Roman Barr
Evidence boundary. This page is a structured project extraction from the linked primary Prevention of Future Deaths source. It is not the report text. Do not infer cause, prevalence or product-wide performance beyond the source and the explicit qualification below.
Open the primary Judiciary source · Source register: SRC-189 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0148 |
| Registered primary source | SRC-189 |
| Report date | 2026-03-04 |
| Coroner area | Coventry |
| Clinical setting | Primary care and ambulance telephone triage |
| Care transition | Asthma self-management and 999 calls to ambulance disposition |
| Primary workflow group | Triage, observations and decision support |
| Primary browsing context | Acute and emergency care |
| Predominant information boundary | Patient-to-service channel |
The workflow, browsing-context and predominant-boundary fields are retained navigation aids. They are not additional coronial findings, and a single primary value cannot express every aspect of a multi-setting or multi-mechanism report.
Care-pathway classification
This classification distinguishes where safety-relevant information or work arose, where action was expected and where the digital or information workflow failed. It is a project coding of the source, not a coronial statement. “Origin” does not mean the organisation caused the harm.
| Dimension | Project classification |
|---|---|
| Settings and pathway participants | Patient or home, Primary care, Ambulance, NHS 111 or urgent response |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Patient or public, Primary care |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Primary care, Ambulance or urgent response |
| Directional pathway | Multiple settings or services → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: The report contains a patient-to-ambulance triage failure and a separate primary-care surveillance concern, so origins, destinations and failure points are distributed.
Classification confidence applies only to this care-pathway coding. It is separate from extraction confidence, source authority and causal certainty.
Evidence status and qualification
| Field | Status |
|---|---|
| Extraction confidence | high |
| Verification status | Primary source linked; high-confidence extraction |
| Response evidence status | Response evidence noted |
| Registered response sources | SRC-231, SRC-232, SRC-233, SRC-234 |
| Non-exclusive mechanism codes | LOOP, GOV, HF, ALERT |
Qualification recorded in the dataset: The coroner found that clearer wording would probably have produced a category 1 response and earlier ambulance intervention would probably have prevented death; the report also contains wider capacity and asthma-management factors
“Response evidence noted” means only that the row qualification refers to response/respondent evidence or records a recipient's post-report position. The linked IDs enumerate the official response attachments registered for this row; they do not imply that every response supports every part of the qualification, and they do not establish implementation. “Not assessed” makes no claim about whether a response exists.
Structured project extraction
These fields are analytical summaries, not quotations.
Project summary of the coroner's concern
Unclear NHS Pathways wording and unreliable follow-up of salbutamol overuse could leave severe asthma unrecognised
Requested action
DHSC, NHS England and NHS Pathways, RCGP and CQC to improve triage wording, asthma awareness, reliever-overuse follow-up and handover risk
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | NHS Pathways and primary-care prescribing record |
| Digital function | Remote acuity questioning and reliever-overuse surveillance |
| Failure mode | A scripted colour question was not understood for a darker-skinned patient and repeated salbutamol requests were not reliably identified |
| Human-factors issue | Lay wording did not elicit visible cyanosis and clinicians and family lacked a shared understanding of excessive reliever use |
| Workflow issue | Triage lacked clearer prompts and primary care lacked a consistent identification and follow-up process for overuse |
| Information issue | Critical cyanosis and a longitudinal pattern of reliever use were not converted into actionable risk states |
Downstream Defence trace
No canonical candidate Defence requirement currently cites this report. This does not imply that the mechanism is irrelevant; any mapping must be added and qualified in the controlled requirements register.
The included-case dataset preserves early legacy_military_relevance and legacy_derived_requirement fields for audit history. They are not published here as requirements and must not override the canonical REQ register. New report rows do not need to populate them.