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

In determining the end-of-life arrangements for a child, the court’s paramount concern is the child’s best interests. Continued artificial ventilation may be contrary to those interests where the evidence establishes that there is no prospect of recovery and treatment has become futile. That conclusion does not mean that the child’s life lacks dignity or that care should cease. The court should remain receptive to a flexible palliative care plan, including care outside intensive care, where the child’s condition permits and the arrangement serves the child and family. Jurisdiction to determine matters concerning a child is principally connected with the child’s habitual residence and is not displaced merely because another state offers an alternative care plan or confers citizenship on the child.

The Trust applied in relation to the care and end-of-life arrangements for Alfie Evans, a child who had suffered catastrophic neurodegenerative brain damage and had been receiving long-term ventilation in intensive care. Earlier judgments had concluded that continued artificial ventilation was contrary to his best interests. The present applications followed his extubation and independent breathing.

The parents sought permission for Alfie to be removed immediately to Italy, relying on the involvement of an Italian hospital and the grant of Italian citizenship. They also sought to set aside the earlier declarations, contending that Alfie’s condition was significantly better than previously understood. The court considered jurisdiction, the reliability of the medical evidence, and whether a revised palliative care plan could accommodate care at home, in a hospice or on a ward.

1. Applications refused. The application for Alfie’s immediate removal to Italy was refused. The application to set aside the earlier declarations was also rejected.
2. The court had jurisdiction. Alfie had no connection with Italy and had never visited it. The grant of Italian citizenship did not establish a basis for transferring jurisdiction or displace the jurisdiction of the English court. The principles concerning habitual residence and jurisdiction were restated in Re B (A Child) (Habitual Residence: Inherent Jurisdiction) [2016] UKSC 4.
3. The medical evidence remained compelling. The court found no significant change in Alfie’s condition. His brain had been almost entirely destroyed by neurodegenerative disease, leaving no prospect of recovery. His ability to sustain respiration after extubation did not undermine the earlier conclusion that continued artificial ventilation was contrary to his best interests.
4. Futility did not equate to a lack of dignity. The court distinguished between the further preservation of life by artificial ventilation, which was contrary to Alfie’s best interests, and the provision of compassionate palliative care.
5. The court encouraged a flexible and cooperative palliative plan. Since Alfie was breathing independently, it was appropriate to explore whether he could spend his final hours or days at home, in a hospice, or on a ward rather than in intensive care. The plan should accommodate the distress of his parents and the treating staff and should not be treated as fixed where circumstances changed.

The judgment records that earlier decisions in the same proceedings had been assessed by the Court of Appeal, the Supreme Court and the European Court of Human Rights, and that their conclusions remained unimpeached. No citations for those decisions are stated in the judgment.