Newcastle upon Tyne Hospitals NHS Foundation Trust v FB & Ors [2025] EWCOP 60 (T3)
Case No COP20024075[2025] EWCOP 60 (T3)IN THE HIGH COURT OF JUSTICE
IN THE COURT OF PROTECTION
IN THE MATTER OF THE MENTAL CAPACITY ACT 2005
1st Mezzanine, Queen's Building
Venue Royal Courts of JusticeDate Wednesday, 12 November 2025
Strand
London WC2A 2LL
Before
MS JUSTICE HARRIS DBE(Sitting as a nominated judge of the Court of Protection)
Between
NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUSTApplicantFBRespondent(by her litigation friend, the Official Solicitor)RespondentNM and DMRespondentMR S KARIM KC, MS K RIDDELL and MR A MAY appeared for Applicant TrustMS S ROPER KC and MR M SHERLOCK appeared for Official Solicitors for the First RespondentJUDGMENT(As Approved)Digital Transcription by Epiq Europe Ltd,Lower Ground, 46 Chancery Lane, London WC2A 1JEWeb: www.epiqglobal.com/en-gb/Email: civil@epiqglobal.co.uk(Official Shorthand Writers to the Court)This Transcript is Crown Copyright. It may not be reproduced in whole or in part other than in accordance with relevant licence or with the express consent of the Authority. All rights are reserved.This judgment was delivered in private. The judge has given leave for this version of the judgment to be published on condition that (irrespective of what is contained in the judgment) in any published version of the judgment the anonymity of the children and members of their family must be strictly preserved. All persons, including representatives of the media, must ensure that this condition is strictly complied with. Failure to do so will be a contempt of court.
JUDGE HARRIS:
[1]This is the matter of Newcastle upon Tyne Hospitals NHS Foundation Trust v FB, NM and DM.[2]This is an application by the Newcastle upon Tyne NHS Foundation Trust seeking a declaration with respect to medical treatment for a young person, FB, who is aged 19 years old. The Trust have been represented today by Mr Karim KC. The Official Solicitor, who acts on behalf of FB, has been represented today by Ms Roper KC.[3]FB lives with her special guardians, who are her former foster carers. They are respondents to this application but have not participated in this hearing. I am, however, satisfied on the basis of the papers that they support the Trust's application.[4]It goes without saying that this is an extremely sad matter and with the court's decision today, I send my very best wishes and thoughts to FB and her family.[5]I turn to the background to the application.[6]What is sought by the Newcastle upon Tyne NHS Foundation Trust is a declaration that it is in the best interests of FB that she be afforded no further treatment for her acute myeloid leukaemia but be left to enjoy the best quality of life possible for her with palliative care only when required.[7]FB was diagnosed as a child with trisomy 8 mosaicism, which is a rare chromosome disorder. She has a significant learning disability which involves short attention span, low processing speed, struggling to follow adult directions or agenda, limited awareness of dangers and limited numeracy and literacy skills. She struggles to regulate emotions and has poor fine and gross motor skills.[8]Those learning needs and disabilities are associated with, at times, challenging behavioural difficulties, which mean that she requires one to one care. She is able to make simple day to day decisions about what she would like to do and so forth, but she lacks capacity to make complex decisions, such as regarding medical treatment and care.[9]A COP3 assessment of her capacity has been filed within these proceedings by her treating clinician, Dr L, which has not been challenged before me.[10]In July of this year, FB was diagnosed with a high risk form of acute myeloid leukaemia ("AML"). It is not regarded by her treating clinical team as curable by treatment with chemotherapy alone. Chemotherapy may achieve remission of the disease but relapse is regarded as inevitable, with death probable within the next 12 to 24 months.[11]The only potential cure is allogenic haematopoietic stem cell transplant ("stem cell transplant" as I will refer to it). The treating clinicians, however, do not consider, after very careful and detailed consideration, that FB will be able to tolerate the demanding treatment regime that stem cell transplant will require, given her underlying clinical vulnerabilities and significant learning needs. They regard the prospects of success to be limited. It is for that reason that they seek a best interests declaration that it is not in FB's best interests to undertake the stem cell transplant or any of the alternative treatments that may be available which, whilst not curative, may extend her life by a further limited period.[12]The view of FB’s treating clinical team is that it is in her best interests to focus on promoting the highest quality of life that they can over her remaining time and whilst the disease is in remission, and thereafter, upon relapse, provide her with the best possible palliative care.[13]In terms of the evidence which has been before the court, I have been assisted by a very detailed statement by Dr X, treating consultant haematologist at the NHS Trust, dated 31 October. I have also read and considered a psychological report authored by Dr A and Dr B, again from the NHS Trust, dated 24 October. I have considered a second opinion by Dr Y, who is a consultant haematologist at the Leeds NHS Teaching Trust. I have also been assisted by an independent expert report commissioned by the Official Solicitor, Dr Daniel Wiseman, a consultant haematologist at the Christies Hospital in Manchester, and I have also seen and considered minutes of the best interests meetings on 16 October and 28 October. Finally, I have seen attendance notes on FB's special guardians, setting out their views and feelings.