“I attempted to discuss Baby J more and explained that he is not well. I told the mother that she had been admitted with collapse and a heart problem and that she needed a c-section. The mother said "I don’t know. Why is that?" she was distracted when we told her the baby was not well and then a tangential discussion occurred where she was not on topic or responding to discussion regarding the baby, but said "the rest have all been alright." I told her that she was muddled and confused at present and not able to make decisions regarding the baby in my opinion, and asked her if it was ok to speak to her mother and partner regarding her wishes. She gave the impression that this was ok, albeit she did not directly answer the question.” c. Dr N recounts another conversation at 13:30 the same day in her updating evidence: “I visited the mother again at 13:30pm today and showed her pictures of Baby J. The mother took the pictures and looked at them. She said "when will he be better". Her friend was present and we explained that we did not think that Baby J would get better and she said "it is so sad." The mother's friend asked her if she would like to see Baby J and she said "maybe". We explained he had a breathing tube in place and the mother said "it is horrible". She didn’t recall being in hospital and said there is not much she can do. She then said "the only thing you could do" and then was unable to finish the sentence. I explained that Baby J is only alive due to the pipe helping him breathe. The mother said "I thought he was alright. Never? How do you know?" I explained that Baby J has brain problems that are not curable. She said "ok" and then became distracted.”
“The background is of very low amplitude with no convincing cerebral cortical activity seen. Occasional higher amplitude slow component is seen with some superimposed faster rhythms; these might be artefactual/ at times related to muscle activity observed. There are no epileptiform abnormalities, and no electrographic seizures are recorded. These findings are in keeping with severe diffuse encephalopathy and in the clinical context most likely due to severe hypoxic brain injury although the ongoing sedation with the prematurity could be contributing to this depressed EEG.”
“Extensive diffusion restriction throughout both cerebral hemispheres (predominantly white matter but some cortex also), deep grey nuclei and brainstem is consistent with a severe, profound pattern of hypoxic-ischaemic injury.”
“Do Not Attempt Resuscitation” and “no cardiopulmonary resuscitation”
"Babies with significant neurological injury may show some improvement with time as cerebral oedema (swelling of the brain) resolves. This explains why Baby J now shows more breathing efforts and more movement than previously. However the degree of neurological impact on MRI and EEG would still result in significant and profound impairment in the longer term. There is a risk that by delaying extubation, his respiratory centre improves to the point that he survives indefinitely (with a poor quality of life and significant burden of suffering). For this reason, we would not support delaying redirection of care whilst waiting for improvement in maternal capacity to consent."
“It remains my view that it is in Baby J’s best interests to withdraw intensive care including ventilation as soon as possible for the reasons set out in my previous statement. By this treatment continuing Baby J is subject to ongoing burdens and risks with no prospect of the treatment benefitting him.”
“...if Baby J is able to breathe and survive, it is still highly likely that he will survive with severe disabilities. He might not be able to see or hear, he might not be able to swallow or manage his secretions. He might be dependent on gastrostomy feeds for his nutrition. He might not be able to walk or talk…”
“My professional view remains that it is not in Baby J’s best interests to continue his intubation and ventilation (intensive care). I do not think this is providing any benefit to him when at the same time it is exposing him to the burdens of intensive care. These burdens include discomfort of having a breathing tube in the windpipe, frequent blood tests that are needed to manage his ventilation and frequent suctioning (almost two hourly). He is also exposed to risks associated with ventilation such as pneumothorax (air leaks from the lungs to the chest cavity which might require draining if concerning enough) and infection. Having a long line in place also increases the risk of infection and extravasation (infusion fluids leaking to outside veins) injury.”
“I based my view in accordance with the Royal College of Paediatrics and Child Health (RCPCH) guidance document titled: Making decisions to limit treatment in life-limiting and life threatening conditions in children: a framework for practice. In my view, Baby J’s condition might come under the following categories of the framework: a) Category 1C : “Inevitable death, where death is not immediately imminent but will follow and where prolongation of life by LST confers no overall benefit”
“The severity and location of Baby J’s brain injury — notably involving the basal ganglia, thalami, and brainstem — are associated with very poor prognosis. In studies of neonatal HIE with similar patterns, around 89% of infants suffer death or severe neurodevelopmental impairment, and one cohort showed 95% had a grave outcome or died. Among survivors of severe HIE, up to 80% develop major disabilities, with the remainder often facing cognitive, motor, and behavioural impairments. These findings indicate an extremely poor prognosis, with no realistic prospect of neurological recovery or awareness. Since repatriation to [X], Baby J’s condition has evolved. The acute brain swelling seen earlier has subsided, and he now demonstrates some weak spontaneous breathing above the ventilator. This means that if life-sustaining ventilation were withdrawn, he may continue to breathe for a variable period — ranging from hours to days — although sudden and early death remains possible. Importantly, any survival in this context would not be accompanied by awareness or quality of life, but would represent continued existence in a state of profound neurological injury.”
