Great Ormond Street Hospital for Children Foundation NHS Trust v NO & KK & Ors

In determining whether life-sustaining treatment should be withheld from an incapacitated child, the court must make an independent and objective assessment of the child’s best interests. Welfare is considered in the widest sense, including medical, emotional and sensory effects, the burdens and prospects of treatment, likely outcomes, and the child’s perspective. There is a strong presumption in favour of prolonging life, but it is not absolute. Treatment may lawfully be withheld where it offers no commensurate benefit, is futile or ineffective, and would cause substantial pain, distress or suffering. The court may override parental disagreement, but cannot require clinicians to provide treatment contrary to their professional judgment.

Great Ormond Street Hospital applied for declarations concerning MK, an infant with hypoplastic left-heart syndrome and severely underdeveloped pulmonary arteries. The hospital sought authority not to provide cardiopulmonary resuscitation, inotropes, intubation, mechanical ventilation, intra-osseous access, further central venous lines or chest drains.

MK’s parents opposed the application and wished potentially life-prolonging interventions to remain available. MK was separately represented through her guardian. The medical evidence was unanimous that no further surgical treatment could improve her condition, that her death was imminent, and that the proposed interventions were highly invasive, burdensome and unlikely to succeed. The central issue was whether withholding those interventions was in MK’s best interests.

1. Best interests and jurisdiction. The court made an independent and objective decision from MK’s perspective. The child’s welfare was paramount and included medical, emotional, sensory and other welfare considerations. The court could intervene where parents disagreed with clinicians, even if the parental position could not be characterised as unreasonable: Re T (Wardship: Medical Treatment) [1997] 1 WLR 242; Wyatt v Portsmouth NHS Trust [2005] EWCA Civ 1181.
2. There was a strong presumption favouring the prolongation of life, reflecting the human instinct to survive, but the presumption was not absolute. Treatment causing increased suffering without commensurate benefit could be contrary to the child’s best interests: Re J (A minor) (wardship: medical treatment) [1991] Fam 33.
3. The court undertook a balancing exercise. It considered the benefits and burdens of the proposed interventions, their prospects of success, their likely effect on MK’s quality of life, and her pain, fear and distress. The assessment had to consider her overall condition rather than isolated symptoms or treatments. The approach was consistent with Re A (A Child) [2016] EWCA Civ 759 and Aintree University Hospital NHS Foundation Trust v James [2013] UKSC67.
4. MK’s condition was irreversible. The proposed CPR, intubation, mechanical ventilation and chest drainage were invasive, painful and unlikely to restore health or provide a meaningful benefit beyond a short prolongation of life. They carried a substantial risk of further deterioration or death. Palliative and comfort care therefore better served her best interests.
5. The court could not require doctors to carry out treatment contrary to their professional judgment. The positive obligation under article 2 of the ECHR did not require futile treatment which responsible medical opinion considered contrary to the patient’s best interests: Re Y (No 1) [2015] EWHC1920 (Fam); R (Burke) v The General Medical Council [2005] EWCA 1003.

The declarations sought by the hospital were granted. It was not in MK’s best interests to receive the specified invasive or aggressive interventions, and it was lawful for them to be withheld.