University Hospitals Plymouth NHS Trust v B (A Minor) (Urgent Medical Treatment)

A court may authorise life-saving medical treatment for a child who has capacity to understand the treatment but refuses it. The controlling consideration is the child’s objectively assessed best interests. The court must exercise its own independent judgment and consider the child’s attitude, the nature and prospects of the treatment, medical and emotional factors, parental and medical views, and the child’s wishes and feelings.

There is a strong, but rebuttable, presumption in favour of preserving life. A competent child’s refusal is not necessarily binding where a person with parental responsibility or the court can lawfully consent to treatment. Where refusal creates an immediate and grave risk of death, the court may act urgently and without notice.

The applicant NHS Trust sought urgent, without-notice authority to administer intravenous fluids and intravenous and subcutaneous insulin to a sixteen-year-old child suffering from life-threatening diabetic ketoacidosis. The child understood the risks, had stated that she wished to die, and refused insulin, although she had agreed to hospital admission, blood testing and insertion of an intravenous cannula.

The child was not represented because of the urgency. Her grandfather supported treatment. The central issue was whether the proposed treatment was in her best interests despite her refusal.

1. Application granted. The court authorised the NHS Trust to administer the proposed intravenous fluids and insulin treatment without B’s consent.
2. A child is Gillick competent in relation to medical treatment where she has sufficient understanding and intelligence to understand fully what is proposed. However, unlike a competent adult, a competent child’s refusal is not binding where a person with parental responsibility or the court consents to treatment.
3. The court’s paramount consideration was B’s best interests. It had to exercise its own independent and objective judgment, beginning from the assumed perspective of the patient. Best interests include medical, emotional, sensory and instinctive considerations and require the court to balance the competing factors rather than apply a mathematical test.
4. The court considered the treatment’s nature, burdens and prospects of success; the views of the treating clinicians and B’s grandfather; B’s age, understanding, wishes and feelings; and the strong presumption in favour of preserving life. That presumption was not irrebuttable, but was particularly compelling because untreated diabetic ketoacidosis would probably lead to cerebral oedema and death, while the proposed treatment was standardised, effective and supported by a consensus of reasonable medical opinion.
5. B’s wishes and feelings required consideration but did not determine the outcome. The court was not required to accept them where doing so would result in manifest and potentially fatal harm. Her agreement to aspects of treatment also indicated that her refusal of insulin was not entirely fixed.
6. Given the narrow window for treatment and the grave consequences of delay, it was appropriate to decide the urgent application on counsel’s submissions without arranging representation for B.