Barking, Havering and Redbridge University Hospitals NHS Trust v AS & Anor [2026] EWCOP 15 (T3)

This judgment was delivered in open court. 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 respondents 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 may be a contempt of court.[2026] EWCOP 15 (T3)Case No COP 20030421
IN THE COURT OF PROTECTION
IN THE MATTER OF THE MENTAL CAPACITY ACT 2005
Venue Royal Courts of Justice, Strand, London, WC2A 2LLDate 24/03/2026
Before
MR JUSTICE PEEL
Between
BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUSTApplicantASRespondentsTRespondent
Katie Gollop KC (instructed by Hill Dickinson LLP) for ApplicantSophia Roper KC (instructed by the Official Solicitor) for 1 st RespondentOliver Lewis (instructed by Irwin Mitchell LLP) for 2nd RespondentHearing Hearing dates: 17-18 March 2026
Approved JudgmentThis judgment was handed down remotely at 10.30am on 24 March 2026 by circulation to the parties or their representatives by e-mail and by release to the National Archives..............................MR JUSTICE PEELPeel J:
[1]I shall refer to the subject of this application as “AS”. AS is 83 years old.[2]This is an application in the Court of Protection by the Trust dated 11 March 2026 for a “Declaration that it is lawful and in [AS’s] best interests to continue risk feeding (with no insertion of an NG tube/PEG), cease blood tests, IV fluids and potassium, take a palliative care approach to ensure comfort and discharge to a more comfortable and appropriate setting under the fast track pathway.”[3]The First Respondent is AS herself, represented by the Official Solicitor who supports the application.[4]By consent, I ordered that her son T be joined as Second Respondent. He advances a case on behalf of the wider family who oppose the application. Regrettably there has been a breakdown of communication between the family and the clinicians. I am confident that at all times the family and the clinicians have been motivated by the best interests of AS, even if they have not seen eye to eye as to what her best interests require. Despite the concerns of the family, from everything I have seen and heard, the clinicians have treated AS with the utmost care and dedication.[5]The application came before me on 17 March 2026. The Trust, AS (through the Official Solicitor) and T were represented. All parties agreed it was desirable for a decision to be made as soon as possible. I heard oral evidence on 17 March from Dr G, a treating Consultant Geriatrician at the relevant hospital, and from T. Oral submissions were made the next day. I reserved written judgment, but gave my decision shortly after the end of submissions so as to enable the parties to begin planning the next steps. I informed the parties that I acceded to the Trust’s application and approved the proposed care plan. Brief description of P[6]T told me that AS, before her recent medical issues, was an active lady, full of life and very sociable, despite having some disabilities. She is adored by her six sons, who regard her as the centre of the family. She is brave, having faced past health difficulties. The love of the family for her was palpable in the courtroom where T and three of his brothers were in attendance. I was shown short videos of AS in hospital which allowed me the privilege of seeing her as a human being, rather than simply a person described on paper. Advance Statement[7]On 29 June 2025, before the onset of her medical issues which are now the subject of the court’s consideration, AS, with the assistance of T, signed a document titled “Advance Statement” in which she said:
“I would like to make this advance statement about my future care if I were to lose capacity”. “If my health becomes very poorly or in an emergency situation – I would want all treatments and care necessary to prolong my life”. “If I was at the end of my life I would want my life to be prolonged using any treatment including by artificial means”
. These wishes aligned with her Muslim faith. Relevant medical background

Relevant medical background

[8]On or around 5 September 2025, AS sustained a massive stroke involving three blood vessels and causing significant damage to her brain; it occurred in the context of atrial fibrillation. She was aphasic (unable to understand or produce speech). She was admitted to hospital between 5 September and 18 November 2025. Of particular relevance to this application is that she had very severely impaired swallowing function. She had a nasogastric tube (“NG tube”) inserted for nutrition and hydration until 20 October 2025. During that period she had significant issues with the NG tube, repeatedly vomiting and regurgitating. I am satisfied on the evidence I have heard from Dr G that when the NG tube was removed, she had not regained swallowing functionality. She was discharged home on 18 November 2025, entirely bed bound and with limited feeding by oral intake. At home, she was cared for by her family, and in particular T, who are devoted to her.[9]On 25 November 2025, AS was admitted to hospital, presenting with a urinary tract infection (UTI) and lower respiratory tract infection symptoms. The family were concerned about her feeding. On 5 December 2025, in the presence of a doctor and her son T, she declined a further NG tube insertion. She was discharged home on 19 December 2025.