Manchester University NHS Foundation Trust v RNM & Ors

In applications concerning life-sustaining treatment for a child lacking capacity, the court must make an independent and objective assessment of the child’s best interests. That assessment has a broad scope and requires the court to balance the benefits of preserving life and of the proposed treatment against its invasiveness, burdens, pain, suffering, prognosis and wider emotional and welfare considerations. There is a strong but rebuttable presumption in favour of preserving life. Treatment may properly be withdrawn where the burdens and suffering outweigh the benefits and continuation is not in the child’s best interests. The views of parents and clinicians must be carefully considered, but the court’s decision is directed to the child’s welfare.

The Trust applied under the inherent jurisdiction for declarations permitting withdrawal of invasive ventilatory support and approval of a palliative care plan for RN, a three-year-old child who had been born at 23 weeks and had severe irreversible brain and brain-stem injury. RN had remained in hospital throughout his life and was dependent on invasive mechanical ventilation, intensive nursing care and artificial feeding.

RN’s parents opposed the application. They sought continuation of treatment, including consideration of a tracheostomy and portable ventilation with a possible move home. RN was separately represented by his Children’s Guardian, who supported the Trust. The central issue was whether continued ventilation, or the parents’ proposed alternatives, were in RN’s best interests.

1. Declarations made. The court concluded that continuation of life-sustaining treatment was not in RN’s best interests and made the declarations sought by the Trust.
2. The court’s task was to exercise its own independent and objective judgment. The welfare assessment had a broad canvas, including medical, emotional, sensory and other relevant considerations. It required a balancing exercise rather than a mathematical calculation: Manchester University NHS Foundation Trust v Fixsler & Ors and the authorities summarised there were applied.
3. The presumption in favour of preserving life remained important but was rebuttable. The court had to consider the nature and prospects of the treatment, its burdens and likely outcome, and whether it provided a commensurate benefit. The court adopted the approach stated in Aintree University Hospitals NHS Foundation Trust v James, namely that the focus is on whether providing treatment is in the patient’s best interests.
4. The medical evidence established that RN’s brain and brain-stem injury was irreversible. He could not breathe independently, clear secretions or protect his airway, and required frequent invasive interventions. His dystonic episodes were increasing in frequency and severity and caused pain and distress. Medication could reduce those burdens, but increased sedation also reduced his awareness of comfort from his parents.
5. The parents’ observations of comfort and possible recognition were given proper weight and were not discounted. However, they had to be assessed against the wider clinical evidence, the absence of sustained objective evidence of purposeful interaction, RN’s progressive deterioration and the burdens and risks of continued ventilation or tracheostomy. A home-care plan was very unlikely to be feasible because of the complexity of RN’s condition, recurrent infections and need for specialist support.
6. The court also observed that, where collaboration cannot resolve disagreement about treatment limitation, arrangements should be made to avoid delay in bringing the matter before the court.