“, giving rise to a risk of future deaths: The MATTERS OF CONCERN are as follows”
Dated 4 Mar 2026, from the coroner for Coventry. Sent to 5 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 29 Apr 2026. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated4 Mar 2026
- Deadline29 Apr 2026
- Published on judiciary.uk18 Mar 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in March 2026. |
| NHS England | Response publishedPublished on judiciary.uk in March 2026. |
| NHS Pathways/ NHS Digital | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 29 Apr 2026. A reply may have been sent and not yet published. |
| Royal College for GP’s | Response publishedPublished on judiciary.uk in March 2026. |
| Care Quality Commission | Response publishedPublished on judiciary.uk in March 2026. |
The coroner’s concerns
, giving rise to a risk of future deaths: The MATTERS OF CONCERN are as follows. – 1. 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. 2. 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. 3. 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. 4. 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. 5. 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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to act. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29th April 2026.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2026-0148
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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