[10]On 21 December 2025, she represented and was discharged home the next day, where she remained until 3 January 2026.[11]On 3 January 2026, she was re-admitted to hospital with a history of reduced eating and drinking for 3-4 days, and a cough. The working diagnosis was a UTI and she was treated with antibiotics. The family raised the possibility of a NG tube or a percutaneous endoscopic gastrostomy tube (PEG tube).[12]Dr B, AS’s current treating Consultant Geriatrician, first saw AS on 9 January 2026.[13]By two weeks after admission (therefore by about 17 January 2026), AS had deteriorated further. There had been a reduction in her oral intake to about 50-100mls per day. IV fluids were given intermittently when her urine levels dropped below acceptable levels. She was visited by the palliative care team and her life expectancy was assessed at less than three months.[14]A mental capacity assessment was carried out on 20 January 2026 and it was noted that in answer to questions she replied “ssshhhh” and did not point to pictures as suggested. On 27 January 2026, a further assessment was carried out. She said “tadada” response to all questions, including both open and closed questions, and again did not point to visual aids. On both occasions, she was assisted by an Urdu interpreter.[15]On 22 January 2026, a MDT meeting took place, followed by a Best Interests meeting with the family. The conclusions of the clinicians were: i) AS lacked capacity. ii) Risk feeding was appropriate. iii) NG tube feeding is typically used as a short term intervention (for 4-6 weeks) following an acute stroke to assess whether swallowing function improves. In AS’s case, there was no meaningful change in her swallowing ability and further NG tube insertion was considered inappropriate. iv) PEG feeding was deemed inappropriate as the risks outweighed the potential benefits. Potential risks included peritonitis, severe infection, secretions, vomiting and procedure related complications. It would be difficult to obtain venous access. The family indicated that in their view AS should not be discharged without either NG tube or PEG tube feeding.[16]On 26 February 2026, a further professionals meeting took place. Oral intake remained low, at about a couple of spoonfuls a day. AS remained aphasic. Food was being offered but it was regularly refused, either held in her mouth or falling out. Feeding via a NG tube or a PEG tube continued to be judged inappropriate. There was no apparent clinical benefit, and multiple risks. The consensus was that IV fluids should cease for patient comfort as they risked fluid overload. The preferred approach was palliative care, which could take place in a home setting.[17]On 10 March 2026 a further Best Interests meeting took place. It was recorded that: i) AS continued regularly to refuse food, fluids or medication and/or to be unable to swallow them. She had severe weight loss and was very frail. ii) IV access was increasingly difficult, with generalised swelling as a result of fluid accumulating in tissues rather than circulation so that cannulas were difficult to insert. There was a risk of fluids entering her lungs. iii) The view was that she was approaching the end of her life. AS was dying because of natural disease progression, not starvation. iv) NG and/or PEG tube feeding were not recommended due to poor tolerance, high risk of vomiting/regurgitation, and general discomfort with no discernible benefit. Artificial feeding and IV fluids would cause harm, not benefit. v) AS’s best interests would be served by focus on comfort.[18]I am told that AS’s weight reduced from 50.3 kgs on 15 November 2025 to 36.9 kgs on 7 March 2026. The clinical evidence[19]Dr B did not give oral evidence, but provided a written statement in which he says: i) AS’s condition is critical and irreversible. She is on and off dehydrated, and her potassium levels are decreasing. She is very frail after her stroke. ii) AS currently receives a small amount of risk feeding. She has regular blood tests. IV fluids and potassium are given intermittently. iii) It is in her best interests to continue to receive risk feeding and water orally. A NG tube and a PEG tube would not be appropriate. Blood tests should cease, as should IV fluids and potassium. A palliative care approach should be taken, to include oral feeding and medication. iv) Blood tests are inappropriate as there is no indication for them and they will not change her prognosis. v) IV fluids are not in her interests. The IV fluids are not staying in her veins and instead go into her tissue which causes uncomfortable swelling. As fluid builds up she will get to a state of fluid overload. Diuretics cannot be administered because there would be a drastic drop in blood pressure and reduced oxygen supply to the organs, leading to kidney or heart failure. The IV line is increasingly difficult to insert and if the swelling increases it will become impossible. vi) Subcutaneous provision of fluids is not appropriate and in any event potassium cannot be given subcutaneously. vii) A NG tube is not clinically appropriate. It has not previously shown any meaningful change in ability to swallow. There are risks, in particular refeeding syndrome, aspiration and fluid overload. It is invasive and uncomfortable. When she had capacity, AS declined the NG tube re-insertion. viii) The PEG tube carries too many complications, with low likelihood of clinical benefit.