County Durham & Darlington NHS Foundation Trust v SS & Ors

When parents and clinicians disagree about life-sustaining treatment for a child lacking capacity, the court must make its own independent and objective decision based on the child’s best interests. Best interests require a broad balancing exercise, including medical, emotional, sensory and instinctive considerations, together with the treatment’s burdens, benefits and prospects of success. There is a strong but non-absolute presumption in favour of preserving life. It may be outweighed where treatment is futile, medically inappropriate, or its burdens substantially exceed its benefits. Decisions must be based on the individual child’s circumstances. Appropriate palliation remains care and may be authorised even where life-sustaining treatment is withheld or limited.

The Trust applied under the inherent jurisdiction for declarations authorising clinicians to treat S, a profoundly disabled seven-year-old child, in accordance with their clinical discretion, including whether to attempt resuscitation after collapse, and to provide appropriate comfort care. S had severe neurological disability, advanced kyphoscoliosis, respiratory vulnerability and a very limited prospect of successful resuscitation or recovery from intensive care.

The parents opposed the application and sought delay, further expert evidence and treatment abroad. The Local Authority, Children’s Guardian and independent expert supported the Trust. The central issue was whether the proposed limitations on treatment were in S’s best interests.

1. Outcome. The declarations sought by the Trust were granted. It was lawful and in S’s best interests for the Trust and responsible clinicians to act in accordance with their clinical discretion, including decisions whether to resuscitate, and to provide treatment and nursing care directed to minimising pain and distress and preserving dignity.
2. The court had to exercise its own independent and objective judgment. The issue was not whether the parents’ or doctors’ views were reasonable, but what was objectively in S’s best interests, assessed in the widest sense.
3. The relevant considerations included medical, emotional, sensory and instinctive factors. The strong presumption in favour of preserving life was important but not absolute. It could be outweighed where treatment was futile or medically inappropriate, or where its burdens, including pain, distress and loss of dignity, outweighed its benefits.
4. The assessment was fact-specific. S’s disabilities were relevant only to the individual evaluation of the likely benefits and burdens of treatment, not because disability diminished the value of her life. The evidence showed that resuscitation and intensive care were highly unlikely to succeed, carried a substantial risk of injury and distress, and were unlikely to provide a meaningful or sustainable benefit.
5. Carefully planned palliation was more beneficial for S than intensive care. A change from life-sustaining treatment to palliation was consistent with the moral duty to provide care and did not amount to abandonment or euthanasia. The RCPCH 2015 Framework provided complementary ethical guidance.
6. The parents’ relationship with S and their views about her welfare were carefully considered, but their own wishes were relevant only insofar as they illuminated S’s interests. The decision had to be made without delay because S was critically frail and could collapse at any time.

First-instance decision. No appellate history is stated in the judgment.