Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0608, written 4 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Dec 2025 |
|---|---|
| Reference | 2025-0608 |
| Deceased | Antonio Galisi-Swallow |
| Coroner | Oliver Longstaff |
| Coroner area | West Yorkshire (Eastern) |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
OFFICE OF THE
SENIOR CORONER
for the County of West Yorkshire
(Eastern District)
His Majesty’s Coroner’s Office
The Coroner’s Courts
Burgage Square
Wakefield WF1 2TS
Telephone: 01924 302180
Email: hmcoroner@wakefield.gov.uk
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Professor Simon Kenny, National Clinical Director for Children and Young People,
NHS England
2. Paediatric Critical Care Society
CORONER
I am Oliver Robert Longstaff, HM Area Coroner for the Coroner Area of West Yorkshire (East).
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of The Coroners (Investigations) Regulations 2013.
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
1
2
3
4
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.
CORONER’S CONCERNS
During the course of the Inquest the evidence revealed matters giving rise to concern. In my
opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it
is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
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.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you or your
organisation have the power to take such action. 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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely
by 26/03/2026. I, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons or
5
6
7
8
their legal representatives: Antonio’s parents; Leeds Teaching Hospitals Trust; Professor
Stephen Playfor.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.
Signed:
9
OLIVER LONGSTAFF
HM Area Coroner
West Yorkshire (E)
Date: 29 January 2026
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Oliver Robert Longstaff
HM Area Coroner for West Yorkshire (East)
Coroner’s Service
71 Northgate
Wakefield
West Yorkshire
WF1 3BS
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
23rd March 2026
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
include patient selection,
contraindications, cautions, and local prescribing issues (such as who can prescribe,
review and monitoring details, and limitations on use).
local protocols. Such protocols should
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.
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.
2.
3.
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.
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).
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.
Yours sincerely,
National Medical Director
NHS England
2nd Floor
2 Redman Place
London
E20 1JQ
United Kingdom
+44 (0)300 323 0140
14 January 2026
Oliver Longstaff
HM Coroner
The Coroners Court
Burgage Square
Wakefield
WF1 2TS
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
Antonio Galisi-Swallow. I would like to express my sincere condolences to Antonio’s
family.
, regarding the very sad death of
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
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.
Yours sincerely,
Chief Executive
CBE MD FRCS FRCEM
Page | 2
Attention! This email originates from outside of Wakefield Council. Do not open attachments or click links unless you are sure this email comes from a known sender and you know the content is safe. . To: Oliver Robert Longstaff HM Area Coroner West Yorkshire (East) 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, Yours sincerely, President, Paediatric Critical Care Society
See every Prevention of Future Deaths report matching Child Death (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.