[20]According to the papers, the clinical view is that although life expectancy is an inexact science, the team think she is unlikely to live longer than a month. Second Opinion[21]A second opinion has been obtained from Dr O, a Consultant Physician in Stroke Medicine and Geriatric Medicine, who agreed with the Trust’s approach. She says in her report: i) AS is aphasic, with no meaningful verbal communication and unable to follow verbal or non verbal commands. There is likely to be visual impairment. She is drowsy but rousable, but offers no meaningful interaction and her vocalisations are incomprehensible. She is frail, and has subcutaneous oedema. She has minimal oral intake and therefore experiences malnutrition and general physiological decline, as well as worsening renal function associated with reduced hydration. She attempted to offer AS a small amount of yoghurt, which she accepted but did not swallow. ii) AS lacks capacity. iii) A total anterior circulation infarct, which has been observed by neuroimaging, carries a poor prognosis. Given her age, severity of neurological injury, and lack of recovery over several months, “the likelihood of meaningful neurological recovery is extremely low”. iv) PEG insertion after a stroke does not improve functional outcomes and may increase the likelihood of severe disability in survivors. v) The Best Interests analysis should take into account: a) According to the family, AS valued active medical treatment, and the Advance Statement requests all active treatment options to be pursued, although there is no direct mention of artificial nutrition. b) Artificial feeding may prolong life but is unlikely to improve neurological function or independence. c) A PEG insertion would carry substantial burdens, including aspiration, infection, tube complications and repeated hospital admissions, and would be unlikely to improve the neurological outcome. It would not provide meaningful clinical benefit. d) Artificial feeding would prolong survival with severe disability without improving quality of life. e) Comfort feeding should continue to be offered f) NG feeding has already been tried without meaningful benefit, and AS demonstrated significant intolerance with vomiting and regurgitation. Using it as a bridge to PEG insertion is unlikely to be in AS’s interests. g) The preferred approach is a palliative care pathway. The Official Solicitor[22]An agent of the Official Solicitor visited AS on 16 March 2025. AS was in and out of sleep, not speaking or responsive other than (perhaps) a quiet “mm” sound, although it was unclear if that was in fact a response. The agent asked AS if she was “ok”, to which AS tilted her head slightly which seemed to be in response to the question. One of AS’s sons (not T) was there, and AS seemed to track him with her eyes. On occasions, AS nodded slightly, and she gripped her son’s hand. When the agent said goodbye, AS appeared to nod slightly. The son asked the agent to watch him give her water; AS seemed to open her mouth but there was no sign of swallowing.[23]She was told by a nurse that AS only opens her mouth if she wants to. She won’t swallow. If she has any more than 5ml, she is sick. She is no longer eating or drinking. She will not take medication orally. They provide fluids (including potassium) only when her urine is below an appropriate level. When she receives fluids, that causes swelling. The nurse said AS never speaks but occasionally smiles. Oral evidence of Dr G[24]Dr G was an impressive witness; calm, clear and measured. He has a full and comprehensive understanding of AS’s condition. I accept his evidence unreservedly. He told me that: i) Inserting a NG tube now would be a very different proposition from the one which was inserted in September 2025: a) Although the risk of vomiting/regurgitation is unchanged, what has changed is what would happen to the feed. The gut is now almost certainly swollen, so that absorption of feed would be significantly decreased and nutritional benefit much reduced. b) A likely consequence of the swollen gut would be diarrhoea. She already has broken skin on her buttock. Diarrhoea would require regular, uncomfortable repositioning which in turn would increase the risk of pressure ulcers. Diarrhoea would involve fluid discharge, and exacerbate dehydration. c) Refeeding syndrome would also be a likely consequence, reducing potassium, phosphate and magnesium levels, which would require daily supplements delivered intravenously, and therefore extra fluid which would add to the already high levels of swelling and increase the risk of fluid entering the lungs and causing breathing problems. d) AS has a hiatus hernia which means that feeding via a NG tube would make indigestion reflux more likely. ii) NG feeding is unlikely to prolong life and could shorten it if it leads to complications. It would only prolong life if it was entirely successful but in his view the variety of risks and complications would be likely to make the NG tube unsuccessful, and shorten life. He thinks that AS’s life expectancy as a result of her neurological condition is measured in weeks, not months. iii) A NG tube would be uncomfortable for AS. It would not be a