Inquest concludes boy’s death at Leeds hospital caused by 'prolonged use of sedative'
The 15-year-old died after being administered Propofol for over 120 hours
The death of a 15-year-old boy at Leeds General Infirmary was caused by the prolonged use of the sedative Propofol, an inquest has concluded.
Antonio Galisi-Swallow, who had autism and learning disabilities, died in the early hours of October 7 2021 following successful surgery to treat a congenital heart defect.
Following the four-day inquest at West Yorkshire Coroner’s Court, Area Coroner Oliver Longstaff recorded a narrative conclusion.
The court that had Propofol been administered in line with Leeds Teaching Hospitals NHS Trust’s current guidelines, his death would likely have been prevented.
Following his heart surgery on September 30 2021, Antonio was kept sedated in the Paediatric Intensive Care Unit on Propofol and morphine.
The plan had been to wake him the next morning, but extubation (removal of a tube) was delayed when staff suspected a chest infection.
He remained on Propofol for at least 121 hours, during which time he exhibited various symptoms including a high fever and cardiovascular instability.
A consultant provided evidence that the symptoms were characteristic of Propofol Infusion Syndrome (PRIS), stating that prolonged use of the drug in children is “controversial” and should not exceed 24-48 hours.
The teenager went into cardiac arrest on October 7, and resuscitation attempts were unsuccessful.
A post-mortem confirmed the cause of death as prolonged Propofol administration.
The court heard that Leeds Teaching Hospitals NHS Trust has since developed new guidelines for Propofol use in children and young people, and under these new rules, Antonio “almost certainly” would have survived.
His mother, Milena Galisi, said: “My son went into hospital as a healthy, happy boy for a planned procedure that was supposed to make his life better.
"Instead, I watched him suffer for days as he became more and more unwell, and my concerns were not listened to.
"No family should ever have to see their child die in such a traumatic and avoidable way. I hope that by speaking out, more awareness will be raised about the dangers of Propofol so that no other child loses their life like Antonio did".
Solicitor Beatrice Morgan, representing the family, said:
“This is a devastating case. Antonio’s heart surgery was successful, and he should have recovered.
"Instead, he was kept on a drug that his clinicians knew carried serious risks when used for prolonged sedation. Rather than consider alternative sedatives, Propofol was continued for six days.
"The expert evidence is unequivocal—Antonio died from Propofol Infusion Syndrome, and his death was preventable. "
The family now hopes that lessons are learned and that no other child is exposed to these avoidable dangers".
Leeds Teaching Hospitals NHS Trust has been approached for a response to this story.