“Short-term: Baby J is capable of shallow spontaneous breathing, but this was observed with a breathing tube in situ, ensuring airway patency. On extubation, there is a significant risk that his airway will not remain protected. Given his profound hypotonia, absent gag reflex, and copious secretions, there is a high likelihood of airway obstruction (e.g. tongue falling back, pooling of secretions, or possible vocal cord palsy). This may result in apnoea and sudden death soon after withdrawal of ventilation. Medium-term: If extubation is tolerated, survival could be variable in duration but would not represent neurological recovery. While some neuronal plasticity is theoretically possible in the developing brain, the extent and distribution of Baby J’s injury — affecting both cerebral hemispheres, basal ganglia, thalami, and brainstem — mean that there is no realistic possibility of meaningful recovery. He would remain profoundly impaired and entirely dependent. Long-term: Survival would almost certainly be associated with profound neurological impairment, including severe spastic quadriplegic cerebral palsy, global developmental delay, epilepsy, and lifelong complete dependency. Any reflexive or brainstem-driven activity (e.g. gasping, hiccups, clonus) would not equate to awareness or purposeful interaction.”
“Balancing these factors, it is my opinion that it is not in Baby J’s best interests for intensive life-sustaining treatment to be continued.”
“In my independent expert opinion, the medical evidence is consistent and overwhelming: Baby J has sustained a catastrophic hypoxic–ischaemic brain injury, leaving him with no realistic prospect of meaningful recovery. The continuation of invasive intensive care would serve only to prolong his suffering. The course most consistent with his best interests is withdrawal of intensive care and provision of palliative comfort-focused support at [X], in the presence of his family.”
“…his care should remain firmly on a palliative pathway, led by the neonatal and children’s palliative care teams at [X]. This would allow him to remain close to his mother, who is herself critically unwell, and his wider family. Should he survive beyond the short term, care should transition to community paediatric palliative services and hospice support. If survival extends unexpectedly into months, referral to Child Development Services could be considered, though in view of the severity of his brain injury he would be expected to have profound, lifelong neurodisability, including severe cerebral palsy, epilepsy, intellectual impairment, and complete dependency.”
“I know for a fact if [the mother] had the right state of mind, she would not want him to have this life. We have both done support work, she was a care coordinator, and she knows her stuff. They were both support workers for adults with additional needs and are aware of implications for Baby J's life. It is not fair for Baby J.”
“56 The court may grant a declaration declaring that treatment in accordance with the recommendation of the child’s doctors can take place, on the grounds that it is in the child’s best interests (see In re B (A Minor) (Wardship: Medical Treatment)[1981] 1 WLR 1421 ). The jurisdiction of the court to make such an order arises where a child lacks the capacity to make the decision for him or herself, in the context of a disagreement between those with parental responsibility for the child and those treating the child (An NHS Trust v MB (A Child Represented by CAFCASS as Guardian Ad Litem)[2006] EWHC 507 (Fam) ;[2006] 2 FLR 319 ). The court has no power to require doctors to carry out a medical procedure against their own professional judgment. 57. As I have observed in previous cases, the legal framework that the court must apply in cases concerning the provision of medical treatment to children who are not “Gillick” competent is well settled. The following key principles can be drawn from the authorities, in particular In re J (A Minor) (Wardship: Medical Treatment)[1991] Fam 33 , R (Burke) v General Medical Council (Official Solicitor intervening)[2005] EWCA 1003 ;[2006] QB 273 , An NHS Trust v MB, Portsmouth Hospitals NHS Trust v Wyatt[2005] EWCA Civ 1181 ;[2005] 1 WLR 3995 , Kirklees Council v RE[2014] EWHC 3182 (Fam) ;[2015] 1 FLR 1316 and In re Gard (A Child) (Child on Life Support: Withdrawal of Treatment)[2017] EWCA Civ 410 ;[2018] 4 WLR 5 : i. The paramount consideration is the best interests of the child. The role of the court when exercising its jurisdiction is to take over the parents’ duty to give or withhold consent in the best interests of the child. It is the role and duty of the court to do so and to exercise its own independent and objective judgment. ii. The starting point is to consider the matter from the assumed point of view of the patient. The court must ask itself what the patient's attitude to treatment is or would be likely to be. iii. The question for the court is whether, in the best interests of the child patient, a particular decision as to medical treatment should be taken. The term “best interests” is used in its widest sense, to include every kind of consideration capable of bearing on the decision, this will include, but is not limited to, medical, emotional, sensory and instinctive considerations. The test is not a mathematical one, the court must do the best it can to balance all of the conflicting considerations in a particular case with a view to determining where the final balance lies. Within this context *16 the wise words of Hedley J in Portsmouth NHS Trust v Wyatt (Southampton NHS Trust intervening)[2004] EWHC 2247 (Fam) ;[2005] 1 FLR 21 at [21] should be recalled: “This case evokes some of the fundamental principles that undergird our humanity. They are not to be found in Acts of Parliament or decisions of the courts but in the deep recesses of the common psyche of humanity whether they be attributed to humanity being created in the image of God or whether it be simply a self-defining ethic of a generally acknowledged humanism.” iv. In reaching its decision the court is not bound to follow the clinical assessment of the doctors but must form its own view as to the child's best interests. v. There is a strong presumption in favour of taking all steps to preserve life because the individual human instinct to survive is strong and must be presumed to be strong in the patient. The presumption however is not irrebuttable. It may be outweighed if the pleasures and the quality of life