NHS England
NHS / Health Body
Disputed
• NHS England stated that NICE guidance NG245 provides advice on salbutamol overuse, including self-management and identifying at-risk individuals. • The guidance recommends including advice in self-management programmes for patients to contact a healthcare professional if asthma control deteriorates. • The guidance advises considering active identification of people with asthma at risk of poor outcomes, including those over-using short-acting beta2 agonist inhalers. (AI summary)
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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Roman Louie Barr who died on 14th December 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 4th March 2026 concerning the death of Roman Louie Barr on 14th December 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Roman’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Roman’s care have been listened to and reflected upon.
Your Report raises the following concerns:
1. There is limited awareness of salbutamol overuse by patients and families.
2. 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 handover delays are affecting emergency availability.
4. Families are exposing themselves to risk when having to transport critically unwell patients themselves due to ambulance shortages.
5. NHS Pathways triage wording may not be easily understood by lay callers in distress. Salbutamol overuse NICE guidance NG245 provides advice on treatments, self-management and identifying those at risk of poor outcomes, including in relation to the salbutamol inhaler:
1.14.5 Include advice in self-management programmes on contacting a healthcare professional for a review if asthma control deteriorates.
1.15.1 Consider actively identifying people with asthma who are at risk of poor outcomes and tailor care to their needs. Risk factors should include:
• non-adherence to medicines National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
20th April 2026
• over-use of short-acting beta2 agonist (SABA) inhalers (more than 2 inhalers per year)
• needing 2 or more courses of oral corticosteroids per year
• 2 or more visits to an emergency department or any hospital admission for asthma.
It is a legal requirement that all Prescription Only Medicines are supplied with a patient information leaflet. For inhaler prescriptions, these leaflets provide warnings on the risks of increasing the dose of salbutamol and what actions to take if the medicine stops working. All asthma patients should be offered the opportunity of a Personalised Asthma Action Plan and an annual review via their GP practice or respiratory care team, at which these risks can be reinforced and understanding checked. Symptom control and medication use, compliance and inhaler technique would usually be assessed at the routine annual asthma review and medication review (as per NICE guidance). General Practice IT systems allow the prescriber to set a maximum number of prescriptions before highlighting that it needs to be reviewed. Many local systems have issued specific reminders to their prescribers and in local formulary guidelines.
Excessive or repeated requested for inhalers High or early repeat SABA prescribing is recognised nationally as a marker of risk and sub-optimal disease control, rather than an issue that can be addressed through prescribing controls alone. NHS England’s approach focuses on using prescribing data to support risk-based clinical review and pathway-level action, recognising that meaningful improvement requires coordinated clinical responses rather than isolated system interventions. NHS England is taking this work forward through the Respiratory Transformation Partnership, working with partners including Asthma + Lung UK to support risk-based identification and more consistent adoption across systems. In parallel, NHS England is identifying the policy levers required to support any future national framework for respiratory care, recognising the importance of national coherence and prioritisation in enabling sustainable delivery at scale. Although not mandatory, through the GP Quality and Outcomes Framework (QOF), GP practices are incentivised to record patients on a practice asthma register and offer an annual asthma review which includes an assessment of asthma control, the number of exacerbations and a documented personalised action plan. However, whilst it is good practice and there are many examples of ways in which practices can do this, there is no specific requirement for practices to identify salbutamol overuse in individual patients. Community pharmacies are encouraged to counsel patients when they dispense inhalers including salbutamol and whilst it is good practice, there is no specific requirement for them to do so.
