Doctors knew the company that manufactures propofol had warned it should not be used on children and the Committee for Safety in Medicine issued a warning about the drug a year before Gavin Hodge died of suspected heart failure.
An inquest jury in Newcastle upon Tyne yesterday returned a verdict of misadventure, emphasising that they felt the drug was to blame for the boy's death. His parents are considering legal action against the city's Royal Victoria Infirmary.
The coroner, Leonard Coyle, said that he would write to the Committee for Safety in Medicine informing it of the jury's decision.
In November last year, Gavin was taken to the hospital with the respiratory illness croup, which causes inflammation of the larynx. He was in severe distress and was turning blue in the accident and emergency department through lack of breath.
He was discovered to have patchy pneumonia in one lung and a tube was fed down his windpipe to help him breathe.
Gavin, of Kestrel Avenue, Longbenton, Newcastle, was given a mixture of two other anaesthetic drugs but the powerfully built boy was still able to struggle and almost pulled out the tube. So doctors gave him propofol for 72 hours.
His condition deteriorated and his parents Derek, 36, and Debrah, 35, were told he had died on 23 November, four days after the drug was administered.
Two other children in Newcastle and three in the Oxford area have died after being given the drug. They were aged between 12 months and six years and all had respiratory problems.
Dr Joseph Stoddart, consultant in charge of the Royal Victoria Infirmary's intensive care unit, was asked by Peter Henry, solicitor for the Hodge family, whether he knew the manufacturers had advised against the drug being used on children.
He said: 'We often use drugs not recommended, we sometimes have to. The manufacturers are covering themselves in a sense.
'It was a choice of two evils. The ultimate evil would possibly have been death if the tube had been pulled out.
'I took the choice with all the information available at the time.'
Dr Stoddart admitted that the pump that had been feeding the drug into Gavin had been left on at a higher level than it should have been for three or four minutes.
But an inquiry revealed that he had not been given enough for it to be considered an overdose.
The coroner directed members of the jury that misadventure was the verdict they should return if they were satisfied the drug had been to blame.