A coroner has called for urgent reforms to asthma attack guidelines after a 22-year-old mixed-race man died due to a misunderstanding during an emergency call.
Roman Barr tragically succumbed to an asthma attack in December 2023, hours after his parents were told his case was not urgent when they requested an ambulance.
An inquest into his death found that because Mr Barr had a darker skin tone, the emergency call handler’s reference to whether he was a ‘deathly colour’ was misunderstood, despite him being critically unwell, with lips turning blue.
The term ‘deathly colour’ is commonly understood to mean a person becoming unusually pale – a change often associated with illness, shock or death as blood flow is either reduced or stops.
Becoming pale is a common physical warning sign of an asthma attack, as well as a change in colour, dark circles near the eyes, a flushed face, and runny eyes.
However, due to Mr Barr’s naturally darker complexion, the Coventry coroner concluded that the call handler should have asked questions about Mr Barr’s lips rather than the colour of his skin.
In her prevention of future deaths report, area coroner Linda 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.
Roman Barr (pictured, left with his father Darren) died from an asthma attack in late 2023
‘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.’
Mr Barr was working when he suffered the asthma attack on December 14, 2023, before being taken home by his father, Darren.
The 22-year-old tried using his inhaler but his condition did not improve, prompting his father to call for an ambulance.
However, Mr Barr was not assessed as a ‘critical’ case, and the family was told it would take several hours for an ambulance to be available.
They called 999 three times, but when Darren 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’.
As his condition deteriorated, the family decided to drive him to hospital themselves.
During the journey Mr Barr suffered a cardiac arrest, and his mother climbed into the passenger footwell to perform CPR.
The car was involved in a crash on the way to the hospital and Mr Barr was not able to be resuscitated. He tragically died, while his mother was also ‘severely injured’ by the crash.
At the conclusion of Mr Barr’s inquest, it was said that he ‘died as a result of an asthma attack’.
The conclusion continued: ‘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.’
Ms Lee told the inquest that Mr Barr had been using his inhaler more often than usual before his death – which can signify a worsening condition.
She recommended a change to asthma care guidelines, to improve the identification of patients who may be at higher risk of a severe attack.
‘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,’ said Ms Lee.
‘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, Mr Barr’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.’