are sufficiently small and the pain and suffering and other burdens are sufficiently great. vi. Within this context, the court must consider the nature of the medical treatment in question, what it involves and its prospects of success, including the likely outcome for the patient of that treatment. vii. There will be cases where it is not in the best interests of the child to subject him or her to treatment that will cause increased suffering and produce no commensurate benefit, giving the fullest possible weight to the child's and mankind's desire to survive. viii. Each case is fact specific and will turn entirely on the facts of the particular case. ix. The views and opinions of both the doctors and the parents should be considered. The views of the parents may have particular value in circumstances where they know well their own child. However, the court must also be mindful that the views of the parents may, understandably, be coloured by emotion or sentiment. There is no requirement for the court to evaluate the reasonableness of the parents’ case before it embarks upon deciding what is in the child's best interests. In this context, in An NHS Trust v MB Holman J, in a passage endorsed by the Court of Appeal in In re A (A Child)[2016] EWCA Civ 759 ; [2016] Med LR 427 at [34] , said as follows: “The views and opinions of both the doctors and the parents must be carefully considered. Where, as in this case, the parents spend a great deal of time with their child, their views may have particular value because they know the patient and how he reacts so well; although the court needs to be mindful that the views of any parents may, very understandably, be coloured by their own emotion or sentiment. It is important to stress that the reference is to the views and opinions of the parents. Their own wishes, however understandable in human terms, are wholly irrelevant to consideration of the objective best interests of the child save to the extent in any given case that they may illuminate the quality and value to the child of the child/parent relationship.” x. The views of the child must be considered and be given appropriate weight in light of the child's age and understanding.” i. The paramount consideration is the best interests of the child. The role of the court when exercising its jurisdiction is to take over the parents’ duty to give or withhold consent in the best interests of the child. It is the role and duty of the court to do so and to exercise its own independent and objective judgment. ii. The starting point is to consider the matter from the assumed point of view of the patient. The court must ask itself what the patient's attitude to treatment is or would be likely to be. iii. The question for the court is whether, in the best interests of the child patient, a particular decision as to medical treatment should be taken. The term “best interests” is used in its widest sense, to include every kind of consideration capable of bearing on the decision, this will include, but is not limited to, medical, emotional, sensory and instinctive considerations. The test is not a mathematical one, the court must do the best it can to balance all of the conflicting considerations in a particular case with a view to determining where the final balance lies. Within this context *16 the wise words of Hedley J in Portsmouth NHS Trust v Wyatt (Southampton NHS Trust intervening)[2004] EWHC 2247 (Fam) ;[2005] 1 FLR 21 at [21] should be recalled: “This case evokes some of the fundamental principles that undergird our humanity. They are not to be found in Acts of Parliament or decisions of the courts but in the deep recesses of the common psyche of humanity whether they be attributed to humanity being created in the image of God or whether it be simply a self-defining ethic of a generally acknowledged humanism.” iv. In reaching its decision the court is not bound to follow the clinical assessment of the doctors but must form its own view as to the child's best interests. v. There is a strong presumption in favour of taking all steps to preserve life because the individual human instinct to survive is strong and must be presumed to be strong in the patient. The presumption however is not irrebuttable. It may be outweighed if the pleasures and the quality of life are sufficiently small and the pain and suffering and other burdens are sufficiently great. vi. Within this context, the court must consider the nature of the medical treatment in question, what it involves and its prospects of success, including the likely outcome for the patient of that treatment. vii. There will be cases where it is not in the best interests of the child to subject him or her to treatment that will cause increased suffering and produce no commensurate benefit, giving the fullest possible weight to the child's and mankind's desire to survive. viii. Each case is fact specific and will turn entirely on the facts of the particular case. ix. The views and opinions of both the doctors and the parents should be considered. The views of the parents may have particular value in circumstances where they know well their own child. However, the court must also be mindful that the views of the parents may, understandably, be coloured by emotion or sentiment. There is no requirement for the court to evaluate the reasonableness of the parents’ case before it embarks upon deciding what is in the child's best interests. In this context, in An NHS Trust v MB Holman J, in a passage endorsed by the Court of Appeal in In re A (A Child)[2016] EWCA Civ 759 ; [2016] Med LR 427 at [34] , said as follows: “The views and opinions of both the doctors and the parents must be carefully considered. Where, as in this case, the parents spend a great deal of time with their child, their views may have particular value because they know the patient and how he reacts so well; although the court needs to be mindful that the views of any parents may, very understandably, be coloured by their own emotion or sentiment. It is important to stress that the reference is to the views and opinions of the parents. Their own wishes, however understandable in human terms, are wholly irrelevant to consideration of the objective best interests of the child save to the extent in any given case that they may illuminate the quality and value to the child of the child/parent relationship.” x. The views of the child must be considered and be given appropriate weight in light of the child's age and understanding.”
