Alder Hey Children's NHS Foundation Trust v Evans & Anor

In determining whether life-sustaining treatment should continue for a child, the court must decide whether providing the treatment is in the child’s best interests. The inquiry concerns welfare in its widest sense, including medical, social and psychological considerations, the burdens and prospects of treatment, its likely outcome, the child’s perspective where ascertainable, and the views of those concerned with the child’s welfare.

Treatment futility does not by itself require immediate withdrawal. The court must evaluate the child’s overall circumstances, including dignity, possible suffering, parental views and any religious or ethical beliefs. Where treatment offers no prospect of recovery or meaningful benefit, and palliative care is required, continued invasive treatment may cease to serve the child’s best interests.

Alder Hey Children’s NHS Foundation Trust applied for a declaration that continued ventilatory support for Alfie Evans was not in his best interests and that continued treatment was therefore unlawful. Alfie’s parents opposed the application and sought further treatment, including transfer abroad, tracheostomy, feeding access and possible home ventilation.

The medical evidence established a progressive and ultimately fatal neurodegenerative disorder, profound neurological impairment, dependence on ventilation and no realistic prospect of recovery. The central issue was whether continued ventilation, and the proposed alternative treatment and transfer plans, were in Alfie’s best interests.

1. Best interests. The court applied the approach stated by Baroness Hale in Aintree University Hospital NHS Trust v James [2013] UKSC 67. The question was whether providing ventilation was in Alfie’s best interests, not whether withdrawal was preferable. Welfare had to be assessed in the widest sense, including medical, social and psychological considerations, the nature and prospects of treatment, its likely outcome, Alfie’s likely attitude and the views of those concerned with his welfare.
2. The principle that the child’s best interests must prevail, including where parents hold an alternative view for the best of motives, was reaffirmed from Yates and Gard v Great Ormond Street Hospital for Children NHS Foundation Trust [2017] EWCA Civ 410. Parental wishes were important and were carefully considered, but they were not determinative.
3. The futility of treatment did not lead automatically to immediate withdrawal. Life had intrinsic value, and the court considered the parents’ religious beliefs, Alfie’s dignity, the possibility of pain or discomfort, the burdens and risks of transfer, and the availability of palliative care.
4. The evidence showed that Alfie’s brain had suffered catastrophic progressive degeneration. He had no realistic prospect of neurological recovery, could not sustain life without ventilation, and further testing or treatment would not improve his condition. The proposed transfer and treatment plans offered no prospect of therapeutic benefit and created significant burdens and risks.
5. Continued ventilation was therefore futile, compromised Alfie’s future dignity and failed to respect his autonomy. Continued ventilatory support was no longer in his best interests. The Trust’s application was granted and the appropriate plan was good-quality palliative care aimed at keeping Alfie comfortable and allowing him to die with dignity.