The family of a 22-year-old Coventry man who died following an asthma attack has called for a radical overhaul of national asthma guidance and response.
Fitness lover Roman Barr died on 14 December 2023 after a sudden, severe asthma attack. While multiple calls were made to emergency services, an ambulance call handler used scripted questions to assess Roman’s situation. He was deemed a category two emergency, meaning it would be several hours for an ambulance to arrive.
The inquest heard how his parents were left with no choice but to drive him to hospital themselves, however he went into cardiac arrest and could not be resuscitated.
Coventry coroner Linda Lee concluded on 3 March, ‘on the balance of probabilities, earlier intervention by an emergency ambulance would have prevented his death’.
Following the inquest, a Prevention of Future Deaths (PFD) report was issued by the coroner highlighting the key areas that led to Roman’s death. It has been addressed to several national bodies, including the Department of Health and Social Care and NHS England, warning that lives will continue to be lost unless national protocols are transformed.
As well as identifying the critical failings that led to Roman’s death, the investigation by the coroner unearthed systemic flaws that could impact the 5.4 million people living with asthma. Specifically:
- The over-reliance on salbutamol (blue) inhalers and the lack of a centralised national database to track and learn from asthma-related fatalities – Roman was said to have used his 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’
- Prolonged ambulance handover times that stripped the area of emergency capacity – in Roman’s case ‘ambulance availability was severely constrained due to significant delays in hospital handovers, leaving no crews free to respond’
- Confusing triage scripts that failed to identify the severity of Roman’s condition – due to Roman’s mixed ethnicity and skin tone, the NHS Pathways question from the call handler about whether he showed a ‘deathly colour’ was not understood
Leading East Midlands law firm Nelsons has been supporting the family through the inquest with Matthew Olner, partner and clinical negligence specialist expressing the weight of the contents within the PFD report.
It found there were multiple missed opportunities to pick up the severity of Roman’s asthma, as well as the ultimate failure to get him a higher category response when he experienced the asthma attack.
Matthew said:
“The PFD report attributed to Roman’s case is an important moment that has the potential for significant change on a national scale. While this will come too late for Roman, I am pleased the family was given the result they deserved – however, ultimately, they will carry this burden for life.
The coroner’s report highlights a lack of national guidance on asthma treatment plans and a breakdown in communication between primary and secondary care. The report found that ambulance controls are using pathways that are at best unsafe and at worst, life threatening.
The report gives the family essential backing to continue to push for change. Nothing is going to bring Roman back but his family hope that, with these recommendations from the coroner, the chances of a tragedy like this befalling another family will be greatly reduced.”
During the inquest, it was heard how Roman’s parents, Tazz and Darren Barr fought to save their son in unimaginable circumstances.
The court heard one of the three 999 calls made, in which Darren said he was asked numerous “irrelevant” scripted questions.”
Darren said:
“That call should have been straightforward and quick, but it was nearly 15 minutes of those irrelevant questions, that many people would struggle to answer. I felt helpless, and I don’t want any other parent to go through that.”
Due to the expected response time, Darren and Tazz made the decision to drive Roman to hospital themselves. During the journey, Roman suffered cardiac arrest and while Tazz attempted CPR, the car was involved in a collision. Tazz sustained serious injuries and is still using a wheelchair as a result. Roman could not be resuscitated and died as a result shortly after arrival.
Following the inquest, Tazz said:
“Roman was the glue of our family, and we have been broken by this experience. But we were so grateful to the coroner for her compassion and understanding of our story, and to give us the tools to take this further and fight for change.
“We thought we had the right medication and that we would have the right emergency response. But we were wrong. There is so much more learning to be done, for everyone – children, adults and professionals, to understand asthma and how to prevent deaths like Roman’s.”
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.
“I am grateful to everyone who has helped us get here so far – the coroner, our solicitor Matthew, and barrister Peter. But this is just the start. I will continue to speak passionately about Roman to everyone and we look forward to hearing the response of all those listed on the PFD report, and hope this brings about the major changes needed.”
If this article relates to a specific case/cases, please note that the facts of this case/cases are correct at the time of writing.