successful bridge to a PEG and in any event, although it is not his speciality, he thought that she would not be a suitable candidate for a PEG. iv) Intravenous fluids will not, contrary to what the family believe, rehydrate AS as the fluids are leaking into the tissues, which is the cause of swelling. Further, inserting a cannula is difficult. Because she is dehydrated, her veins are difficult to make an insertion. The swelling makes the veins hard to find, and because she has had so much intravenous treatment, some veins have clotted off. Similar issues arise with blood tests. He thought that very shortly, provision of IV fluids will become impossible. v) If she were to have a NG tube inserted, AS would not be able to leave hospital and go home, because of the difficulties of managing a NG tube in the community. vi) Overall, he said that the burdens of the treatment sought by the parents outweigh any benefit. In reality, it seemed to me that he could not see any discernible benefit. Oral evidence of T[25]T provided a written statement and gave oral evidence. He and his family have obviously found the events of the past six months distressing. T was courteous and respectful. His devotion for his mother was obvious. The commitment of the family to their mother is exemplary. T, I think, struggled to accept the medical evidence which he has read and heard, and does not agree with it, although he accepts that AS is very unwell. The family are suspicious of the motives and actions of the clinicians. I sensed that he and his family are clutching at the suggested insertion of a NG tube in the hope of a miracle recovery. He said that: i) The family considers that AS’s weight loss is due to neglect by the treating staff. Until the NG tube was removed, AS was making good recovery. ii) They consider that a NG tube should be inserted immediately, and that P’s deterioration is due to lack of feeding rather than neurological injury. AS would thereby improve neurologically, physically and psychologically to a point where a PEG insertion might become possible. They feel that the Advance Statement is being ignored. They do not accept that AS is at the end of her life and oppose the application. iii) AS is a practising Muslim, who believes that only God should decide the time of death. iv) AS is responsive, moves her head, smiles and holds his hand. Capacity[26]There is no dispute that AS lacks capacity and I say no more on this subject. The law: best interests[27]The statutory provisions with which the court is concerned are contained in s4 of the Mental Capacity Ac 2005. “4 Best interests(1) In determining for the purposes of this Act what is in a person's best interests, the person making the determination must not make it merely on the basis of— (a) the person's age or appearance, or (b) a condition of his, or an aspect of his behaviour, which might lead others to make unjustified assumptions about what might be in his best interests.(2) The person making the determination must consider all the relevant circumstances and, in particular, take the following steps.(3) He must consider— (a) whether it is likely that the person will at some time have capacity in relation to the matter in question, and (b) if it appears likely that he will, when that is likely to be.(4) He must, so far as reasonably practicable, permit and encourage the person to participate, or to improve his ability to participate, as fully as possible in any act done for him and any decision affecting him.(5) Where the determination relates to life-sustaining treatment he must not, in considering whether the treatment is in the best interests of the person concerned, be motivated by a desire to bring about his death.(6) He must consider, so far as is reasonably ascertainable— (a) the person's past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity), (b) the beliefs and values that would be likely to influence his decision if he had capacity, and (c) the other factors that he would be likely to consider if he were able to do so.(7) He must take into account, if it is practicable and appropriate to consult them, the views of— (a) anyone named by the person as someone to be consulted on the matter in question or on matters of that kind, (b) anyone engaged in caring for the person or interested in his welfare, (c) any donee of a lasting power of attorney granted by the person, and (d) any deputy appointed for the person by the court, as to what would be in the person's best interests and, in particular, as to the matters mentioned in subsection (6).(8) The duties imposed by subsections (1) to (7) also apply in relation to the exercise of any powers which— (a) are exercisable under a lasting power of attorney, or (b) are exercisable by a person under this Act where he reasonably believes that another person lacks capacity.(9) In the case of an act done, or a decision made, by a person other than the court, there is sufficient compliance with this section if (having complied with the requirements of subsections (1) to (7)) he reasonably believes that what he does or decides is in the best interests of the person concerned.(10) "Life-sustaining treatment" means treatment which in the view of a person providing health care for the person concerned is necessary to sustain life.(11) "Relevant circumstances" are those— (a) of which the person making the determination is aware, and (b) which it would be reasonable to regard as relevant.”[28]The courts have emphasised in a variety of contexts that best interests is a broad concept.[29]The classic formulation is contained in the Supreme Court decision of Aintree University Hospital NHS Trust v James [2013] UKSC 67 where Baroness Hale said:
“[22] Hence the focus is on whether it is in the patient's best interests to give the treatment rather than whether it is in his best interests to withhold or withdraw it. If the treatment is not in his best interests, the court will not be able to give its consent on his behalf and it will follow that it will be lawful to withhold or withdraw it. Indeed, it will follow that it will not be lawful to give it. It also follows that (provided of course they have acted reasonably and without negligence) the clinical team will not be in breach of any duty toward the patient if they withhold or withdraw it. [35]The authorities are all agreed that the starting point is a strong presumption that it is in a person's best interests to stay alive. As Sir Thomas Bingham MR said in the Court of Appeal in Bland, at p 808, "A profound respect for the sanctity of human life is embedded in our law and our moral philosophy". Nevertheless, they are also all agreed that this is not an absolute. There are cases where it will not be in a patient's best interests to receive life-sustaining treatment. [39] The most that can be said, therefore, is that in considering the best interests of this particular patient at this particular time, decision-makers must look at his welfare in the widest sense, not just medical but social and psychological; they must consider the nature of the medical treatment in question, what it involves and its prospects of success; they must consider what the outcome of that treatment for the patient is likely to be; they must try and put themselves in the place of the individual patient and ask what his attitude towards the treatment is or would be likely to be; and they must consult others who are looking after him or are interested in his welfare, in particular for their view of what his attitude would be. [44] As was emphasised in Re J (1991), it is not for others to say that a life which the patient would regard as worthwhile is not worth living. [45] The purpose of the best interests test is to consider matters from the patient's point of view. That is not to say that his wishes must prevail, any more than those of a fully capable patient must prevail. We cannot always have what we want. Nor will it always be possible to ascertain what an incapable patient's wishes are. Even if it is possible to determine what his views were in the past, they might well have changed in the light of the stresses and strains of his current predicament. In this case, the highest it could be put was, as counsel had agreed, that "It was likely that Mr James would want treatment up to the point where it became hopeless". But insofar as it is possible to ascertain the patient's wishes and feelings, his beliefs and values or the things which were important to him, it is those which should be taken into account because they are a component in making the choice which is right for him as an individual human being.”
Analysis

Analysis

[30]I am satisfied, and all parties agreed, that AS lacks capacity. I turn therefore to her best interests.[31]Overall, I find the medical evidence in this case to be compelling. I am satisfied (despite the family’s reservations), that AS’s very severe neurological and brain injuries are incurable and irreversible. Her life limiting condition is a result of her neurological presentation rather than lack of nutrition. She is aphasic. Based on the evidence, which I accept is based on professional expertise rather than pure science, her life expectancy is now a matter of a few weeks. She is extremely frail and weak. A note from the ward round on 16 March 2026 gives a graphic overview of her compromised physiological presentation. She is unable to take more than a tiny amount of food by oral intake each day.[32]Notwithstanding her neurological condition, it is accepted that she derives pleasure from, in particular, being with her family; there is evidence of smiles, holding hands, nodding in response to family members. These indicate an awareness of family and taking comfort from their presence, which is suggestive of some, albeit limited, quality of life. In addition to this evidence of responsiveness, T’s counsel invites me to take into account AS’s views expressed in the “Advance Statement”, prepared before her stroke, that she would wish to have all available treatment, and to afford respect to her personal autonomy. I am confident that when she signed the document, she expressed her wishes at that time. However, the evidence is that(i) she found the NG tube which was inserted in September/October 2025, to be painful and uncomfortable, causing her to vomit and regurgitate and(ii) she rejected a further tube on 5 December 2025, after readmission, clearly indicating to Dr Tandy, in the presence of T, that she did not want it. The circumstances in which she expressed opposition to the NG tube were not explored in evidence, but I am confident that it was an expression of her wish not to be subjected to the intolerability of the tube. It seems to me that, in accordance with s1(2) of the Mental Capacity Act 2005, I should presume that AS was capacitous at the time; the clinicians thought so, and there is no evidence to the contrary. I therefore weigh in the balance not just the Advance Statement signed before the stroke, but also her actions after the stroke in declining a NG tube. I also bear in mind the strongly held views of the family, which are rooted in love for AS and their own religious beliefs.