[14]As regards the final position of the parties, the Official Solicitor having carefully considered not only the written papers but also having heard the benefit of oral evidence from Dr X, is that there is now no dispute between the parties as to the best interests of FB in this profoundly sad situation.[15]The court has been greatly assisted today by the oral evidence of Dr X, who has taken the court through the clinical evidence, the potential benefits of the various treatment options, as well as the burdens and challenges of those treatments and, therefore, the best interests view that has been reached by the treating team in liaison with her family. I say for completeness that I found the evidence of Dr X to be extremely careful and thoughtful. Her evidence was, in my judgment, compelling.[16]I therefore turn in more detail to the medical evidence before the court. Dr X has filed a very detailed statement in which she details the treatment options for FB. Her evidence explains that FB has a particularly high risk form of AML. It involves the deletion of the long arm of chromosome 7P in all of her leukemic cells. In addition, she has a mutation called BCOR, which renders this a high risk disease.[17]As I have noted, the clinical view is that the disease is not curable with chemotherapy alone. It may remit with chemotherapy, but the clinical view is that the only way cure can be achieved is by consolidating that remission with a stem cell transplant.[18]The usual treatment plan for patients in FB's position would be for high dose intravenous chemotherapy, to firstly put the patient into remission. Two courses of chemotherapy have been undertaken for FB, and that remission has been achieved. Once remission is achieved, the stem cell transplant is then undertaken, as long as a suitable donor is available. Again, a matched donor has been identified for FB.[19]In terms of the treatments therefore undertaken to date, the first course of chemotherapy commenced in July with the expected clinical outcomes. The success of that first course was mitigated to some extent. It is regarded as a partially successful response. They therefore undertook a second course of chemotherapy commencing on 22 September. Again, that was successful, although there do still remain some leukemic blast cells. Nevertheless, her response is considered good enough to now open the option of a stem cell transplant.[20]It is important to note however that Dr X made very clear in her oral evidence that both of those courses of chemotherapy, whilst successful in outcome, were suboptimal in terms of delivery due to the impact of FB's learning needs and behaviours during the two courses of treatment. Again, as Dr X made clear in her oral evidence, those challenges were very significant.[21]In order to try and support FB, the treating clinical team sought assistance from a wide range of professionals, from the community learning disability team, the Trust's own in-house learning disability team, the teenage and young adult cancer team, social work colleagues, psychiatrist and psychologist colleagues, the SALT team and Darlington Social Services.[22]In her oral evidence, Dr X helpfully clarified that, whilst at the outset of the treatment they would have welcomed and benefitted from more assistance and understanding as to FB's underlying learning needs and therefore how to best support her to tolerate treatment, having now been treating her for many months and knowing her well, she was now confident that they were able to adapt as well as they can the treatments they deliver to maximise the support to her.[23]In terms of the adjustments the treating team have made, they are many and varied. The use of paediatric education materials, use of simple language, attempting to maintain consistency of staff, ensuring one to one support through treatments, undertaking the second course of chemotherapy on the stem cell transplant ward, to build relationships and in some ways to test her responses, having additional time with medical and nursing teams, seeking assistance from the family when required and available, and using such techniques as constant supervision and distraction when undertaking the chemotherapy itself. They have also employed the use of general anaesthetics for procedures when merited.[24]Despite those adjustments over the course of the last few months, Dr X in her evidence is clear as to the challenges they have faced. She details how FB has struggled to manage if she had not had the one to one supervision on the ward. She notes that her behaviour is easier to manage and more stable if family are present, but the family have not always been able to commit to that level of presence on the ward. She notes that identifying staff to provide the one to one support has been difficult. FB struggles with new people. They have tried supporting her with healthcare workers. They tried to bring in learning disability trained agency workers, but that did not work due to FB's difficulties with new people, particularly men, and people of different ethnicity. They have therefore had to bring on additional nursing staff to the ward so that nurses with whom she is familiar can provide that one to one support.