X Health Authority v D

In determining medical treatment for a child, the court’s guiding principle is the child’s best interests. That assessment may require authorising highly intrusive treatment where the proposed plan is necessary and proportionate to protect the child’s welfare. The court should focus on the most likely explanation for a grave medical presentation while retaining an open mind about alternative explanations. Decision-making should remain investigative, non-adversarial and directed towards cooperation between the professionals and family. Where treatment involves significant interference with the child’s autonomy, the court should identify the authority for the intervention, explain its reasoning to the child in an age-appropriate way, and promote a return to independence.

The X Health Authority applied to continue protective orders concerning D, a 12-year-old girl with a longstanding and life-threatening refusal to eat. Extensive medical investigations had not identified an organic cause. D had continued to lose weight despite an agreed nasogastric feeding regime involving reasonable and proportionate restraint.

The court was asked to authorise D’s immediate transfer to EM, a specialist eating-disorders unit providing physical, medical and mental-health care. The proposed plan involved continuous observation, nasogastric feeding with physical intervention if necessary, physical examinations, therapy and further investigations. The central issue was whether the transfer and treatment plan were in D’s best interests.

1. Order made. The court authorised D’s immediate transfer to EM, recording that the parents agreed and that the move was in D’s best interests. The treatment plan included level 4 nursing, continuous observation, monitoring of personal care, nasogastric feeding and physical intervention by trained staff if required.
2. The governing principle was the child’s best interests, described as the lodestar of the court’s approach, with reference to Aintree University Hospital NHS Trust v James [2013] UKSC 67, Yates and Gard v Great Ormond Street Hospital for Children NHS Foundation Trust [2017] EWCA Civ 410 and Alder Hey Children’s NHS Foundation Trust v Evans and Others [2018] EWHC 308 (Fam).
3. Although the evidence pointed predominantly towards a psychological explanation after extensive investigation, the court emphasised the need to keep an open mind about other possible explanations. Further organic investigations were therefore to continue alongside psychological, psychiatric, family and physical therapies.
4. The intervention represented a very significant interference with D’s autonomy. Its justification lay in the gravity of her condition, the continuing weight loss and the need for specialist integrated treatment. The plan was directed not merely towards nutrition but towards reducing distress and restoring D’s independence.
5. D was not made a ward of court. The process was investigative, non-adversarial and sui generis. Cooperation and collaboration were essential, including parental engagement with treatment that might be painful or counterintuitive. The case was to be listed again only if further court decisions became necessary.

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