triage time while maintaining safety. 

In  telephone  settings,  assessments  are  conducted  by  trained  non-clinical  health 
advisors. These advisors complete a rigorous training programme and are supported 
at all times by clinicians. If a case is complex or unclear, health advisors are required 
to  escalate  to  clinical  colleagues.  It  is  therefore  a  condition  of  the  NHS  Pathways 
licence is that clinical supervision and escalation support must be available 24/7. 

NHS Pathways Triage Wording 

The  initial  triage  that  occurs  within  the  NHS  Pathways  clinical  decision  support 
software aims to identify life threatening events and result in an emergency ambulance 
disposition. For those calling with severe breathing difficulty, a category 2 emergency 
ambulance is the lowest potential disposition that should be received. Since July 2020 
the  CDSS  has,  in  respect  of  those  with  severe  breathing  difficulty  and  suspected 
asthma as the cause of their breathing difficulty, offered further triage to identify those 
who require a higher category 1 emergency ambulance. At the time of completing this 
work it was agreed that the criteria required for a category 1 ambulance for asthma 
would be severe breathing difficulty with systemic features of illness such as altered 
mental state and appearance of clinical shock. 

The  question  of  concern  “is  the  patient  a  deathly  colour”,  is  the  question  used  to 
identify symptoms of clinical shock within the CDSS. It has been utilised in triage prior 
to 2005. Questions within the system often have supporting information that helps the 
health  advisor  probe  when  necessary,  as  this  one  does.  All  supporting  information 
utilises common style and design but, as with all content, can be subject to iterative 
review  based  upon  feedback  from  providers.  For  example,  if  a provider  identifies  a 
question that health advisors are finding difficult to answer then they can raise this as 
a clinical enquiry to NHS Pathways for review. 

 In November 2020, this question was reviewed within a body of work to improve how 
any reference to skin colour was considered within the CDSS in the context of darker 
skin  tones.  A  range  of  questions  were  amended  with  the  aim  of  improving  the 
identification of clinical features of illness in darker skin tones. The question of concern 
was one such question was updated and the content is included for reference in Figure 
1 below. NHS Pathways remains committed to improving how clinical features utilised 
within triage can be improved for those with darker skin tones. 

Figure 1 

In September 2021, a unit was added to NHS Pathways Core Module 1 mandatory 
training  materials  to  give  health  advisors  and  clinicians  more  detailed  guidance  on 
identifying  skin  colour  changes  in  patients  with  different  skin  colours.    This  training 
includes guidance on how to use the existing supporting information to form probing 
questions to help the caller understand what is being asked, and where on the body 
to  best  check  for  any  change  in  skin  colour.    The  module  includes  an  interactive 
PowerPoint  session  explaining  the  challenges  faced  by  those  of  non-white  skin 
colours, as well as practice case studies and scenarios to help put this information into 
practice.  It has formed a part of NHS Pathways Core Module 1 training since it’s initial 
inclusion in 2021.   

 A number of changes relating to asthma have been incorporated into the CDSS since 
2020,  reflecting  NHS  England’s  commitment  to  preventing  adverse  outcomes  in 
asthma care. 

In  November  2022,  changes  were  made  to  ensure  that  asthma  was  identified  at 
category  3  emergency  ambulance  level.  This  was  further  developed  in  September 
2023 with the identification of asthmatics with less severe breathing difficulty but other 
features of illness at category 2 emergency ambulance level. 

In  January  2024  the  identification  of  altered  mental  state  for  those  presenting  with 
asthma  and  difficulty  in  breathing  was  expanded.  Prior  to  this  change,  the  triage 

 
 identified  confusion  and  drowsiness.  Following  this  change  the  triage  identified 
confusion, agitation and drowsiness. 

In June 2025, in response to feedback from the West Midlands Ambulance Service 
regarding Roman’s death, the CDSS was amended. A piece of work was completed 
and  agreed  with  the  NCAG  and  national  ambulance  teams  that  provided  for  the 
dispatch  of  a  category  1  emergency  ambulance  for  those  with  asthma  and  either 
altered  mental  state  or  appearance  of  clinical  shock.  This  change  lowered  the 
previously agreed threshold for category 1 ambulance for severe breathing difficulty in 
asthma. 

Regional Response 

The  NHS  England  Midlands  regional  team  have  advised  that  they  are  currently 
supporting  West  Midlands  Ambulance  Service 
(WMAS)  with  performance 
improvements by reducing handover delays across West Midlands acute hospitals. 

To ensure WMAS can work towards delivering the Category 2 constitutional standard 
of 18 minutes consistently there is a comprehensive programme of work in place led 
by NHS England Regional Executives (Chief Operating Officer, Medical Director and 
Chief  Nurse)  who  are  working  with  their  respective  Acute  Hospital  Chief  Operating 
Officers, Medical Directors and Chief Nursing Officers to reduce ambulance handover 
delays. 

The  impact  of  prolonged  ambulance  handover  delays  has  a  direct  correlation  on 
ambulance  category  2  performances  and  staff  morale  and  wellbeing.  If  ambulance 
crews  can  handover  the  care  of  the  patient  into  the  care  of  the  acute  hospital 
emergency department in a timelier manner, this then allows crews to be back on the 
road to respond to any emergencies out in the community. 