[25]They have struggled to keep FB within her own cubicle. She is somebody who likes people. She wants to spend time with the nurses and doctors that she likes and favours. She likes to follow around her favourite nurses, seeking to hold hands and have cuddles, and to be with them at the nursing station.[26]If she has not wanted the interventions, she has tended to lash out at times verbally and physically, harming herself and staff. There are numerous recorded incidents of a harmful nature, with these presenting as almost daily issues. The fundamental difficulty, as Dr X made clear, is that she does not understand that these interventions are to try and help her be better.[27]In terms of some of the self-harming behaviours which have interfered with medical delivery, FB can try and disconnect her drips, letting the contents of the infusion drain onto the floor. She has chewed or tried to chew the end of her central line or the infusion line. Less frequently but nevertheless of concern, she has threatened to hang herself with clothing. There have been incidents of head banging against the wall and with items in her room. She has stood on her bed threatening to throw herself onto the floor and there have been a number of incidents of verbal abuse.[28]What is clear from the picture painted in detail by Dr X is that the chemotherapy has been a very distressing experience for FB and, despite those interventions and adjustments by the hospital, compliance has remained a key difficulty.[29]Turning then to the potential next steps. Dr X begins with stem cell transplant. Again, this is the only curative option that the clinical team identify. Without that intervention, they anticipate her disease will relapse probably within one year, certainly within two years and death will occur, sadly, within a few weeks to a short number of months following that relapse.[30]Turning then to the potential options and stem cell transplantation. Of course, the principal benefit of such a transplant would be to give FB the possibility of a long-term cure for her disease. Stem cell transplantation would require three phases of treatment, which again Dr X was able to elaborate on in her oral evidence. The first phase would run from minus seven to day zero, day zero being the day of stem cell infusion. It would involve preparatory chemotherapy, immunosuppression and then infusion of the stem cells. That would involve for FB infusions on a daily basis lasting between 2 and 14 hours. In terms of side effects or symptoms, nausea is a usual symptom requiring further medical support. She would be required to be in isolation.[31]Phase two from day zero to seven, would be the most difficult period, with very low blood counts. It is likely she would suffer from significant mouth and throat pain and would need analgesia, including most likely a running syringe driver to administer morphine. During this period, pain would be likely very high. She is likely to require IV feeding. Given her immunosuppressed state, there is a high risk of infection and sepsis and again she would be in isolation.[32]Dr X in her evidence described this particular phase of treatment as "horrendous". It is a very different and more demanding patient experience from the chemotherapy that FB has already experienced, further exacerbated for FB because she simply would not understand why this was being done to her.[33]The third phase of stem cell transplantation would be from approximately day 17 to 25 and would be a recovery phase when one would hope and expect to see her mouth and gut improving and healing, the risk of sepsis lessening and some strength returning. Again, ideally, this third phase would be undertaken with her in isolation, although it can be manageable to end the second half of this third phase on a ward.[34]There then of course follows a long period of after transplant care where the risks remain high. The major risk of the donor cells rejecting the recipient's body, what is called "graft versus host disease", is a significant risk. It typically manifests in sore mouth, skin redness, skin loss, diarrhoea, which in some cases can be very severe. Indeed, in some cases graft versus host disease can cause death. Patients also typically experience extreme fatigue for a period of three to six months post-transplant before feeling better.[35]In terms of ongoing monitoring, she would require twice weekly review at hospital. However, there would need to be constant alert to FB becoming unwell, which would require immediate return to hospital. Treatment is unpredictable. Any worsening in her health can require a blood transfusion and/or IV antibiotics. It is difficult to be prescriptive. But what this will require is that FB and her family would be unable to travel very far from Newcastle, at least for the first three to six months of this phase.[36]In terms of outcomes, for an average patient of FB's age and with her kind of high risk AML, the clinical team estimate that the risk of transplant related mortality in the first year after this procedure to be around 10 to 15 per cent, with an additional risk of mortality in the second year of around 5 per cent. For an average 19 year old with this form of AML, they would anticipate a risk of relapse, even after transplant, to remain unfortunately high at 30 to 40 per cent and the chance of a patient being alive at two years after the procedure to be approximately 30 to 40 per cent.