AA (A Child), Re

When exercising the inherent jurisdiction in relation to medical treatment of a child, the court must determine the child’s best interests by exercising an independent and objective judgment. The court must give proper weight and respect to the wishes of devoted and responsible parents, but those wishes do not determine the outcome. The assessment is fact-specific and may properly involve a balance sheet of the treatment’s advantages and disadvantages. A proposed alternative must be supported by an identified clinician with the expertise, equipment and infrastructure to provide and oversee it. A treatment which is speculative, temporary or unavailable in practice may properly be rejected where established treatment is the only viable means of preventing grave consequences.

An NHS Foundation Trust applied under the inherent jurisdiction for a declaration that it would be lawful to implant an implantable cardioverter defibrillator in AA, a seven-year-old child who had suffered a cardiac arrest caused by ventricular fibrillation. The parents opposed implantation and preferred a wearable defibrillator. Medical evidence indicated that a further arrest might be fatal or cause severe neurological injury, while implantation involved recognised physical, psychological and practical disadvantages. The central issue was whether implantation was in AA’s best interests.

1. The application was granted. The court declared that implantation of an implantable cardioverter defibrillator in AA would be lawful.
2. The governing test was AA’s best interests, assessed on the particular facts. Applying the approach summarised in An NHS Trust v MB [2006] 2 FLR 319, the court had to reach its own independent and objective judgment.
3. The parents’ views were entitled to respect and substantial weight. However, as explained by Lord Bingham in Re Z (Identification) [1996] 2 WLR 88 at 113, parental wishes could not replace the court’s duty to decide what was best for the child.
4. Following the balance-sheet approach recommended in Re A [2000] 1 FLR 549, the court weighed the risks and disadvantages of implantation against its benefits. The disadvantages included general anaesthesia, infection, lead displacement, inappropriate or painful shocks, psychological effects, scarring, follow-up treatment and later replacement of the battery and leads.
5. The medical evidence established that implantation was the standard recommendation and the only viable treatment capable of reliably detecting and treating a further life-threatening arrhythmia. The risks of not implanting the device were materially greater, since another arrest could result in death or serious neurological damage.
6. The proposed wearable defibrillator was not an equivalent practical alternative. It was regarded by the experts as a temporary bridge, and no clinician or service had been identified to prescribe, fit and oversee it for AA. Applying the guidance in An NHS Trust v SR, the existence of research, possibilities or isolated success stories was insufficient without an identified clinician and the necessary infrastructure to provide the treatment.
7. Having considered the parents’ concerns, the evidence of the treating and independent experts, and AA’s likely future welfare, the court concluded that implantation was in her best interests.