Ambulance shortages and risks for families transporting patients NHS England recognises the ongoing pressures across urgent and emergency care, including ambulance services. To improve the quality and timeliness of patient care, the Department of Health and Social Care and NHS England published the 2025/26 Urgent and Emergency Care Plan (June 2025) and the 10-Year Health Plan for England: Fit for the Future (July 2025). These plans set out key system priorities: reducing ambulance response times, eliminating handover delays over 45 minutes, ending corridor care, improving hospital flow and discharge and expanding urgent care access across primary, community, and mental health settings. Over £370 million in national capital funding supports these improvements. The plans also commit to shifting focus from treatment to prevention, reducing pressure on urgent and emergency care. To ensure timely patient care and release of ambulances back into the community, the 2025/26 Urgent and Emergency Care Plan mandates the “Release to Rescue” approach. The “Release to Rescue” approach will be triggered once a handover reaches 30 minutes and means that all ambulances must complete their handover and leave the hospital site at 45 minutes. NHS England continues to work with ICBs, acute trusts, and ambulance services to deliver the 45-minute maximum handover requirement, strengthen urgent community care, and improve hospital flow and discharge. Risks associated with long community waits for ambulances are regularly discussed at national forums to support shared understanding and coordinated action across the urgent and emergency care system. The Medium-Term Planning Framework (2026/27–2028/29) sets further ambitions for acute and ambulance collaboration, including progress toward the 15-minute handover standard. In 2022, NHS England reminded ambulance services that clinicians should use a risk assessment to decide whether a patient can be advised to make their own way to hospital, typically for Category 3, lower acuity patients. For higher-category patients, the arrangement of an ambulance remains the standard response and priority. Only in exceptional circumstances, after a remote clinical assessment has been completed, which determines that it is clinically appropriate, and that a timely resource is not available, may a clinician advise a higher-category patient to make their own way to hospital. This decision must be recorded on the electronic patient record. Clinicians should use Service Finder (directory of services) to identify the most appropriate service and communicate this to the patient. Non-clinical call handlers must not make this decision, although they may record when a caller chooses to make their own way to hospital.
NHS Pathways NHS Pathways is the Clinical Decision Support System (CDSS) used for remote clinical assessment (triage) in urgent and emergency care. In use since 2005, it
underpins all NHS 111 services and more than half of England’s 999 telephony systems. The tool also supports online triage, in-person and enhanced clinical assessments via modules such as the NHS Pathways Clinical Consultation Support (PaCCS) system. The safety of NHS Pathways triage outcomes - known as "dispositions" - is overseen by the National Clinical Assurance Group (NCAG), an independent intercollegiate body hosted by the Academy of Medical Royal Colleges. Alongside this external scrutiny, NHS Pathways aligns its content with up-to-date national clinical guidance, including NICE (National Institute for Health and Care Excellence), UK Resuscitation Council and UK Sepsis Trust. The system supports over 2.5 million triage assessments each month across telephone, digital, and face-to-face settings. NHS Pathways follows a structured clinical hierarchy. Serious and potentially life- threatening symptoms are assessed first to ensure rapid escalation - such as dispatching an ambulance or involving a clinician. The assessment then progresses to less urgent symptoms, identifying the most appropriate level of care. The tool is not diagnostic. Instead, it works by systematically ruling out more serious causes of symptoms to ensure safe, efficient triage. Relevant history is gathered where clinically necessary to minimise triage time while maintaining safety. In telephone settings, assessments are conducted by trained non-clinical health advisors. These advisors complete a rigorous training programme and are supported at all times by clinicians. If a case is complex or unclear, health advisors are required to escalate to clinical colleagues. It is therefore a condition of the NHS Pathways licence is that clinical supervision and escalation support must be available 24/7. NHS Pathways Triage Wording The initial triage that occurs within the NHS Pathways clinical decision support software aims to identify life threatening events and result in an emergency ambulance disposition. For those calling with severe breathing difficulty, a category 2 emergency ambulance is the lowest potential disposition that should be received. Since July 2020 the CDSS has, in respect of those with severe breathing difficulty and suspected asthma as the cause of their breathing difficulty, offered further triage to identify those who require a higher category 1 emergency ambulance. At the time of completing this work it was agreed that the criteria required for a category 1 ambulance for asthma would be severe breathing difficulty with systemic features of illness such as altered mental state and appearance of clinical shock. The question of concern “is the patient a deathly colour”, is the question used to identify symptoms of clinical shock within the CDSS. It has been utilised in triage prior to 2005. Questions within the system often have supporting information that helps the health advisor probe when necessary, as this one does. All supporting information utilises common style and design but, as with all content, can be subject to iterative review based upon feedback from providers. For example, if a provider identifies a question that health advisors are finding difficult to answer then they can raise this as a clinical enquiry to NHS Pathways for review.