[37]Taking those risks together in an average 19 year old with the same form of AML, the chance of death they estimate to be approximately 60 per cent.[38]But FB is not an average 19 year old, and for FB, with her additional challenges, the risks are heightened. The risk of transplant related mortality is higher. Her clinical team estimate it would be in the range of 25 to 30 per cent in the first year after transplant, and 10 per cent in the second year. Risks are further increased by her inability to optimally comply with transplant care, so risks include her leaving her isolation cubicle, attempting to disconnect drips causing self-injury, refusing blood tests or transfusions, and lack of care around her central line, not allowing staff to examine her and not being able to tolerate necessary and time-critical interventions, including possible admission to ITU. Because of her inability to tolerate less invasive treatment in ITU, it is likely she would need to be intubated, which comes with an increased risk of death.[39]In terms of risk of relapse, again in the view of the clinical time, it is likely to be slightly higher for FB, due to her lack of ability to fully comply with an immunosuppressant regime at home, and they place her relapse risk at between 40 to 50 per cent.[40]Dr X therefore estimates FB's chance of survival two years post-transplant to be just 10 to 15 per cent. That is compared to an average 19 year old patient, whose survival chance would be approximately 40 per cent.[41]In terms of the other alternative treatments that may be available which are non-curative, the other option set out by the doctor is firstly a further third course of chemotherapy. That would be of a similar nature to that which she has already experienced. It would require further inpatient admission for approximately four weeks. The purpose of that would be to try and improve the depth of her current remission of AML with the potential benefit of improving prognosis by a small number of months.[42]Alternatively, she could be treated with a course of oral Azacitidine tablets. Those could be taken at home, supervised by family, but it would require ongoing returns to hospital until blood counts stabilised, initially fortnightly and then every four weeks. There are side effects associated with that course of treatment, the need sometimes for blood product support, with increased risks of hospitalisation due to infection. There is a limited evidence-base as to the prospects of success in the use of such treatment for patients with high risk AML.[43]So, in light of those treatment options, the Trust's position following a formal best interests meeting held on Tuesday, 28 October is that they have concluded that it is not in FB's best interests to undergo stem cell transplantation or further non-curative chemotherapy or a maintenance course of Azacitidine tablets. They agreed at the best interests meeting, with the input of FB's family and the multi-disciplinary team, that she should receive palliative care only when relapse occurs. That is a decision with which FB's IMCA also agrees.[44]In terms of the other evidence before the court, I have also considered carefully the psychological report filed by Dr A and Dr B. They set out clearly how patients with cognitive impairments or learning disabilities, such as FB, have a high risk of distress and poorer adjustments due to difficulties with understanding and communication, and limiting the individual's ability to comprehend the rationale for treatment, anticipate its course or apply verbal coping strategies. They can experience, therefore, heightened anxiety and loss of control when their routines are disrupted and expectations are unclear.[45]That report makes clear that FB presents with a number of known psychological risk factors and challenges likely to intensify and increase her psychological distress and dysregulation. Particular concerns arise from distress and dysregulation during any periods of isolation, her attachment difficulties leading to increased dependency on a small number of staff, amplifying a sense of abandonment or rejection due to the need for isolation, increasing risks of self-harming behaviours, a difficulty of understanding the purpose of this treatment, the emotional impact of the physical side effects, with additional cognitive or neuro-psychological symptoms and potential trauma relating to the interventions.[46]They detail the adjustments which could be introduced to improve FB's ability to tolerate transplant, but make the point that their experience thus far has been that there are significant challenges in using those various adjustments to effectively mitigate the risks to FB.[47]As I have noted, a second opinion was obtained from Dr Y and I have considered his report. In essence, Dr Y agrees with the views of the treating clinical team. He agrees that FB's additional needs substantially impact on the prospects of successful stem cell transplant. He agrees that the issues she faces are likely to substantially increase the likely mortality rate from stem cell transplant to potentially 30 to 40 per cent or greater. He also agrees that the relapse rate is also likely to be increased. He does not diverge from the treating clinical team.