“During the inquest, the court was told that there is no national guidance for the use of…”
Dated 4 Dec 2025, from the coroner for West Yorkshire (Eastern). Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 29 Jan 2026.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated4 Dec 2025
- Deadline29 Jan 2026
- Published on judiciary.uk8 Dec 2025
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| National Institute for Health and Care Excellence | Response publishedPublished on judiciary.uk in December 2025. |
The coroner’s concerns
– 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. 5 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.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0608
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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