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A coronial investigation into the death of Roman Louie Barr, aged 22 who died on 14  December 2023, was opened on 20 June 2024 and concluded on 3 March 2026. The inquest was conducted without a jury. The conclusion reached was a short factual  narrative: “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.”  On 14 December 2023, Roman Louie Barr suffered an asthma attack. His father collected him from work and took him home, where Roman used his nebuliser without improvement. Three calls were made to the ambulance service. During these calls, Roman was assessed as Category 2, and the family were twice advised that no ambulance would be available for several hours. They were asked whether they could transport him to hospital themselves and took the decision to do so. Evidence established that at the time of the first call, Roman was critically unwell, displaying symptoms including bluish lips, but this information was not elicited during triage. Roman was of mixed ethnicity and had a darker skin tone, as his father explained to the call handler. The NHS Pathways question requiring confirmation that the patient was “a deathly colour” was not understood by his father. Clearer prompts—such as asking whether the lips were blue or grey—were not asked. 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. While being driven to hospital, Roman suffered a cardiac arrest. His mother moved into the footwell of the passenger side and commenced CPR as they continued their journey. On arrival at the hospital, the family vehicle was involved in a collision, during which Roman’s mother sustained serious injuries. Roman could not be resuscitated and died shortly after arrival. I also heard evidence that Roman 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. 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. Matters of concern 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. 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. 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. 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. 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

UCL Partners have developed a series of proactive care frameworks to restore routine care by prioritising patients at highest risk of deterioration, with pathways that mobilise the wider workforce and digital/tech, to optimise remote care and self-care, while reducing GP workload. The frameworks include atrial fibrillation, high blood pressure, high cholesterol, type 2 diabetes, asthma and COPD. The frameworks are comprehensive and include: Comprehensive search tools to risk stratify patients – built for EMIS and SystmOne. Pathways that prioritise patients for follow up, support remote delivery of care, and identify what elements of long-term condition care can be delivered by staff such as Health Care Assistants and link workers. Scripts and protocols to guide Health Care Assistants and others in their consultations. Training for staff to deliver education, self-management support and brief interventions. Training includes health coaching and motivational interviewing. Digital and other resources that support remote management and self-management. The frameworks are being implemented by GPs across the country, helping practices to identify who needs priority care, and those whose care can safely be delayed. These frameworks are designed to be adapted to local context and preferences.

The Healthcare Safety Investigation Branch (HSIB) held a webinar on 12 May to discuss asthma management in children, to support the launch of their recent publication: Management of chronic asthma in children aged 16 years and under. For those of you who missed the event, HSIB have made available the webinar recording, presentation slides and Q&As.

Asthma is the most common lung disease in the UK. 1.1 million children are diagnosed with the condition. Healthcare Safety Investigation Branch (HSIB) looked at the risks involved in the management of children aged 16 years and under diagnosed with asthma. Diagnosis and the management of asthma, particularly in children and young people, can be complex. It is important to get it right, as otherwise significant harm or death can result. The investigation was launched after HSIB identified an event involving a 5 year old child. The child had numerous planned and unplanned (emergency) attendances at hospital with respiratory symptoms, before suffering a near fatal asthma attack. Prior to the event, the child had no formal diagnosis of asthma and issues had been identified (but not resolved) regarding adherence to treatment. Safety recommendations HSIB recommends that NHS England and NHS Improvement, as a commissioning body, supports local systems to implement evidence-based interventions, such as standardised information and wheeze management plans, for the parents/ carers of pre-school children. This will be undertaken in conjunction with the British Paediatric Respiratory Society. HSIB recommends that NHS England and NHS Improvement reviews the recommendations arising from the National Review of Asthma Deaths to prioritise and ensure the implementation of recommendations that are outstanding. HSIB recommends that NHS Digital reviews the supporting information for triaging the breathless child up to 16 years of age, to determine whether there are features of life-threatening breathing difficulty. HSIB recommends that NHS England and NHS Improvement supports clinical experts to work with professional bodies to develop training competencies for healthcare professionals with responsibility for caring for children with suspected or confirmed asthma. HSIB recommends that NHS England and NHS Improvement and NHSX identify and integrate data items into information technology systems to develop a greater understanding of the risk factors present in the community HSIB recommends that NHSX, supported by NHS England and NHS Improvement, implements a discovery programme into the roadmap for the digital personal child health record focused on developing support, self-reporting and alerting for asthma self-care. HSIB recommends that Public Health England develops resources for young people and their parents/carers to raise awareness and enable them to self-manage asthma more effectively.

On 28 June 2017, 13 year-old Karanbir Cheemer was at school when another pupil threw a small piece of cheese at him. He was known to be allergic to cheese and he went into anaphylactic shock. Karanbir later died.  In this report, senior coroner ME Hassell, highlights a number of patient safety concerns relating to his death and calls for action to prevent future deaths.

Understanding Patient Data has produced a series of animations to explain how data saves lives. Following the journeys of patients with cancer, a heart attack, diabetes, dementia and asthma, they show the huge range of ways data is used to improve care, and the safeguards that are in place to protect confidentiality.  Better use of data is essential to speed up diagnosis, research new treatments, plan better NHS services and monitor the safety of drugs. And yet, more than two thirds of the population feel they don’t know how patient data is used in the NHS. These animations have been developed in partnership with charities, patients and clinicians. Find out why and how patient data is used.

This webpage from Asthma UK explains how to cut the risk of getting coronavirus and what happens to your usual asthma care.

An initiative to raise standards of asthma care in a prison setting has lessons for the management and care of people with asthma in other healthcare settings. This article is published in the Nursing Times. You can register for guest access which gives you 1 week’s unrestricted access to nursingtimes.net.

On 17 September 2024, Edwin Buckett, commenced an investigation into the death of Billie Wicks aged 16 years. The investigation concluded at the end of the inquest on 6 March 2025. Billie had been brought to the Royal Free Hospital just before midnight the night before her death with an asthma attack.   A first presentation of asthma at the age of 16 years without any family history is unusual, and it was a busy night in the accident and emergency department. Billie was inappropriately discharged at approximately 3.30am without adequate repeat observations or senior clinical review, and so her asthma was not diagnosed or treated. If it had been, she probably would have survived. The MATTERS OF CONCERN are as follows: On the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations. Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical review would have changed the course of her management and saved her life. The registrar who saw Billie the night before her death prescribed an antibiotic, but he was not in the habit of giving the first dose in the department and he did not on this occasion. This meant that Billie’s infection was not tackled as quickly as it could have been. This seems to indicate a training and potentially a guideline need. At the time of Billie’s presentation, the registrar was unaware of the possibility of adult onset asthma. This seems to indicate a training and potentially a guideline need. I heard that Billie was safety netted when she was discharged. Her parents were told to bring her back if they had any concerns. I have heard this safety netting advice being described many, many times in different inquests. What worries me about it in this context is that Billie’s parents had brought her to hospital because they were concerned. They were then reassured by hospital staff. It is therefore difficult to see how this particular advice could be a meaningful instruction. In reality, her parents’ initial concern was well placed and they had responded to it appropriately by bringing Billie to hospital. When Billie began to deteriorate again, her parents’ natural instinct had been blunted by their first visit to the hospital. Whilst I doubt that it would have made a difference in this case, I understand that blood pressure is not yet an observation included in the national paediatric early warning score (PEWS).

With many children living in poverty, understanding how health inequalities affect children and young people is vital in order for the NHS to meet their health care needs. Miranda Davies reviews children’s hospital inpatient care in 2023/24 on five key clinical areas in England – asthma, diabetes, epilepsy, oral health and mental health.