In November 2020, this question was reviewed within a body of work to improve how any reference to skin colour was considered within the CDSS in the context of darker skin tones. A range of questions were amended with the aim of improving the identification of clinical features of illness in darker skin tones. The question of concern was one such question was updated and the content is included for reference in Figure 1 below. NHS Pathways remains committed to improving how clinical features utilised within triage can be improved for those with darker skin tones. Figure 1
In September 2021, a unit was added to NHS Pathways Core Module 1 mandatory training materials to give health advisors and clinicians more detailed guidance on identifying skin colour changes in patients with different skin colours. This training includes guidance on how to use the existing supporting information to form probing questions to help the caller understand what is being asked, and where on the body to best check for any change in skin colour. The module includes an interactive PowerPoint session explaining the challenges faced by those of non-white skin colours, as well as practice case studies and scenarios to help put this information into practice. It has formed a part of NHS Pathways Core Module 1 training since it’s initial inclusion in 2021. A number of changes relating to asthma have been incorporated into the CDSS since 2020, reflecting NHS England’s commitment to preventing adverse outcomes in asthma care. In November 2022, changes were made to ensure that asthma was identified at category 3 emergency ambulance level. This was further developed in September 2023 with the identification of asthmatics with less severe breathing difficulty but other features of illness at category 2 emergency ambulance level. In January 2024 the identification of altered mental state for those presenting with asthma and difficulty in breathing was expanded. Prior to this change, the triage
identified confusion and drowsiness. Following this change the triage identified confusion, agitation and drowsiness. In June 2025, in response to feedback from the West Midlands Ambulance Service regarding Roman’s death, the CDSS was amended. A piece of work was completed and agreed with the NCAG and national ambulance teams that provided for the dispatch of a category 1 emergency ambulance for those with asthma and either altered mental state or appearance of clinical shock. This change lowered the previously agreed threshold for category 1 ambulance for severe breathing difficulty in asthma. Regional Response The NHS England Midlands regional team have advised that they are currently supporting West Midlands Ambulance Service (WMAS) with performance improvements by reducing handover delays across West Midlands acute hospitals. To ensure WMAS can work towards delivering the Category 2 constitutional standard of 18 minutes consistently there is a comprehensive programme of work in place led by NHS England Regional Executives (Chief Operating Officer, Medical Director and Chief Nurse) who are working with their respective Acute Hospital Chief Operating Officers, Medical Directors and Chief Nursing Officers to reduce ambulance handover delays. The impact of prolonged ambulance handover delays has a direct correlation on ambulance category 2 performances and staff morale and wellbeing. If ambulance crews can handover the care of the patient into the care of the acute hospital emergency department in a timelier manner, this then allows crews to be back on the road to respond to any emergencies out in the community. The work on reducing handover delays is part of a national programme (Release to Rescue / 45 minutes programme) to ensure the maximum wait to handover patients into the care of the emergency department is no more than 45 minutes. Delivering this requires a comprehensive amount of work by both the acute trusts (clinically and operationally) working collectively with the respective WMAS ambulance services colleagues to implement this safely. This builds on the successful work that other ambulance services nationally have implemented to reduce ambulance handover delays. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Roman are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 4th March 2026 concerning the death of Roman Louie Barr on 14th December 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Roman’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Roman’s care have been listened to and reflected upon.
Your Report raises the following concerns:
1. There is limited awareness of salbutamol overuse by patients and families.
2. 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 handover delays are affecting emergency availability.
4. Families are exposing themselves to risk when having to transport critically unwell patients themselves due to ambulance shortages.
5. NHS Pathways triage wording may not be easily understood by lay callers in distress. Salbutamol overuse NICE guidance NG245 provides advice on treatments, self-management and identifying those at risk of poor outcomes, including in relation to the salbutamol inhaler:
1.14.5 Include advice in self-management programmes on contacting a healthcare professional for a review if asthma control deteriorates.
1.15.1 Consider actively identifying people with asthma who are at risk of poor outcomes and tailor care to their needs. Risk factors should include:
• non-adherence to medicines National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
20th April 2026
• over-use of short-acting beta2 agonist (SABA) inhalers (more than 2 inhalers per year)
• needing 2 or more courses of oral corticosteroids per year
• 2 or more visits to an emergency department or any hospital admission for asthma.
It is a legal requirement that all Prescription Only Medicines are supplied with a patient information leaflet. For inhaler prescriptions, these leaflets provide warnings on the risks of increasing the dose of salbutamol and what actions to take if the medicine stops working. All asthma patients should be offered the opportunity of a Personalised Asthma Action Plan and an annual review via their GP practice or respiratory care team, at which these risks can be reinforced and understanding checked. Symptom control and medication use, compliance and inhaler technique would usually be assessed at the routine annual asthma review and medication review (as per NICE guidance). General Practice IT systems allow the prescriber to set a maximum number of prescriptions before highlighting that it needs to be reviewed. Many local systems have issued specific reminders to their prescribers and in local formulary guidelines.