[48]I have also considered the independent expert report of Dr Wiseman and again, the position of Dr Wiseman is that, whilst the estimates regarding prospects of success versus likelihood of mortality differ slightly, they are roughly the same as the treating clinical team and he does not again differ in any significant way from the views of Dr X. It is Dr Wiseman's overall position that adjusted for FB's particular needs, there is an over 60 per cent chance of death within the first three years of transplant and a higher risk of remission given her particular challenges.[49]The court therefore has before it a clinical consensus. There is agreement between the clinicians that FB's learning disability and the particular challenging behaviours she has when in hospital, alongside the high risk form of AML she has, will increase the risk of death from stem cell transplant. That is, in simple terms, because it is impossible for the treating team to deliver optimal treatment and to deliver treatment in accordance with the strict restrictive regime required for a prolonged period of weeks and that attempts to do so are likely to cause very high levels of distress and psychological harm to FB.[50]Neither Dr Y nor Dr Wiseman raise any concerns regarding the attempts of the treating team to adjust the delivery of treatment to meet FB's needs. They are both clear that in their clinical opinion, the hospital have done all that they can to try and adjust delivery of treatment to optimise the effectiveness of it.[51]In terms of other evidence that this court must have close regard to, I have considered the report of the IMCA, Ms D who details FB’s wishes and feelings from her discussion with her. She records that FB does know that she is in hospital because she has cancer, but she expressed a desire to return home to normal life, to a familiar home, a reference to her favourite school jumper, to playing with younger family members and undertaking normal activities, that she did not express any desire for more invasive treatment.[52]In terms of the IMCA's overall assessment, it was her view that FB's wishes and feelings point towards maintaining a quality of life, time at home and everyday enjoyment.[53]In terms of her family members, that is also the view of her parents, who wish to focus on promoting the best possible quality of life for the time that FB has left.[54]I turn then to the law. I can gratefully adopt the analysis of the law as set out within the position statement of Mr Karim KC on behalf of the applicant Trust. It is not contentious.[55]In accordance with section 4 of the 2005 Act, the best interests determination is set out in accordance with the framework that the court is to follow. The court must take into account the wishes and feelings, past and present, of FB, and the views of those who are engaged in caring for her. There is of course a strong presumption when undertaking the best interests analysis in preserving life, as set out, for example, in Re M (Best Interests: Deprivation of Liberty) [2013] EWHC 3456 (COP). In considering the best interests of FB, medical best interests are not the only consideration. The court must look to the patient's wider best interests as set out clearly by Butler-Sloss LJ in Re MB [1997] EWCA Civ 3093 and Lady Hale in Aintree University Hospitals NHS Foundation Trust v James [2013] UKSC 67 The Court must consider the social and psychological interests of P, as well as their medical best interests.[56]Weighing very heavily with the court in these circumstances must also be FB's Article 2 right to life. It is clearly firmly engaged. But whilst of course FB has a right to life, that does not equate to preserving her life at all costs.[57]I also have regard to her Article 8 right to respect for her private and family life, and insofar as is possible, upholding her own autonomy and her expression of her own wishes and feelings. Article 8 underpins the importance of section 4's regard to the wishes and feelings of FB.[58]Within the context of that legal framework, I therefore turn to the court's decision.[59]I start first with FB's capacity. As I have noted, a COP3 was filed by Dr L, a member of the treating team at the Trust, which has not been challenged before me. I am satisfied and do declare on the basis of that assessment, which again has been set out in more detail by Dr X today, that FB lacks capacity by reason of her underlying learning disability to conduct these proceedings or to make decisions as to her own medical treatment and care.[60]I therefore have jurisdiction to undertake the best interests analysis under section 4. With great sadness, I declare on the basis of the evidence before me that it is not in the best interests of FB to receive any further treatment by way of stem cell transplant, further chemotherapy or oral tablets. It is, in my judgment, in her best interests that she be allowed to live the remainder of her life, so far as is possible, at home with her family, doing the activities that she likes, free from the distress of hospitals and what has been described to me today as the horrific experience of further invasive treatment.