King's College Hospital NHS Foundation Trust v T & Ors

In deciding whether life-sustaining treatment should be withdrawn from a child, the court must determine the child’s overall best interests. The assessment is holistic and includes medical, emotional and social welfare factors. There is a strong but rebuttable presumption in favour of treatment which prolongs life. Parents’ wishes and religious beliefs are important considerations, but the court may authorise withdrawal where continuation provides no real benefit and is likely to cause further suffering or deterioration. A balancing sheet is a useful method of structuring the assessment. If continued treatment is not in the child’s overall best interests, the court may declare its withdrawal lawful.

An NHS Trust applied for permission to withdraw mechanical ventilation from ZT, a 17-month-old child who had suffered catastrophic and irreversible hypoxic-ischaemic brain injury and remained dependent on ventilation. The medical evidence was unanimous that continued treatment served no purpose and conferred no benefit, although the parents believed that ZT responded to them and that recovery remained possible. They opposed withdrawal on emotional and religious grounds. The central issue was whether withdrawal of ventilation was in ZT’s overall best interests.

1. Application granted. Permission was given to withdraw ZT’s mechanically assisted ventilation, with palliative measures to preserve his comfort and dignity.
2. The governing test was the child’s overall best interests. The court had to consider all relevant factors, including medical, emotional and social welfare considerations. It was necessary to determine where the objective balance of the child’s best interests lay, applying the guidance in Wyatt v Portsmouth NHS Trust [2006] EWCA 1181 and An NHS Trust v B and others [2006] EWCA 507.
3. A strong presumption favoured continuation of treatment which prolonged life. That presumption was rebuttable when weighed against the other welfare considerations. The parents’ opposition, love, religious convictions and belief in possible recovery were important factors, but they did not determine the outcome.
4. The court conducted a balancing exercise. It weighed the presumption in favour of life, the parents’ devotion and the possibility of responsiveness against the irreversible brain and brain-stem injury, the absence of meaningful improvement, the lack of awareness or interaction, the invasive and potentially painful treatment, and the risks of infection, further injury and deterioration.
5. On the evidence, mechanical ventilation merely sustained life. It conferred no real benefit and created a strong probability of further pain, suffering and deterioration without any realistic prospect of restoring health. Withdrawal was therefore in ZT’s overall best interests and lawful.
6. A reporting-restrictions order remained in place to protect the identities of the child and his parents. The Trust could be identified after the child’s death, subject to the stated notification mechanism.

First-instance decision. No prior appellate decision was stated in the judgment.