[33]There is no curative treatment for AS’s condition and, in particular, a NG tube, or a PEG tube, or IV fluids will not prolong life to any significant extent. Indeed, as Dr G said, if complications and further interventions are required by AS as a result of such artificial feeding (which he considered inevitable), her lifespan would be reduced. There would be minimal nutritional benefit because of AS’s swollen gut. The burdens and risks of artificial feeding include: i) Fluid overload from the IV lines, associated swelling, increased difficulty in inserting the cannula, a risk of fluid entering the lungs, and associated pain and discomfort. ii) The NG and PEG tubes would be invasive and uncomfortable. AS has rejected the NG in the past and it seems likely to me that to reinsert it would be physically painful (with the possibility of vomiting/regurgitation) and emotionally harmful given that she is resistant to the NG tube. There would be risks of secretions and aspiration. iii) The risk of refeeding syndrome. iv) The risk of indigestion reflux is increased by AS’s hiatus hernia. v) The risk of secretions and aspirations. vi) The likelihood of diarrhoea, and consequential discomfort in repositioning and pressure sores. vii) As a result of the above, the likelihood of a need for further medical interventions.[34]Any or all of these risk are, in my judgment, likely to occur and would represent an intolerable burden for AS who is extremely frail. The insertion and maintenance of a tube would be likely to cause her significant harm. To subject her to discomfort, pain and distress is a powerful factor against artificial feeding which would have minimal benefit, even in the unlikely event of it being successful. Unless the insertion of a NG tube for 4-6 weeks is an outright success with no complications, which on the evidence is highly unlikely, I can discern no meaningful benefit in re-inserting a tube, or in the continuation of IV lines.[35]Dr B stated that the purpose of a NG tube is a short term trial to attempt to improve feeding in acute stroke patients. It is not a long term treatment plan. The suggestion by the family that it could provide a bridge to a PEG tube is in my judgment untenable because(i) in and of itself, a NG tube carries with it an unacceptable level of burden and risk for AS and(ii) a PEG tube is not indicated in this case for reasons explained above.[36]I must look at the whole picture, and consider AS’s interests in the widest sense, essentially taking into account the family’s wishes, AS’s expressed wishes in the Advance Statement and when offered a NG tube in December 2025, her experiences of NG tube feeding, the religious faith of AS and her family, AS’s limited life expectancy, and the advantages and disadvantages of tube feeding. This is not a case where the Trust seeks withdrawal of life support which will inevitably lead to death in a matter of hours. What is sought is authorisation not to provide treatment which would at best extend life for a very short period of time, but which would carry with it risks and burdens, including pain and discomfort which would be in my judgment intolerable for AS. Overall, in my judgment, the likelihood of successful NG tube feeding is remote and even if successful it would at best provide AS with short prolongation of life. Set against that are the clear disadvantages, the likelihood that it will not work, the associated pain and distress for AS, the likelihood of further intervention being needed to address complications and AS’s clear indication in December 2025 that she does not want a further NG tube.[37]Finally, it is in my judgment relevant that if the Trust were to proceed with a NG tube, that would effectively preclude AS from returning home because it would not practically be possible to feed AS in this way in the community. In my judgment, it is likely that AS would prefer to be at home, surrounded by her loved ones, rather than on a hospital ward. And it is likely that she would prefer to be as comfortable as possible rather than subjected to invasive and distressing treatment.[38]The clinical evidence on these matters is unanimous, and the Second Opinion supports the Trust’s plan. The sad reality of this case, in my judgment, is that AS’s best interests are best served by authorising the Trust to withhold the medical steps referred to in the application, and to move to a palliative care plan. With a heavy heart, and acknowledging as I do the devastation of AS’s family who cling on to the hope of recovery or improvement, I accede to the Trust’s application. I approve the palliative care plan which incudes the possibility of discharge home with community support. I appreciate that this will be a bitter blow for the family, but I hope they will now focus on the remaining precious time with their mother.