Hospitals NHS Trust v MTR (Mother) & Ors

In an urgent medical-treatment case, the court must determine a child's best interests through an independent, objective and holistic assessment. A strong presumption in favour of preserving life is not absolute. It may be outweighed where treatment offers no commensurate benefit and imposes pain, distress or other burdens. The court must consider the treatment's nature and prospects, its likely outcome, the child's likely attitude, and the views of parents and clinicians. Where a child is actively dying and an intervention is non-curative and distressing, the court may authorise a ceiling of care and palliative treatment despite parental opposition. Any interference with engaged ECHR rights must be necessary and proportionate.

TR, a one-month-old child with confirmed Trisomy 18 and a serious cardiac condition, had deteriorated with seizures, apnoea and bradycardia while receiving neonatal care. The Hospitals NHS Trust sought declarations that a revised care plan was in her best interests, including no escalation to resuscitation, organ support or invasive ventilation, removal from ICU monitoring, holding, and palliative care without CPAP.

The application had been listed for directions, but overnight deterioration led the Trust to seek a final order urgently. The parents opposed parts of the plan, chiefly withdrawal of ICU monitoring and continuation of CPAP. The Children’s Guardian had no opportunity to complete ordinary inquiries. The central issues were whether the court should determine the application immediately and whether the proposed treatment ceiling and palliative plan were in TR’s best interests.

1. Application granted. The revised care plan was approved. The Trust was authorised not to escalate treatment to cardiopulmonary resuscitation, organ-support drugs or invasive ventilation; to remove ICU observation monitoring; to hold TR; to provide palliative care and clinically indicated medication and cannulation; and to provide comfort oxygen without CPAP or positive pressure applied to the face.
2. Urgency. Independent apnoea, a falling heart rate and rapid deterioration indicated that TR might die within hours. Dr Z’s evidence was accepted. CPAP caused pain and distress, was neither curative nor palliative, and impeded physical contact with her family. An adjournment would prolong suffering, so an immediate final determination was justified despite the Guardian’s inability to complete the usual inquiries.
3. Legal framework. Where a child lacks capacity and there is disagreement between those with parental responsibility and treating clinicians, the court may make a best-interests declaration and must exercise its own independent and objective judgment: Manchester University NHS Foundation Trust v Fixsler and others [2021] EWHC 1426 and An NHS Trust v MB [2006] EWHC 507 (Fam). The court is not bound by the clinical assessment and cannot require doctors to carry out a procedure contrary to their professional judgment.
4. The best-interests inquiry is broad and fact-specific. It includes medical, emotional, sensory, social and psychological considerations, the nature and prospects of treatment, its likely outcome, the child’s likely attitude, and the views of parents and clinicians. The presumption in favour of preserving life is strong but rebuttable. Treatment causing increased suffering without commensurate benefit may be contrary to best interests. The principles in Aintree University Hospital NHS Foundation Trust v James [2013] UKSC 67, including the lawful withdrawal of treatment not in the patient’s best interests, were applied.
5. TR had no cure, a very limited life expectancy, and no realistic prospect of benefit from the disputed interventions. CPAP caused demonstrable distress, while cardiac surgery was not offered and would not address the underlying condition. Although the parents’ love, wishes and knowledge of TR were carefully considered, the overall balance favoured palliative care and the approved ceiling of treatment. The court also recognised that the engaged ECHR rights required any interference to be necessary and proportionate.