Guy’s and St Thomas’ NHS Foundation Trust v A (A Child) & Ors

In determining a child’s best interests, the court must assess welfare in the widest sense, including medical, psychological, social, cultural and religious considerations. The focus is whether providing treatment is in the child’s best interests. If it is not, withholding or withdrawing it is lawful, provided the clinical team acts reasonably and without negligence.

The value and sanctity of human life remain fundamental, but they do not require treatment that confers no benefit, causes harm, and merely prolongs dying. Strongly held parental faith and beliefs must receive substantial respect, although the court’s decision remains directed to the child’s best interests. Where brain-stem death testing in an infant has produced anomalous results, an application based on best interests may be preferable to one seeking certification of death.

The Trust applied for authorisation to withdraw mechanical ventilation and related treatment from an infant who had suffered catastrophic hypoxic-ischaemic brain injury, intracranial and spinal injuries, fractures and retinal haemorrhages. Brain-stem death had initially been diagnosed, but the diagnosis was rescinded after the child developed spontaneous respiratory effort.

The court then considered whether continued ventilation was in the child’s best interests. The evidence showed profound irreversible injury, no meaningful prospect of benefit, progressive deterioration, substantial treatment burdens and an inability reliably to assess pain or awareness. The parents wished ventilation to continue because of their religious faith and hope of recovery. The central issue was whether continued life-sustaining treatment should be authorised despite those beliefs and the presumption in favour of preserving life.

1. Best-interests framework. The court applied the approach in Aintree University Hospital NHS Trust v James [2013] UKSC 67. The assessment had to address welfare in the widest sense, the nature and prospects of the treatment, its likely outcome, the child’s perspective so far as it could be ascertained, and the views of those concerned with his welfare.
2. The focus was whether providing ventilation was in A’s best interests, rather than whether withholding or withdrawing it was. If treatment was not in his best interests, it was lawful to withdraw it. The court also had to recognise the value of human life and the strong domestic-law presumption in favour of preserving it, as reflected in An NHS Trust v Y [2018] UKSC 46 and Burke v UK [2006] ECHR 1212.
3. The parents’ faith and beliefs were important factors. They were entitled to serious respect, but they did not determine the outcome. The court had to balance them against the severity of the injury, the absence of any ability to benefit from treatment, the possibility of pain, and the burdens and harms caused by continued ventilation.
4. Raqeeb was distinguished. In that case the child had minimal awareness, was not in pain, was medically stable, faced a low treatment burden and had a realistic plan for continued care. Those features were absent here.
5. On the evidence, A was dying, treatment was futile, ventilation merely protracted death, and its burdens included increasingly high ventilatory pressures with risks of lung injury and cardiac collapse. Continued ventilation therefore conferred harm without benefit and was contrary to A’s best interests.
6. The court directed withdrawal of ventilation and provision of palliative care. It also observed that the anomalous brain-stem death testing raised questions about the Code of Practice for the Diagnosis and Confirmation of Death in infants, particularly those under six months and with open fontanelles. Pending further guidance, applications in similar cases should generally be framed around best interests rather than certification of brain-stem death.