Guy's and St Thomas' Children's NHS FoundationTrust & Anor v Knight & Anor

In deciding whether life-sustaining treatment should be withdrawn from a child, the court must assess the child’s best interests objectively, with welfare paramount and from the child’s perspective. The preservation of life attracts a strong but rebuttable presumption. The absence of pain or conscious awareness does not remove the need to consider the burdens of the child’s condition and treatment. Parental wishes and family relationships are relevant but are not determinative and cannot replace the child-focused assessment. Where a proposed trial is merely a means to a longer-term treatment outcome, the court must consider the end goal, the process required and the prospects of success. A trial should not be authorised where the proposed treatment would itself be contrary to the child’s best interests.

The NHS Trust responsible for caring for a five-year-old child with severe brain damage and a persistent vegetative state applied under the inherent jurisdiction for declarations that she should not undergo a tracheostomy, that mechanical ventilation should be withdrawn, and that treatment should thereafter be limited so that she would be allowed to die.

The child had been mechanically ventilated in a paediatric intensive care unit for nearly two years. Her mother opposed withdrawal and proposed a trial of portable ventilation followed by transition to long-term ventilation at home. The children’s guardian supported the Trust’s application. The central issues were whether continued ventilation in intensive care, or a trial directed towards home ventilation, was in the child’s best interests.

1. Best-interests framework. The court had to determine the child’s best interests objectively, treating welfare as paramount and considering the matter from the child’s assumed perspective. The presumption in favour of preserving life was important but rebuttable. Relevant medical, emotional and welfare factors had to be balanced, including the views of the parents, treating clinicians and independent experts.
2. Burdens despite absence of pain. The child was in a persistent vegetative state, with no conscious awareness, no prospect of neurological improvement and no subjective benefit from continued ventilation. Nevertheless, her profound loss of function and the invasive treatment required to maintain her life were objective burdens on her person. The absence of pain or sensation did not make those burdens irrelevant.
3. Parental wishes. The mother’s wishes, the family relationship and the benefits of family care were relevant considerations. They were not determinative. The court could not treat the parent’s wish to bring the child home, or benefits to other family members, as the child’s best interests. The assessment had to remain focused on the child.
4. Proposed home-ventilation trial. The proposed trial was a means to the end of long-term ventilation at home. The court had to consider the end goal, the process required and the prospects of success. Long-term ventilation at home would provide no benefit to the child, would continue substantial burdens, and carried greater risks with less sophisticated equipment and personnel. The prospects of successful transition were remote. It was therefore contrary to the child’s best interests to authorise either home ventilation or the proposed trial.
5. Declarations. Continued mechanical ventilation was contrary to the child’s best interests. A tracheostomy would serve no useful purpose and was unnecessary. The court declared that it was lawful and in the child’s best interests that no tracheostomy be provided, that mechanical ventilation be withdrawn, and that clearly defined limits be imposed on subsequent treatment so that she would be allowed to die. The precise circumstances of withdrawal were left for agreement, including the possibility of withdrawal at the family home.