4 Mar 2026 Roman Louie BARR · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 6 Risk to critically unwell patients and families when families transport patients to hospital during time-critical emergencies View source Delays in ambulance handover reducing emergency ambulance availability View source Failure to reliably identify excessive or repeated requests for salbutamol inhalers View source Lack of a consistent follow-up process for salbutamol overuse patterns View source Limited awareness of the significance of salbutamol overuse in patients and families View source Failure of NHS Pathways triage wording to be readily understood by callers in distress View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Roman Louie BARR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after no ambulance was available for several hours, leading his family to transport him to hospital. The principal concerns were limited awareness and follow-up of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks to families transporting critically unwell patients, and unclear NHS Pathways triage wording.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Asthma + Lung UK; that does not assign responsibility.
PFD Monitor interpretation Risk to critically unwell patients and families when families transport patients to hospital during time-critical emergencies
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Asthma + Lung UK; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover reducing emergency ambulance availability
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Asthma + Lung UK; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably identify excessive or repeated requests for salbutamol inhalers
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Asthma + Lung UK; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent follow-up process for salbutamol overuse patterns
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Asthma + Lung UK; that does not assign responsibility.
PFD Monitor interpretation Limited awareness of the significance of salbutamol overuse in patients and families
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Asthma + Lung UK; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS Pathways triage wording to be readily understood by callers in distress
Wider context from the report “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 .
” Open source report
4 Mar 2026 Roman Louie BARR · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 6 Limited awareness of salbutamol overuse and its association with poorly controlled asthma View source Delays in ambulance handover at local hospitals View source Failure to reliably identify excessive or repeated requests for salbutamol inhalers View source Failure of NHS Pathways triage wording to be readily understood by callers in distress View source Risk to critically unwell patients and families when no ambulance is available and families transport patients themselves View source Lack of a consistent follow-up process for salbutamol overuse patterns View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Roman Louie BARR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after information indicating the need for an urgent ambulance response was not obtained, no ambulance was available for several hours, and his family transported him to hospital. The principal concerns included limited awareness and monitoring of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks when families transport critically unwell patients, and unclear NHS Pathways triage wording.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Asthma + Lung UK; that does not assign responsibility.
PFD Monitor interpretation Limited awareness of salbutamol overuse and its association with poorly controlled asthma
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Asthma + Lung UK; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover at local hospitals
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Asthma + Lung UK; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably identify excessive or repeated requests for salbutamol inhalers
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Asthma + Lung UK; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS Pathways triage wording to be readily understood by callers in distress
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Asthma + Lung UK; that does not assign responsibility.
PFD Monitor interpretation Risk to critically unwell patients and families when no ambulance is available and families transport patients themselves
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Asthma + Lung UK; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent follow-up process for salbutamol overuse patterns
Wider context from the report “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.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations