Prolonged use of sedative caused death of 15-year-old boy with autism, inquest concludes

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.  

A four-day inquest into Antonio’s death was held at West Yorkshire Coroner’s Court in Wakefield from 1 - 4 December 2025. 

Antonio underwent successful heart surgery at Leeds General Infirmary for a congenital heart defect on 30 September 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 extubation (removal of endotracheal tube from a patient's windpipe) was delayed after staff suspected he had developed a chest infection. 

Antonio remained on Propofol for at least 121 hours. During this period 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 6 October, 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 7 October. 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 He explained that in Antonio’s case, Propofol should have been withdrawn and replaced by an alternative sedative agent within 24-48 hours.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. 

Following conclusion of the inquest, a Prevention of Future Deaths (PFD) report has been sent to the National Institute for Health and Care Excellence (NICE), flagging the lack of national guidance for the use of Propofol for short term sedation in children and young people on PICUs.  

Issuing copies of the PFD report to the Chief Coroner, Antonio’s parents and Leeds Teaching Hospitals Trust, the report states: 

“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. 

“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.” 

Antonio’s mother Milena Galisi is represented by Beatrice Morgan, human rights solicitor at law firm Leigh Day.   

Milena 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.” 

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." 

*This article was updated 9 December 2025