Coroner calls for changes to how asthma attacks are assessed after ‘skin tone’ confusion in death of 22-year-old

A coroner has called for urgent improvements to how asthma attacks are assessed by emergency services after a mixed-race 22-year-old died due to a misinterpretation of him being described as a 'deathly colour'.

Roman Barr was assessed as not being an urgent case when his parents called for an ambulance, and was told he would have to wait several hours for one to arrive.

Mr Barr was of mixed race and had a 'darker skin tone', so the description of being a 'deathly colour' was misinterpreted, even though he had 'bluish lips' and was critically ill.

A lack of ambulance availability meant that he died on the way to the hospital when his parents decided to drive him themselves after suffering a cardiac arrest.

Now a coroner has said that early intervention from emergency services could have prevented Mr Barr's death.

On December 14 2023, Mr Barr was at work when he had an asthma attack, and his dad took him home, where he tried to use his inhaler but had no improvement.

His dad called for an ambulance, but he was not assessed as a 'critical' case, and his family was told it would take several hours for an ambulance to be available.

His family called 999 three times, but when his dad 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'.

At Mr Barr's inquest, it was found that he died from asthma and a narrative conclusion was given.

This conclusion said: "The deceased died as a result of an asthma attack.

"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.”

Read full story

Source: The Independent, 16 April 2026