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Skin Tone Misunderstanding Fatal in Asthma Attack
16 Apr
Summary
- Call handler error led to fatal misunderstanding of 'deathly colour'.
- 22-year-old died after delayed ambulance response to asthma attack.
- Coroner calls for urgent guideline reforms after tragic event.
A tragic asthma attack claimed the life of 22-year-old Roman Barr in December 2023, following a critical misunderstanding during an emergency ambulance request. The call handler's question about the patient being a 'deathly colour' was not properly understood by Roman's father, as the term typically refers to paleness, a sign not as evident on darker skin tones.
Roman, who had a mixed-race background, exhibited signs of a severe asthma attack, including blue lips. Despite his critical condition, the family was informed that an ambulance would take several hours to arrive due to severe constraints, including hospital handover delays. This led to the family attempting to transport him to the hospital themselves.
During the journey, Roman suffered a cardiac arrest. His mother performed CPR while the car was involved in a crash. Roman Barr was pronounced deceased, having died as a result of the asthma attack. An earlier ambulance response could have prevented his death.
In the aftermath, the area coroner, Linda Lee, highlighted that Roman had been using his reliever inhaler more frequently, indicating poor asthma control. The coroner recommended changes to asthma care guidelines to improve the identification of high-risk patients. GP practices have since reviewed their monitoring of patients with high salbutamol use.