“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.”
“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.”
“As the authorities to which I have already made reference underline again and again, the sole principle is that the best interests of the child must prevail and that must apply even to cases where parents, for the best of motives, hold on to some alternative view.”
“Article 2… imposes a positive obligation to give life-sustaining treatment in circumstances where, according to responsible medical opinion, such treatment is in the best interests of the patient but does not impose an absolute obligation to treat if such treatment would be futile.”
“The Court will recall the applicant Trust’s position has been (and remains) that long term invasive ventilation is not an option that the applicant is offering in this case, as such treatment would be futile, is not clinically indicated and would in the circumstances be considered unethical. There is now unequivocal and overwhelming evidence from the treating team and the second opinion doctor that it is in Baby J’s best interests to be extubated as soon as is practicable, in a planned way, and to receive palliative care...”
“There is a strong presumption in favour of trying to preserve life. Yet the medical evidence seems to all point in one direction. Brain function for this child now and in the future is exceedingly limited. We are told that maintaining ventilation is futile. We are told that Baby J is starting to feel pain, and the Local Authority was asked to agree to an increase in morphine. This is an incredibly unhappy and sad case. The Local Authority has debated at all levels what is best for this baby. The Local Authority does not want suffering for Baby J, we are being told that whatever happens this boy’s life is the bleakest.”
“[T]he touchstones for the Official Solicitor in this difficult decision for the court are: a. Dr R’s 2nd opinion that “In my independent expert opinion, the medical evidence is consistent and overwhelming: Baby J has sustained a catastrophic hypoxic–ischaemic brain injury, leaving him with no realistic prospect of meaningful recovery. The continuation of invasive intensive care would serve only to prolong his suffering. The course most consistent with his best interests is withdrawal of intensive care and provision of palliative comfort-focused support ...” b. The neurological examinations on24 August 2025 : “Baby J was unresponsive, with eyes closed and no reaction to voice or pain. He was profoundly hypotonic, lying in a frog-like posture. Deep tendon reflexes were absent, with only distinct ankle clonus on stimulation. Palmar grasp was absent and plantar grasp weak on the right only. He showed no facial movements, no gag or rooting reflex, and no protective responses to suction despite copious secretions. Pupils were small and equal; there was no visual fixation or auditory response. Spontaneous activity was limited to reflex withdrawal and abnormal posturing, with occasional lip-smacking, ET tube sucking, hiccups, and clonus. No seizures were observed.” c. That doctor’s opinion, based on the neurological examinations he has undertaken, of the severity and location of Baby J’s brain injury, involving the basal ganglia and brainstem, being associated with very poor prognosis; of there being no realistic possibility of meaningful neurological recovery; and the burdens on Baby J of the interventions that would be necessary to sustain his life, particularly in the context of the opinion that, “Importantly, any survival in this context would not be accompanied by awareness or quality of life, but would represent continued existence in a state of profound neurological injury.” d. That 2nd opinion being consistent with the opinion of Dr G (a member of the treating clinical team), who opines that “if Baby J is able to breathe and survive, it is still highly likely that he will survive with severe disabilities. He might not be able to see or hear, he might not be able to swallow or manage his secretions. He might be dependent on gastrostomy feeds for his nutrition. He might not be able to walk or talk, in which case he will be wheelchair dependent. He might have some combination of these disabilities in any combination or all of them.” e. The list of burdens of ongoing treatment set out by Dr G. f. The opinion of Dr G when considering the relevant RCPCH guidance that Baby J might come under Category 1C or if he survives Category 2C. g. Importantly, in the context of that medical evidence, the views of all family members who have been asked by professionals: all say that Baby J should be relieved of his suffering and his treatment ended.”