Royal National Orthopaedic Hospital Trust v ZY & Anor

In an application concerning medical treatment for a child, the court must determine best interests from the child’s perspective and in the widest sense. It must identify the factors that genuinely matter, give them proper weight, and balance them. Medical evidence is important but does not bind the court. Parental wishes are relevant only so far as they illuminate the quality and value of the parent-child relationship. A young child’s views carry weight according to age and understanding. Where urgent treatment is required, the court may proceed without adjourning to obtain the child’s views if delay would materially prejudice the child’s welfare.

The Royal National Orthopaedic Hospital NHS Trust sought a declaration under the inherent jurisdiction that it was in the best interests of ZY, aged seven, to undergo an image-guided core needle biopsy of a suspected malignant tumour in his right ankle under general anaesthetic. ZY’s mother opposed the general anaesthetic, although she did not oppose the biopsy itself. The medical evidence indicated that the biopsy was urgent, that general anaesthesia was standard and safest for a child of ZY’s age, and that avoiding it created risks of distress, a non-diagnostic result and tumour-cell contamination. The issues were whether the proposed procedure was in ZY’s best interests and whether the hearing should be adjourned to obtain his views.

1. Declaration granted. It was in ZY’s best interests to undergo an image-guided core needle biopsy under general anaesthetic.
2. The governing approach was an unfettered welfare assessment from the individual’s point of view. The court had to consider best interests in the widest sense, identify the factors that mattered in the particular case, give each proper weight and balance them. The court was not bound by the medical witnesses’ evaluation, although medical evidence could carry significant weight: Re E and Another (Minors: Blood Transfusion) [2021] EWCA Civ 1888.
3. The starting presumption that it was in a person’s best interests to stay alive was appropriate because the suspected tumour might be malignant and potentially fatal. The urgent biopsy offered the best prospect of a reliable diagnosis and timely treatment.
4. The risks of proceeding without general anaesthesia, including pain and distress, an unsuccessful or delayed diagnosis, and possible spread of cancer cells, significantly outweighed the ordinary low risks of a light general anaesthetic. The clinical recommendation that the procedure be performed under general anaesthetic was accepted.
5. The mother’s consistent objection could not outweigh the manifest welfare advantages of effective treatment. Parental views were relevant only so far as they illuminated the quality and value of the child-parent relationship: NHS Trust v MB and Others [2006] EWHC 507 (Fam).
6. Although the court had no direct account of ZY’s wishes, an adjournment was not in his best interests. At seven, there was no suggestion that he was Gillick competent in relation to the proposed treatment, and delay in diagnosis could make treatment more difficult.