Great Ormond Street Hospital for Children NHS Foundation Trust v MX & Ors

In applications concerning life-sustaining treatment for a child lacking capacity, the court must determine the child’s objective best interests. Welfare is paramount and includes medical, emotional, sensory, social and psychological interests. There is a strong but non-absolute presumption in favour of prolonging life. The court must balance treatment burdens against realistic benefits and consider the child’s individual circumstances, family evidence and responsible medical opinion.

Where the child’s condition is fluctuating and unpredictable, the court should avoid blanket declarations excluding treatment that may later provide symptom relief or assist recovery from a reversible deterioration. Treatment ceilings may be specified, while leaving future decisions to be made in the child’s best interests.

Great Ormond Street Hospital applied under the inherent jurisdiction for declarations concerning the treatment of X, a nine-year-old child with profound disabilities, end-stage renal disease, chronic lung disease and intestinal failure. The Trust sought declarations that specified invasive and non-invasive treatments were not in X’s best interests and were unlawful, and that X should receive palliative care.

During the proceedings, the parents accepted most proposed treatment limitations. The remaining issues were whether X should receive Optiflow ventilation during a future deterioration and whether she should be re-admitted to paediatric intensive care. The central question was whether those interventions might provide a realistic benefit without disproportionate burden in the context of a fluctuating and terminal condition.

1. Best interests. The application was determined by the objective best-interests test under the inherent jurisdiction. The child’s welfare was paramount. The court considered medical, emotional, sensory, social and psychological welfare, the child’s capacity for pleasure and interaction, the burdens and prospects of treatment, the wishes and evidence of the parents, and the views of clinicians. The presumption favouring prolongation of life was strong but not absolute: treatment could properly be withheld where its burdens outweighed any commensurate benefit. The principles in Wyatt v Portsmouth NHS Trust [2005] EWCA Civ 1181, Aintree University Hospital NHS Foundation Trust v James [2013] UKSC 67 and Re A (A Child) [2016] EWCA Civ 759 were applied.
2. Optiflow. The independent evidence established that Optiflow was relatively non-burdensome and might relieve respiratory distress or bridge a short, reversible deterioration. A blanket declaration excluding it would therefore not be in X’s best interests. It was permitted where the senior bedside clinician, after consulting the parents, considered that there was a realistic prospect of symptom relief and return to X’s pre-deterioration baseline. It had to be discontinued if X improved, became distressed, deteriorated despite it, or failed to improve after seven days. It was not to be used as an alternative to CPAP, BiPAP or invasive ventilation, during severe respiratory distress or active dying, or for more than 14 days.
3. Re-admission to intensive care. The court refused to declare that re-admission to PICU was necessarily contrary to X’s best interests. The burdens of PICU had not been established as determinative, and symptom-management plans had to be individualised. Given the fluctuation and unpredictability of X’s condition, a future admission might be appropriate to provide Optiflow or another treatment within the agreed ceilings of care.
4. The court also criticised the failure to involve X’s parents in the hospital ethics committee process and observed that meaningful family participation should generally form part of such processes.

First-instance decision of the High Court (Family Division). No appeal or lower-court decision is stated in the judgment.