Source · Prevention of Future Deaths

Antonio Galisi-Swallow

Ref: 2025-0608 Date: 4 Dec 2025 Coroner: Oliver Longstaff Area: West Yorkshire Eastern Responses identified: 1 / 3 View PDF

There is an absence of national guidance for the use of propofol for short-term sedation in children and young people in paediatric intensive care units.

Date 4 Dec 2025

56-day deadline 29 Jan 2026 est.

Responses identified 1 of 3

Child Death (from 2015)

Coroner's concerns

AI summary

There is an absence of national guidance for the use of propofol for short-term sedation in children and young people in paediatric intensive care units.

View full coroner's concerns

During the inquest, the court was told that there is no national guidance for the use of propofol for short term sedation in children and young people on PICU’s. Following Antonio’s death, the Leeds Teaching Hospitals Trust has devised and implemented a “Guideline of the use of propofol for short term sedation in children and young people on PICU (by consultant approval only)”. The consultant paediatric intensivist who appeared at the inquest as an independent expert witness wholeheartedly endorsed that document, and opined that, had its provisions been in place in October 2021, it is likely that Antonio would not have died when he did. A copy of that document is attached. As a coroner making a report of this nature, it is not for me to recommend to any third party that the document developed by the Leeds Teaching Hospitals Trust, or any document like it, should be either more widely disseminated or adopted as official guidance.

Responses

1 respondent

National Institute for Health and Care Excellence Other

14 Jan 2026 PDF

Noted

NICE declines to develop national guidance on propofol for short-term sedation in children on PICUs, stating that local protocols are more appropriate due to varying local prescribing issues. They suggest that NHS England or the Paediatric Critical Care Society could consider suggesting that all PICUs develop local protocols. (AI summary)

View full response

Dear Mr Oliver

Re: Regulation 28 Prevention of Future Deaths Report (Antonio Galisi- Swallow)

I write in response to your regulation 28 report dated 4 December 2025 and addressed to my predecessor , regarding the very sad death of Antonio Galisi-Swallow. I would like to express my sincere condolences to Antonio’s family.

The patient safety leads at NICE have discussed the report and understand that your request is that we develop national guidance on propofol for short term sedation in children and young people on paediatric intensive care units (PICUs).

Our conclusion is that NICE is not the appropriate organisation to develop guidance in this area, and I have explained the reasoning for this below.

The summary of product characteristics (SPC) and the British National Formulary (BNF) entry for propofol do include an indication for sedation of children under 16 years, however it is a specific contraindication in section 4.3 of the SPC: ‘Propofol must not be used in patients of 16 years of age or younger for sedation for intensive care. Safety and efficacy for these age groups have not been demonstrated (see section 4.4)’.

I would like to make it clear that we are not saying that propofol should not have been used in this situation, as many drugs are not licensed for use in children due to a lack of specific paediatric research evidence. However, use of these types of drugs should be supported by strong local protocols. Such protocols should include patient selection, contraindications, cautions, and local prescribing issues (such as who can

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prescribe, review and monitoring details, and limitations on use). As these issues will vary by locality, they are best described in local guidance. .

The Paediatric Critical Care Society Standards outline the requirements for care, and Standard L3-505 lists the clinical guideline that each PICU should have; these include ‘Drug administration and medicines management’ and ‘Procedural sedation and analgesia’. We would expect guidance on the use of propofol to be included in this.

Our view is that this issue would be best addresses by NHS England or the Paediatric Critical Care Society (PCCS) who could consider the suggestion that all PICUs develop local protocols such as the one used in Leeds. The following contacts may be useful to you for this purpose:

• NHS England’s national clinical director for children and young people, Professor

• PCCS via

I hope that the information above is helpful and would like to reiterate my sincere condolences to Antonio’s family.

Report sections

Investigation and inquest

On 12/10/2021 I commenced an investigation into the death of Antonio Galisi-Swallow who died aged 15 in the Leeds General Infirmary on 7th October 2021, three weeks short of his 16th birthday. The investigation concluded at the end of the Inquest on 04/12/2025. The medical cause of death was 1a) Propofol-Related Infusion Syndrome (“PRIS”); b) Prolonged Propofol Administration Post Cardiac Surgery; 2) Trisomy 21 with Surgically-Corrected Congenital Cardiac Malformation. In summary, the narrative conclusion to the inquest was that Antonio died from the effects of receiving a continuous propofol infusion of 5634 milligrams plus additional bolus doses over a period of 121 hours, while in post-operative sedation on the Paediatric Intensive Care Unit (“PICU”).

Circumstances of the death

Antonio had Downs, ADHD and was on the Autistic Spectrum Disorder. He was born with Tetralogy of Fallot, a congenital cardiac malformation that required a series of surgical interventions. He underwent a pulmonary valve implantation procedure on 30th September 2021 to address his severe pulmonary valve regurgitation. Following surgery, Antonio was admitted to the PICU under sedation with significant ventilatory requirements related to a presumed chest infection for which he was given antibiotics, requiring mechanical ventilation for a longer period than originally intended. Antonio’s sedation was maintained from 30th September by a constant propofol infusion and occasional bolus doses, the overall rate of infusion being gradually reduced, but never stopped. From 4th October, Antonio developed a persistent and increasing fever, though his infection markers were falling. On 5th October he was noted to have a Stage 1 acute kidney injury, although his infection markers were either normal or still falling. His clinical features were consistent with a resolving chest infection, his worsening pyrexia and renal failure being likely due to another pathological process. On 6th October, concern was raised for the first time that Antonio’s deterioration might be due to PRIS. His propofol was stopped and replaced with fentanyl. Blood tests for creatine kinase, triglycerides and lactate were strongly supportive of the suggested diagnosis. By the evening of that day, Antonio was displaying what an expert witness described as almost all the classically reported features of PRIS. Tests and investigations to confirm a diagnosis continued into the early hours of 7th October, although Antonio’s parents expressed concerns that their son had been through enough and should be allowed to pass away. He went into cardiac arrest at 0337h and, despite attempts at resuscitation, was pronounced deceased at 0400h.

Action should be taken

I have been advised by Professor Jonathan Benger, Chief Executive, National Institute for Health and Care Exellence (to which organisation this report was originally sent) that your organisation is more appropriately placed to act upon it. I attach a copy of Professor Benger’s letter to me dated 14/01/2026.

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Report details

Reference: 2025-0608
Date of report: 4 December 2025
Coroner: Oliver Longstaff
Coroner area: West Yorkshire Eastern

Responses identified

Responses identified 1 of 3

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 29 Jan 2026 (estimated).

Sent to

National Institute for Health and Care Excellence

Paediatric Critical Care Society

National Clinical Director for Children and Young People,

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.