Excessive or repeated requested for inhalers High or early repeat SABA prescribing is recognised nationally as a marker of risk and sub-optimal disease control, rather than an issue that can be addressed through prescribing controls alone. NHS England’s approach focuses on using prescribing data to support risk-based clinical review and pathway-level action, recognising that meaningful improvement requires coordinated clinical responses rather than isolated system interventions. NHS England is taking this work forward through the Respiratory Transformation Partnership, working with partners including Asthma + Lung UK to support risk-based identification and more consistent adoption across systems. In parallel, NHS England is identifying the policy levers required to support any future national framework for respiratory care, recognising the importance of national coherence and prioritisation in enabling sustainable delivery at scale. Although not mandatory, through the GP Quality and Outcomes Framework (QOF), GP practices are incentivised to record patients on a practice asthma register and offer an annual asthma review which includes an assessment of asthma control, the number of exacerbations and a documented personalised action plan. However, whilst it is good practice and there are many examples of ways in which practices can do this, there is no specific requirement for practices to identify salbutamol overuse in individual patients. Community pharmacies are encouraged to counsel patients when they dispense inhalers including salbutamol and whilst it is good practice, there is no specific requirement for them to do so.
Ambulance shortages and risks for families transporting patients NHS England recognises the ongoing pressures across urgent and emergency care, including ambulance services. To improve the quality and timeliness of patient care, the Department of Health and Social Care and NHS England published the 2025/26 Urgent and Emergency Care Plan (June 2025) and the 10-Year Health Plan for England: Fit for the Future (July 2025). These plans set out key system priorities: reducing ambulance response times, eliminating handover delays over 45 minutes, ending corridor care, improving hospital flow and discharge and expanding urgent care access across primary, community, and mental health settings. Over £370 million in national capital funding supports these improvements. The plans also commit to shifting focus from treatment to prevention, reducing pressure on urgent and emergency care. To ensure timely patient care and release of ambulances back into the community, the 2025/26 Urgent and Emergency Care Plan mandates the “Release to Rescue” approach. The “Release to Rescue” approach will be triggered once a handover reaches 30 minutes and means that all ambulances must complete their handover and leave the hospital site at 45 minutes. NHS England continues to work with ICBs, acute trusts, and ambulance services to deliver the 45-minute maximum handover requirement, strengthen urgent community care, and improve hospital flow and discharge. Risks associated with long community waits for ambulances are regularly discussed at national forums to support shared understanding and coordinated action across the urgent and emergency care system. The Medium-Term Planning Framework (2026/27–2028/29) sets further ambitions for acute and ambulance collaboration, including progress toward the 15-minute handover standard. In 2022, NHS England reminded ambulance services that clinicians should use a risk assessment to decide whether a patient can be advised to make their own way to hospital, typically for Category 3, lower acuity patients. For higher-category patients, the arrangement of an ambulance remains the standard response and priority. Only in exceptional circumstances, after a remote clinical assessment has been completed, which determines that it is clinically appropriate, and that a timely resource is not available, may a clinician advise a higher-category patient to make their own way to hospital. This decision must be recorded on the electronic patient record. Clinicians should use Service Finder (directory of services) to identify the most appropriate service and communicate this to the patient. Non-clinical call handlers must not make this decision, although they may record when a caller chooses to make their own way to hospital.
NHS Pathways NHS Pathways is the Clinical Decision Support System (CDSS) used for remote clinical assessment (triage) in urgent and emergency care. In use since 2005, it
underpins all NHS 111 services and more than half of England’s 999 telephony systems. The tool also supports online triage, in-person and enhanced clinical assessments via modules such as the NHS Pathways Clinical Consultation Support (PaCCS) system. The safety of NHS Pathways triage outcomes - known as "dispositions" - is overseen by the National Clinical Assurance Group (NCAG), an independent intercollegiate body hosted by the Academy of Medical Royal Colleges. Alongside this external scrutiny, NHS Pathways aligns its content with up-to-date national clinical guidance, including NICE (National Institute for Health and Care Excellence), UK Resuscitation Council and UK Sepsis Trust. The system supports over 2.5 million triage assessments each month across telephone, digital, and face-to-face settings. NHS Pathways follows a structured clinical hierarchy. Serious and potentially life- threatening symptoms are assessed first to ensure rapid escalation - such as dispatching an ambulance or involving a clinician. The assessment then progresses to less urgent symptoms, identifying the most appropriate level of care. The tool is not diagnostic. Instead, it works by systematically ruling out more serious causes of symptoms to ensure safe, efficient triage. Relevant history is gathered where clinically necessary to minimise triage time while maintaining safety. In telephone settings, assessments are conducted by trained non-clinical health advisors. These advisors complete a rigorous training programme and are supported at all times by clinicians. If a case is complex or unclear, health advisors are required to escalate to clinical colleagues. It is therefore a condition of the NHS Pathways licence is that clinical supervision and escalation support must be available 24/7. NHS Pathways Triage Wording The initial triage that occurs within the NHS Pathways clinical decision support software aims to identify life threatening events and result in an emergency ambulance disposition. For those calling with severe breathing difficulty, a category 2 emergency ambulance is the lowest potential disposition that should be received. Since July 2020 the CDSS has, in respect of those with severe breathing difficulty and suspected asthma as the cause of their breathing difficulty, offered further triage to identify those who require a higher category 1 emergency ambulance. At the time of completing this work it was agreed that the criteria required for a category 1 ambulance for asthma would be severe breathing difficulty with systemic features of illness such as altered mental state and appearance of clinical shock. The question of concern “is the patient a deathly colour”, is the question used to identify symptoms of clinical shock within the CDSS. It has been utilised in triage prior to 2005. Questions within the system often have supporting information that helps the health advisor probe when necessary, as this one does. All supporting information utilises common style and design but, as with all content, can be subject to iterative review based upon feedback from providers. For example, if a provider identifies a question that health advisors are finding difficult to answer then they can raise this as a clinical enquiry to NHS Pathways for review.
