Roman Barr
3 Apr 2026 · Coroner Linda Lee · Coventry
This report repeats 15 earlier warnings. See the linked reports.
The coroner's concerns
1. overuse of salbutamol inhaler
“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. unrecognised reliever overuse
“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.”
3. ambulance unavailability during emergency
“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.”
4. family transport of critically unwell patient
“Risks when families transport critically unwell patients The absence of an available ambulance for several hours resulted in the family transporting [the deceased] to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency.”
5. misunderstanding of NHS Pathways triage question
“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”
Linked reports
Identical hazardConfidence 0.92 · high
Earlier report
“During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.”
This report
“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.”
Identical hazardConfidence 0.92 · high
Earlier report
“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”
This report
“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.”
Closely relatedConfidence 0.90 · high
Earlier report
“The pre-determined questions are the same whether the caller is an adult or a child. [name redacted] struggled to comprehend some of the medical terminology used during these calls.”
This report
“Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information.”
Identical hazardConfidence 0.92 · high
Earlier report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital”
This report
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available”
Repeats an earlier warningJohn Seagrove, Pauline Humphris and Patricia Steggles23 Nov 2023 · 2 years 4 months earlier
Identical hazardConfidence 0.90 · high
Earlier report
“What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks.”
This report
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”
Closely relatedConfidence 0.85 · high
Earlier report
“Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.”
This report
“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”
Identical hazardConfidence 0.95 · high
Earlier report
“availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.”
This report
“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.”
Repeats an earlier warningHarry Dunn: Prevention of Future Deaths Report (1)4 Jul 2024 · 1 year 9 months earlier
Identical hazardConfidence 0.90 · high
Earlier report
“The Inquest heard that EMAS was unable to meet mean response standards at the time of the 999 call.”
This report
“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,”
Identical hazardConfidence 0.90 · high
Earlier report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”
This report
“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.”
Identical hazardConfidence 0.90 · high
Earlier report
“The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance time.”
This report
“Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought”
Closely relatedConfidence 0.90 · high
Earlier report
“This delay being significantly contributed to by the handover delays in hospitals.”
This report
“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.”
Identical hazardConfidence 0.90 · high
Earlier report
“Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”
This report
“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”
Identical hazardConfidence 0.90 · high
Earlier report
“Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances.”
This report
“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.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up”
This report
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available”
Identical hazardConfidence 0.90 · high
Earlier report
“Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays”
This report
“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”
Responses
No published response was found on judiciary.uk.