[61]Turning first to stem cell transplant, sadly the overwhelming evidence before the court is that stem cell transplant, whilst the only curative option, in FB's case has only very limited prospects of success, given the high risk AML disease and the additional challenges of delivering optimal treatment due to her learning needs and her lack of understanding which results in self-harming, distressing and disruptive behaviours. Given those particular circumstances, the prospects of successful treatment, I am satisfied in accordance with the evidence of Dr X, are low, indeed as low as 10 to 15 per cent. Whilst not futile to try, sadly in this case, given those modest, limited prospects, we are close to futility.[62]In terms of the experiences of FB thus far, I also have to weigh in the best interests analysis that she has found the chemotherapy difficult and challenging and something which has caused her distress. Stem cell transplant treatment, as was very clear from the evidence of Dr X, would impose a far higher burden upon her. It would be exceptionally difficult to achieve compliance for FB with such a highly restrictive and invasive regime.[63]I am satisfied that the treating clinical team at the NHS Trust have done all they possibly can to adjust delivery of treatment to support FB and to maximise the success of the treatment being delivered, but there are, I am satisfied, limits to what they have been able to achieve, and the challenges, distress and disruptions have continued on an almost daily basis.[64]It is therefore clear from the evidence that the burdens of undertaking this treatment for FB, and in particular the experience of stem cell transplant would be very significant indeed. The treatment itself as described by Dr X would be horrendous for any 19 year old young person, but that would be hugely increased for FB, who simply will not understand what is happening to her and why.[65]Just to take one element of this treatment regime, she would be required to be in isolation for a number of weeks, in and of itself that would prove intolerable for her.[66]Subjecting her to the burdens of that treatment regime, I am satisfied would also impact on her psychological interests. It would, I am satisfied, cause her enormous psychological distress, to be subject to such a regime of treatment without having that understanding as to why it is being done to her.[67]When the court takes together the prospects of a successful outcome, balanced against the burdens of that treatment, both physical and psychological, I am satisfied that, even on a clinical basis and looking only at her clinical best interests, it would not be in her interests to undertake that treatment.[68]I also of course have to look to her broader interests, including her own wishes and feelings insofar as they can be ascertained. I approach that with a degree of caution because FB does not have a full understanding of her disease, nor that she is highly likely to suffer remission and sadly death within a relatively short period of time. However, insofar as she has expressed her wishes and feelings, she has said that she would want normality, to be at home and without any more hospital or treatments. As I say, whilst approaching it with a degree of caution, this court should accord weight to those understandable feelings.[69]I also have regard to her family and their focus on wishing to ensure FB the best quality of life for the time that she has left, again without the burdens of ongoing hospital visits, monitoring and treatments.[70]So, whilst this court of course weighs heavily the strong presumption in favour of preserving life, looking holistically at her best interests and balancing the benefit of the stem cell transport against the very significant wider burdens, clinical, psychological and social, I am satisfied that, given the limited prospects of success, it is not in her best interests to undertake that course of treatment.[71]Turning to the alternative treatments, I can deal with those relatively briefly. Starting first with a further course of chemotherapy, the benefits of such further treatment again would, on the evidence before me, be limited. It may increase the time that she has before remission by perhaps two to three months, but again, the burdens of undertaking a third course of chemotherapy would be very considerable for FB. It would require further hospital admission, incurring all of the challenges and distresses of treatment she has experienced thus far, and I am satisfied that those benefits do not outweigh the burdens of further admission and what that would mean for FB's quality of life.[72]Similarly, as regards ongoing treatment by way of the oral tablets, I note the benefits for a patient in FB's position are unevidenced, but again, the burdens for her would be considerable. She does not like taking tablets and would not wish to do so, but also and significantly, it would mean again increased monitoring with potential side effects, risking further periods of hospitalisation and invasive treatments, all of which would prove distressing and burdensome for FB.[73]In summary, I do not think the court can put it any better than it was expressed by Dr X, as she concluded her evidence. Dr X said to the court that it would be in the best interests of FB in her view to focus on her quality of life and to give her as much freedom as is possible and to let FB be FB for as long as she has left. With great respect to Dr X, I agree with that best interests analysis.[74]That is the decision of the court. Epiq Europe Ltd hereby certify that the above is an accurate and complete record of the proceedings or part thereof. Lower Ground, 46 Chancery Lane, London WC2A 1JE Email: civil@epiqglobal.co.uk