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

20th April 2026

• 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.

Dear Ms Lee 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 in 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. DHSC and NHSE actions Improving handover and ambulance responses NHS England and the Department of Health and Social Care recognise 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 community waits for ambulances are regularly discussed at national forums to 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. The primary purpose of triage is to quickly identify priority symptoms (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. The NHS Pathways Licence Agreement with provider services mandates that 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 the 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. 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. On the concerns you raised on monitoring of reliever overuse, to support implementation of NICE’s guidance "Asthma: diagnosis, monitoring and chronic asthma 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. I hope this response is helpful. Thank you for bringing these concerns to my attention. MINISTER OF STATE FOR HEALTH

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 Inspector of Primary Care and Community Services, , CBE, 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.