The work on reducing handover delays is part of a national programme (Release to 
Rescue / 45 minutes programme) to ensure the maximum wait to handover patients 
into the care of the emergency department is no more than 45 minutes. Delivering this 
requires  a  comprehensive  amount  of  work  by  both  the  acute  trusts  (clinically  and 
operationally)  working  collectively  with  the  respective  WMAS  ambulance  services 
colleagues  to  implement  this  safely.  This  builds  on  the  successful  work  that  other 
ambulance  services  nationally  have  implemented  to  reduce  ambulance  handover 
delays. 

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 
Roman are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

 
 Yours sincerely,  

National Medical Director  
NHS England

Vice Chair Member Standards 

Mrs Linda Lee 
Acting Area Coroner for Coventry & Warwickshire 

12 June 2026 

Dear Mrs Lee  

Regulation 28 Report to Prevent Future Deaths - regarding the death of Mr Roman Louie Barr 

Thank you for asking us to comment on the matters of concern following the sad death of Mr Roman 
Louie Barr, who died on the 14th of December 2023. Our sincere condolences go to his family and friends 
given the difficult circumstances and the ongoing questions on how this could have been prevented. We 
will address the issues raised as requested in the hope that the response can help answer the concerns 
of the Coroner and Roman’s loved ones. 

You have two matters of concern for GPs relating to this tragic death: 

Limited awareness of salbutamol overuse: 

Evidence showed that patients and families may not appreciate the clinical significance of 
increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma. 

Identification and follow-up of reliever overuse: 

Evidence showed that excessive or repeated requests for salbutamol inhalers may not be 
reliably identified within existing systems, and there may be no consistent process for follow-
up when such patterns occur, meaning deteriorating asthma may go unrecognised. 

To give context to the family, The Royal College of General Practitioners works to improve patient 
care by encouraging the highest possible standards in general medical practice by supporting members, 
setting standards, providing education and training, promoting   research, advocating and representing 
the College and its 56,000 members.  

General Practitioners have a broad curriculum, and the College is responsible for the definitive 
educational framework for all doctors undertaking GP speciality training. There are five areas of 
capability aligned to the General Medical Council’s Generic Professional Capabilities Framework, and 
these are supported by 22 Clinical Topic Guides, including Respiratory Health.  

RCGP hosted a One Day Essential Respiratory Health Update for members in March 2026 and 
updates on Asthma management content remains available for free. This followed the 2025 RCGP 
online eLearning ‘Asthma: updates to diagnosis and treatment’ reporting the recommendations of the 
2024 NG245 ‘Asthma: diagnosis, monitoring and chronic asthma management’. 

The 2014 National Review of Asthma Deaths (NRAD) titled ‘Why Asthma still kills’ was a key 
document reviewing records of patients who died from Asthma and made recommendations that 

Royal College of General Practitioners 
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 continue to influence care in General Practice- one such observation was that 39% of the patients 
reviewed had requested 12 short-acting reliever inhalers like Salbutamol in the year before their death, 
which became a key metric to highlight urgent concern when reviewing repeat medications through 
electronic surveillance, (nationally rolled out in England in 2019), to invite such patients to a structured 
Asthma Review in order to provide them with a written Personalised Asthma Action Plan (PAAP). All 
patients with Asthma should have an annual review of their symptoms, inhaler technique and history 
of exacerbations. Asthma Reviews should also be triggered to follow up any episode of asthma that 
has resulted in hospital admission, with the opportunity of developing the PAAP. Asthma Reviews also 
represents an opportunity to highlight patient-facing resources such as videos and written information 
featured on RightBreathe and Asthma + Lung UK websites. 

Sadly, the numbers of patients dying from Asthma in the UK has not significantly changed in the years 
since the NRAD report. Further annual guidance followed and current consensus published by the 
Global Initiative of Asthma (GINA) identifies modest overuse as more than three short-acting relievers 
used per year. 

GP Information Technology Systems record GP Consultations and information relating to asthma care. 
There is no single GP IT System and suppliers include EMIS, SystmOne and Medicus. GP systems 
enable repeat prescribing for a set number of medications to be issued before needing reauthorisation 
by a prescriber.  It is at this point that the clinician will consider the possibility of overuse or underuse 
of inhalers such as Salbutamol, with the opportunity to recall the patient if safety concern is identified. 
This recall should trigger a review of asthma symptoms and identification of poor control (compared to 
the common clinical scenario of overordering of inhalers that aren’t being used), and optimising asthma 
management according to current guidance. Systems themselves do not automatically alert examples 
such as monthly requests for Salbutamol nor incidence of using 3 or more reliever inhalers per year, 
and it is the responsibility of clinical teams to put in place recall systems and mechanisms to recognise 
and review those at risk and provide best possible asthma care. 

There is no information when Roman’s most recent asthma review was conducted, what other asthma 
inhalers he was taking, whether his medication was adjusted, nor if there was history of exacerbations 
or admissions indicating the level of asthma control that could have been opportunities to intervene.  

Suggestions for concerns regarding the NHS Pathways and Ambulance services are beyond the remit 
of the Royal College of General Practitioners. 

Once again, our condolences go to Roman’s family and friends. I hope the comments provide a full 
picture of where the RCGP can seek to influence the prevention of future deaths within training and 
continuing professional development. 

Yours faithfully 

Vice President Member Standards