Nottingham University Hospitals NHS Foundation Trust v Indi Gregory & Ors

In medical-treatment cases concerning children, the court must make its own objective assessment of the child’s best interests. The assessment is holistic and includes medical, emotional, sensory, social and psychological considerations.

There is a strong presumption in favour of preserving life, but it is not absolute. It may be outweighed where life-sustaining treatment causes significant pain or distress, offers no realistic prospect of recovery or commensurate benefit, and merely prolongs a short and severely compromised life.

The court must consider the parents’ views with care, while recognising that parental wishes are relevant only insofar as they illuminate the child’s welfare. Expert evidence is admissible only where necessary in family proceedings.

The Trust applied under the inherent jurisdiction for declarations that invasive life-sustaining treatment for Indi Gregory should not continue, including invasive ventilation, CPR and other critical-care interventions. The application was amended after Indi deteriorated and became continuously intubated and ventilated.

Her parents opposed the application. They argued that her condition and prognosis required further investigation, that infection or alternative treatment might explain her deterioration, and that she retained some awareness and benefit from life. The Children’s Guardian supported the Trust.

The central issues were whether further expert evidence was necessary and whether withdrawal of invasive treatment was in Indi’s best interests.

1. Application granted. The court declared that withdrawal of invasive treatment in accordance with the proposed care plan was in Indi’s best interests. The plan included weaning from intubation within one week, followed by non-invasive ventilation for up to one week, with palliative care and treatment to alleviate pain.
2. The proceedings were family proceedings because they concerned declaratory relief under the inherent jurisdiction in relation to a minor. The Family Procedure Rules 2010 therefore applied. The test for additional expert evidence was whether it was necessary, meaning imperative rather than merely useful, reasonable or desirable. On the evidence, there was no evidential gap requiring further expert opinion.
3. The court’s paramount consideration was Indi’s best interests. It had to exercise its own independent and objective judgment, considering welfare in the widest sense. Relevant matters included the nature and prospects of the proposed treatment, its burdens and likely outcome, the child’s experience and attitude so far as ascertainable, and the views of the parents and clinicians.
4. There was a strong presumption that preserving life is in a child’s best interests, but the presumption was not irrebuttable. The benefits of continued life and treatment had to be balanced against pain, distress, the burdens of invasive procedures, quality of life and the prospects of recovery or meaningful benefit.
5. There was no minimum pain threshold. Pain formed part of the overall best-interests assessment. The court accepted the unanimous medical evidence that Indi’s condition was incurable, progressively deteriorating and untreatable; that invasive treatment caused significant pain and distress; that CPR and cardiac intervention would be futile or impracticable; and that continued treatment would not produce commensurate benefit.
6. The parents’ views were powerful and carefully considered, but their wishes were not determinative. The court accepted that Indi had some inherent value and that her family relationships brought her comfort and joy. Those considerations were outweighed by the severe burdens of treatment, minimal engagement with the world, absence of recovery prospects and very limited life expectancy.