Coroner calls for changes to how asthma attacks are assessed after ‘skin tone’ confusion in death of 22-year-old

A coroner has called for urgent improvements to how asthma attacks are assessed by emergency services after a mixed-race 22-year-old died due to a misinterpretation of him being described as a ‘deathly colour’.

Roman Barr was assessed as not being an urgent case when his parents called for an ambulance, and was told he would have to wait several hours for one to arrive.

Mr Barr was of mixed race and had a ‘darker skin tone’, so the description of being a ‘deathly colour’ was misinterpreted, even though he had ‘bluish lips’ and was critically ill.

A lack of ambulance availability meant that he died on the way to the hospital when his parents decided to drive him themselves after suffering a cardiac arrest.

Now a coroner has said that early intervention from emergency services could have prevented Mr Barr’s death.

On December 14 2023, Mr Barr was at work when he had an asthma attack, and his dad took him home, where he tried to use his inhaler but had no improvement.

His dad called for an ambulance, but he was not assessed as a ‘critical’ case, and his family was told it would take several hours for an ambulance to be available.

His family called 999 three times, but when his dad assessed his symptoms to the call handler, he misunderstood what they meant by a ‘deathly colour’.

He told the call handler that his son was of mixed race and had a ‘darker skin tone’, so he was seen as not being in a critical condition.

Mr Barr had ‘bluish lips’ at the time and was ‘critically unwell’.

His family decided to drive him to the hospital themselves, but on the way, he suffered a cardiac arrest, and his mother moved into the passenger footwell to give him CPR.

When they arrived at the hospital, the car was involved in a crash, and Mr Barr was not able to be resuscitated and died.

His mother was also ‘severely injured’ by the crash.

At Mr Barr’s inquest, it was found that he died from asthma and a narrative conclusion was given.

This conclusion said: “The deceased died as a result of an asthma attack.

“Information indicating the need for an urgent ambulance response was not obtained, and because no ambulance was available for several hours, he was taken to hospital by his family.

“On the balance of probabilities, earlier intervention by an emergency ambulance would have prevented his death.”

In a prevention of future deaths report, Area Coroner for Coventry, Linda Lee, found that clearer wording of questions from call handlers needed to be made to prevent similar deaths.

The report, sent to the Secretary of State for Health and Social Care, NHS England, the Royal College of GP’s, and the Care Quality Commission, said that changes to ambulance availability also needed to be made.

Ms Lee said: “The NHS Pathways question requiring confirmation that the patient was ‘a deathly colour’ was not understood by [Mr Barr’s] father.

“Clearer prompts—such as asking whether the lips were blue or grey—were not asked.

“A recommendation made during the subsequent review to amend this NHS Pathways wording was not accepted by those responsible for the system’s content.

“Ambulance availability was severely constrained due to significant delays in hospital handovers, leaving no crews free to respond.

“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.”

Ms Lee said that Mr Barr had been using his inhaler more frequently leading up to his death.

She said: “I also heard evidence that [Mr Barr] had been using his blue (salbutamol) inhaler more frequently than recommended, indicating poor asthma control, and that neither he nor his family were aware of the clinical significance of this increased use.

“Following his death, the GP practice conducted a review and introduced measures to better identify and monitor patients with high salbutamol use, including keeping a list of such patients, automatically booking reviews when further inhalers are requested, liaising with community pharmacists, and placing alerts on patient records to support timely assessment.

“Notwithstanding the Drug Safety Update issued on 25 April 2025 reminding clinicians of the risks associated with increased salbutamol use, the evidence in this case indicates that the importance of excessive reliever use may still not be fully recognised by patients or by primary care.”

Following the inquest, Roman’s father Darren said: “Roman was my soulmate. We spent a lot of time together, both of us passionate about fitness and bodybuilding, through which he built an amazing network of friends and admirers.

“Everywhere we go now, we get the same shocked response to our story – it has an impact on everyone. 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.”