Use of sedative caused death of 15-year-old boy with autism at Leeds General Infirmary, inquest concludes
The mother of a teenage boy who died in hospital in Leeds in a “traumatic and avoidable way” has issued an appeal.
An inquest into the death of 15-year-old Antonio Galisi-Swallow this week found that he died as a result of the prolonged use of the sedative drug Propofol at Leeds General Infirmary.
Recording a narrative conclusion, Area Coroner Oliver Longstaff accepted expert evidence and stated that had Propofol been administered in line with the Leeds Teaching Hospitals NHS Trust’s new guidance, it is unlikely Antonio would have died when he did.
Antonio’s mother, Milena Galisi, said: “Antonio 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.”
A four-day inquest into Antonio’s death was held in Wakefield from Monday until Thursday, December 4, this week.
The court heard that Antonio underwent successful heart surgery at Leeds General Infirmary for a congenital heart defect on September 30, 2021.
In the days that followed, Antonio – who had learning disabilities and autism – was kept sedated in the Paediatric Intensive Care Unit with an infusion of Propofol and morphine. The inquest heard the plan had been to keep him sedated overnight and wake him the next morning, but the removal of tubing from his windpipe was delayed after staff suspected he had developed a chest infection.
Antonio remained on Propofol for at least 121 hours, during which time his temperature repeatedly spiked, reaching over 40°C, and he showed multiple signs of multi-organ distress. Despite test results indicating that he was responding to antibiotics, clinicians continued to work on the basis that an infection was causing his symptoms. Antonio’s mother, Milena Galisi, told the inquest she’d repeatedly raised her concerns as she watched his condition deteriorate.
The inquest heard that by October 6, Antonio had worsening cardiovascular instability, kidney injury, high fevers, and signs of rhabdomyolysis – symptoms that expert evidence later confirmed were characteristic of Propofol Infusion Syndrome (PRIS).
Antonio went into cardiac arrest in the early hours of October 7. Resuscitation attempts were unsuccessful, and he died that morning. A post-mortem noted the underlying cause of death as prolonged Propofol administration.
Expert evidence from a consultant paediatric intensivist said that Antonio’s deterioration was not consistent with an uncontrolled infection and was, on the balance of probabilities and with a high degree of certainty, caused by PRIS.
He told the court that the prolonged use of Propofol in children is “controversial” and is not recommended because of the risk of PRIS. He explained that in Antonio’s case, Propofol should have been withdrawn and replaced by an alternative sedative agent within 24-48 hours. He explained the difficulties in managing PRIS, and that in his opinion “avoidance” is the most important factor.
Since Antonio’s death, Leeds Teaching Hospitals NHS Trust has produced guidelines relating to the use of Propofol in children and young people. The expert said that had Propofol been used in-line with current guidelines - which didn’t exist then - Antonio “almost certainly” would have survived.
Dr Magnus Harrison, Chief Medical Officer at Leeds Teaching Hospitals NHS Trust, said: “We are deeply sorry for the tragic loss of Antonio. Our medical teams did everything they could to save his life and our condolences and thoughts are with his family at this very difficult time.
“There is no national guidance on the use of propofol for short term sedation in children and young people in intensive care, however, since Antonio’s death the Trust has devised and implemented its own guidelines. We recognise this will be of little comfort for Antonio’s family, and we are sorry for the pain they have endured.”
Antonio’s mother Milena Galisi is represented by Beatrice Morgan, human rights solicitor at law firm Leigh Day.
Beatrice Morgan 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.