In November 2020, this question was reviewed within a body of work to improve how any reference to skin colour was considered within the CDSS in the context of darker skin tones. A range of questions were amended with the aim of improving the identification of clinical features of illness in darker skin tones. The question of concern was one such question was updated and the content is included for reference in Figure 1 below. NHS Pathways remains committed to improving how clinical features utilised within triage can be improved for those with darker skin tones. Figure 1
In September 2021, a unit was added to NHS Pathways Core Module 1 mandatory training materials to give health advisors and clinicians more detailed guidance on identifying skin colour changes in patients with different skin colours. This training includes guidance on how to use the existing supporting information to form probing questions to help the caller understand what is being asked, and where on the body to best check for any change in skin colour. The module includes an interactive PowerPoint session explaining the challenges faced by those of non-white skin colours, as well as practice case studies and scenarios to help put this information into practice. It has formed a part of NHS Pathways Core Module 1 training since it’s initial inclusion in 2021. A number of changes relating to asthma have been incorporated into the CDSS since 2020, reflecting NHS England’s commitment to preventing adverse outcomes in asthma care. In November 2022, changes were made to ensure that asthma was identified at category 3 emergency ambulance level. This was further developed in September 2023 with the identification of asthmatics with less severe breathing difficulty but other features of illness at category 2 emergency ambulance level. In January 2024 the identification of altered mental state for those presenting with asthma and difficulty in breathing was expanded. Prior to this change, the triage
identified confusion and drowsiness. Following this change the triage identified confusion, agitation and drowsiness. In June 2025, in response to feedback from the West Midlands Ambulance Service regarding Roman’s death, the CDSS was amended. A piece of work was completed and agreed with the NCAG and national ambulance teams that provided for the dispatch of a category 1 emergency ambulance for those with asthma and either altered mental state or appearance of clinical shock. This change lowered the previously agreed threshold for category 1 ambulance for severe breathing difficulty in asthma. Regional Response The NHS England Midlands regional team have advised that they are currently supporting West Midlands Ambulance Service (WMAS) with performance improvements by reducing handover delays across West Midlands acute hospitals. To ensure WMAS can work towards delivering the Category 2 constitutional standard of 18 minutes consistently there is a comprehensive programme of work in place led by NHS England Regional Executives (Chief Operating Officer, Medical Director and Chief Nurse) who are working with their respective Acute Hospital Chief Operating Officers, Medical Directors and Chief Nursing Officers to reduce ambulance handover delays. The impact of prolonged ambulance handover delays has a direct correlation on ambulance category 2 performances and staff morale and wellbeing. If ambulance crews can handover the care of the patient into the care of the acute hospital emergency department in a timelier manner, this then allows crews to be back on the road to respond to any emergencies out in the community. The work on reducing handover delays is part of a national programme (Release to Rescue / 45 minutes programme) to ensure the maximum wait to handover patients into the care of the emergency department is no more than 45 minutes. Delivering this requires a comprehensive amount of work by both the acute trusts (clinically and operationally) working collectively with the respective WMAS ambulance services colleagues to implement this safely. This builds on the successful work that other ambulance services nationally have implemented to reduce ambulance handover delays. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Roman are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.