Antonio Galisi-Swallow

Dear Mr Longstaff, Re: Regulation 28 Report – Death of Antonio Galisi-Swallow Thank you for your report dated 29 January 2026. On behalf of the Paediatric Critical Care Society (PCCS), I wish to acknowledge the concerns you have raised and to outline the actions we are taking to reduce the risk of future deaths. We have liaised closely with NHS England colleagues regarding the actions required in response the Reg28 report. Below are the PCCS actions we have agreed to undertake.
1. Communication to PCCS Members We have informed all PCCS members—over 1300 multidisciplinary professionals across the UK—of the risk of Propofol-Related Infusion Syndrome (PRIS). In this communication, we highlighted the issues raised in your report and referenced the case. We also emphasised the need for every paediatric critical care unit to maintain local guidance for the use of propofol in PCC. This communication was disseminated in February 2026.
2. Joint Position Statement PCCS has convened a specialist group including paediatric intensivists, anaesthetists and pharmacists, with representation from PCCS, the Association of Paediatric Anaesthetists (APA) and the Neonatal and Paediatric Pharmacists Group (NPPG). This group is producing a joint position statement on the use of propofol in paediatric critical care. We expect to publish this on our respective websites in the Summer of 2026.
3. Revision of PCCS Quality Standards As part of the scheduled update to the PCCS Quality Standards (Version 7), we will introduce a mandatory minimum standard requiring all Level 3 paediatric critical care units to have an agreed local guideline for propofol use. This revision will be published later this year. We are committed to supporting safe sedation practice across paediatric critical care and believe the actions above represent meaningful steps to address the concerns identified in your report. Please let me know if further information would assist your consideration. On behalf of PCCS,

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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Antonio Galisi-Swallow who died on 7th October 2021. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29th January 2026 concerning the death of Antonio Galisi-Swallow on 7th October 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Antonio’s parents and family. NHS England is keen to assure the family and yourself that the concerns raised about Antonio’s care have been listened to and reflected upon. Your Report raises concerns that there is no national guidance for the use of propofol for short term sedation in children and young people on Paediatric Intensive Care Units (PICUs). Summary of Product Characteristics (SPC) and the British National Formulary (BNF) entry for propofol do include an indication for the 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)’. We have had sight of Professor response to your Report and concur with him that the above does not mean that propofol cannot be used in clinical practice 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 prescribe, review and monitoring details, and limitations on use). NHS England commission PICU services in line with Paediatric Critical Care Society (PCCS) standards. Standard L3-505 lists clinical guidance that each PICU should have in use and these include ‘Drug administration and medicines management’ and ‘Procedural sedation and analgesia’. PICU services are responsible for developing their own local guidelines as a requirement of PCCS standards.

[Page 2] Locally developed guidance (taken through Trust governance) is mandated and is part of NHS England’s commissioning documentation as well as professional standards. Locally developed guidance allows guidance to be specific to the Trust’s PICU and the population being treated there, as there are different uses for drugs in different PICUs. For example a cardiac PICU will use different doses of drugs. In response to the Inquest touching the death of Antonio Galisi-Swallow NHS England and the PCCS will take forward the following actions:
1. The PCCS communications team has shared a "President's message" - an email bulletin to all PCCS members ( professionals actively involved in or contributing to paediatric critical care, including doctors, nurses, and allied health professionals) referencing the Regulation 28 Report and the risk of propofol infusion syndrome in PICUs. This has been completed as of February 2026.
2. PCCS will produce a position statement on the use of propofol in Paediatric Intensive Care to formally raise awareness amongst the PICU community. This will be produced in collaboration with the National Paediatric Pharmacy Group (NPPG) and the Association of Paediatric Anaesthetists (APA). This statement will be shared with all PCCS members and hosted on the PCCS website. (Expected completion date: Summer 2026).
3. The next iteration of the PCCS standards ( Version 7 is currently under development) will include a specific requirement that all PCC units must have a local guideline for the use of propofol in PICU. (Expected completion date: end of 2026) NHS England will support with the development and implementation of the actions to ensure all PICUs have appropriate arrangements in place for the safe use of propofol. Action 2 allows engagement with the relevant professional groups (anaesthetists and pharmacy) and is a formal communication to ensure units take swift action without waiting for the longer-term action of the overall standards re-write (Action 3 listed above). 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 Antonio, 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.