Great Ormond Street Hospital for Children NHS Foundation Trust v Neriman Braqi & Anor

In deciding whether life-sustaining treatment should be withdrawn from a non-Gillick competent child, the court must exercise its own independent and objective judgment as to the child’s best interests. Best interests are assessed in the widest sense, including medical, emotional, sensory, social and familial considerations. The strong presumption in favour of preserving life is powerful but rebuttable.

The court must balance the benefits of continued treatment, including family relationships and the child’s inherent value, against the burdens of the underlying condition and treatment. Parental views require careful consideration and may illuminate the value of the parent-child relationship, but parental wishes do not determine the objective best-interests assessment.

The Trust applied for declarations that it was lawful and in Ayden Braqi’s best interests to withdraw life-sustaining treatment, including invasive mechanical ventilation, and to provide palliative care. Ayden, an infant with severe SMARD1, was completely ventilator-dependent and had no prospect of leaving intensive care. His mother opposed the application and wished treatment to continue. His Children’s Guardian supported the Trust.

The central issue was whether the benefits of continued ventilation outweighed the burdens of Ayden’s condition and the treatment required to sustain his life.

1. Best interests. The court had to exercise its own independent and objective judgment. The governing question was whether continued treatment was in Ayden’s best interests, rather than whether withdrawal was beneficial. The assessment included his welfare in the widest sense, not merely medical considerations, and required consideration of the treatment, its burdens, its prospects and likely outcome, and his likely attitude towards it: Aintree University Hospital NHS Foundation Trust v James [2013] UKSC 67; Re A (A Child) [2016] EWCA 759.
2. Balancing exercise. There was a strong but rebuttable presumption in favour of preserving life. The court had to balance that factor and the real benefits Ayden obtained from his mother and family against the severe, progressive and irreversible burdens of SMARD1, invasive ventilation, suctioning, physiotherapy, desaturation episodes, pain, fear and life in intensive care. The benefits of family contact were genuine and significant, but they did not outweigh the overall burdens.
3. Parental views and clinical evidence. Ayden’s mother’s views were carefully considered. They were relevant to the value of the parent-child relationship and to Ayden’s responses, but her wishes did not determine the outcome. The court was not bound by the unanimous clinical assessment, although it accepted the medical consensus on Ayden’s condition, prognosis and treatment burdens. The court also could not require doctors to perform a procedure contrary to their professional judgment, applying Manchester University NHS Foundation Trust v Fixsler and others [2021] EWHC 1426.
4. Public-law analogy. The court declined to import the approach developed in public-law proceedings under section 31 of the Children Act 1989, including the reasoning associated with Re B (A Child) [2013] UKSC 33 and Re BS (Children) [2013] EWCA 1146, because those authorities concerned materially different applications.
5. Disposition. It was lawful and in Ayden’s best interests to withdraw mechanical ventilation and provide medically supervised palliative treatment, including pain relief and anxiolytics, to minimise distress and preserve dignity. The declarations were made. Ayden’s ventilation was withdrawn on 14 November 2024 and he died shortly afterwards with his family present.