Great Ormond Street Hospital for Children NHS Foundation Trust v A Local Authority & Ors

In end-of-life decisions concerning a child, invasive treatment must be justified by a realistic prospect of benefit to the child. Where treatment would impose significant distress or burden without such benefit, it may be contrary to the child’s best interests. The court may approve a carefully defined plan permitting beneficial treatment, continuing palliative care and withholding burdensome interventions. Applications of this gravity should ordinarily be prepared and heard with sufficient time for the evidence and family members to be properly engaged. Although remote hearings may be proportionate in some circumstances, an entirely remote hearing will rarely be appropriate where the court must determine profound medical and welfare questions.

The Trust applied urgently for declarations concerning the treatment of J, a five-year-old child with profound neurological impairment, chronic kidney disease, recurrent infection and deteriorating respiratory function. It sought approval of non-invasive ventilation and palliative treatment, together with declarations that invasive ventilation, deep suctioning, dialysis, inotropes, manual bagging, chest compressions and CPR were not in J’s best interests.

The initial hearing was adjourned because J’s mother had not had sufficient opportunity to participate, J’s father had not been effectively contacted, and relevant neurological evidence was incomplete. Following further medical discussion and support, J’s mother agreed to the proposed plan. The central issue was whether the declarations accorded with J’s best interests and were lawful.

1. Declarations granted. The court granted the Trust’s declarations in the terms sought. Non-invasive ventilation could continue for as long as it was required and tolerated, together with palliative care, including clinically indicated antibiotics, light suctioning, analgesia and sedation.
2. Invasive ventilation, deep suctioning, dialysis, inotrope support, manual bagging, chest compressions and CPR were not in J’s best interests. J’s condition was grave and deteriorating, and there was no realistic prospect of recovery. Invasive treatment would impose substantial distress and burden without a prospect of ultimate benefit.
3. The court accepted the evidence that J continued to benefit from non-invasive ventilation, whereas deep suctioning was invasive and distressing. The agreed plan therefore distinguished treatment which provided continuing comfort or benefit from interventions which would merely prolong burdensome treatment.
4. Applications of this nature should be made with careful planning. Late applications made under pressure may impair the quality of evidence and the ability of parents to reflect and participate. Timely access to independent legal advice, sensitive medical communication and palliative-care support may enable parents to understand the evidence and make decisions focused on the child’s welfare.
5. Although video hearings had been proportionate during the pandemic, an entirely remote hearing would rarely be appropriate for issues of this gravity. The court should harness the best available quality of hearing, while medical witnesses may still give evidence remotely where suitable.

Not an appeal. The judgment records no prior appellate decision.