Coroner Demands Urgent Asthma Guideline Reform After 22-Year-Old's Tragic Death
A coroner has issued an urgent call for reforms to asthma attack emergency guidelines following the preventable death of a 22-year-old mixed-race man, Roman Barr, who died in December 2023 after critical misunderstandings during an emergency call.
Misunderstood Emergency Terminology
The inquest into Mr Barr's death revealed that when his father Darren called 999 requesting an ambulance, the emergency call handler asked whether Roman was "a deathly colour" - terminology that proved fatally misleading due to the young man's darker complexion.
The term 'deathly colour' is typically understood to mean unusual paleness, a common physical warning sign during asthma attacks when blood flow decreases. However, for individuals with naturally darker skin tones, this visual indicator presents differently, with critical signs manifesting in areas like lips turning blue or grey rather than overall skin pallor.
Area coroner Linda Lee concluded in her prevention of future deaths report that "the call handler should have asked questions about Mr Barr's lips rather than the colour of his skin." Despite Roman displaying classic signs of critical distress including bluish lips, he was not assessed as requiring urgent Category 1 ambulance response.
Systemic Failures and Delayed Response
The coroner's investigation uncovered multiple systemic failures that contributed to the tragedy. Ambulance availability was severely constrained due to significant hospital handover delays, leaving no crews available to respond promptly to emergency calls.
Ms Lee stated: "On the balance of probabilities, had clearer wording been used and the relevant information obtained, Roman would have been categorised as Category 1, for which an ambulance would be expected to arrive within approximately ten minutes even during surge conditions."
Despite recommendations following an internal review to amend the NHS Pathways wording, those responsible for the system's content did not accept the proposed changes, leaving the problematic terminology in place.
The Final Hours and Family's Desperate Efforts
Roman Barr was working when he suffered the asthma attack on December 14, 2023. His father Darren brought him home, where Roman attempted to use his inhaler without improvement. The family called 999 three times but were told it would take several hours for an ambulance to become available.
As Roman's condition rapidly deteriorated, his family made the desperate decision to drive him to hospital themselves. During the journey, Roman suffered cardiac arrest, prompting his mother to climb into the passenger footwell to perform CPR while Darren drove.
Tragically, the car was involved in a crash en route to the hospital. Roman could not be resuscitated and died, while his mother sustained severe injuries in the collision.
Missed Warning Signs and Systemic Recommendations
The inquest revealed that Roman had been using his salbutamol (blue) inhaler more frequently than recommended in the period before his death - a clear indicator of worsening asthma control that neither he nor his family fully understood as clinically significant.
Coroner Lee recommended substantial changes to asthma care guidelines to improve identification of patients at higher risk of severe attacks. She highlighted that the importance of excessive reliever inhaler use may still not be fully recognised by patients or primary care providers, despite existing safety updates.
Following the tragedy, Roman's GP practice implemented new monitoring measures including maintaining lists of patients with high salbutamol use, automatic review bookings when additional inhalers are requested, closer liaison with community pharmacists, and patient record alerts to support timely assessment.
A Father's Plea for Change
Speaking after the inquest, Darren Barr remembered his son as his soulmate, sharing passions for fitness and bodybuilding that had helped Roman build an extensive network of friends and admirers.
"Everywhere we go now, we get the same shocked response to our story - it has an impact on everyone," said Darren. "I want to ensure my son's life does not go to waste, and that we continue Roman's love of helping others. This is not just our story, or Roman's story, it needs to be under the national spotlight."
The coroner's report concludes that Roman Barr died as a result of an asthma attack, with information indicating the need for urgent ambulance response not being obtained during emergency calls. The report states unequivocally that earlier intervention by an emergency ambulance would have prevented his death.
