Hospitals NHS Trust v MTR (Mother) & Ors [2026] EWHC 1867 (Fam)

This judgment was delivered in private and a transparency order is in force. 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 child and members of their family must be strictly preserved. All persons, including representatives of the media and legal bloggers, must ensure that this condition is strictly complied with. Failure to do so may be a contempt of court.[2026] EWHC 1867 (Fam)Case No FD26P00459
IN THE HIGH COURT OF JUSTICE
FAMILY DIVISION
Venue Royal Courts of Justice, Strand, London, WC2A 2LLDate 20 July 2026
Before
MR JUSTICE PEEL
Between
Hospitals NHS TrustApplicantMTR (Mother)RespondentsFTR (Father)RespondentTR (a child by her Children’s Guardian)Respondent
Conrad Hallin (instructed by Kennedys Law) for ApplicantThe First and Second Respondents in person for in personChristopher Osborne (instructed by the Child’s Guardian) for Third RespondentHearing Hearing date: 16 July 2026
Approved JudgmentThis judgment was handed down remotely at 2pm on 20 July 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 am concerned with a little girl, TR, who is 1 month old. She has been on the neonatal unit at hospital since birth. A rare genetic condition, Trisomy 18 (also known as Edward’s syndrome), was suspected during pregnancy, and the diagnosis was confirmed upon birth. It is a severe chromosomal disorder caused by an extra copy of chromosome 18. It triggers profound developmental delays and life-threatening physical defects, including structural heart issues and organ malformations. It affects regulation of breathing, renal function and feeding. Approximately 50% of babies with this diagnosis do not survive beyond one month, and 90% do not survive beyond one year. Death may occur suddenly. There is no curative treatment. TR’s clinical condition has deteriorated with seizures which have increased in frequency and length. In addition, she has a cardiac condition concerning the connection between pulmonary artery and aorta, for which the only treatment is surgery, but, even if such treatment were successful, it would not affect the inevitable consequences of Trisomy 18.[2]When the application was made on 13 July 2026, the clinicians considered that(i) escalation of treatment to cardio-pulmonary resuscitation, intubation, ventilation, surgery or CPAP, and(ii) surgery for the heart condition would not be in TR’s best interests. The parents, while deeply grateful to the treating team for the care being given, wished everything possible to be done to avoid or delay TR’s death. They agreed that (i) cardio-pulmonary resuscitation and (ii) invasive intubation and ventilation would not be appropriate. Where they differed from the clinicians was in respect of the following which they wished to remain available as options: i) High flow cannula oxygen, which the clinicians say would not reverse the underlying apnoea. ii) Continuous Positive Airway Pressure (“CPAP”), which she has previously received, and became agitated and tachycardiac. Again, it would not reverse the underlying condition. iii) Cardiac surgery. The clinicians consider this would not be indicated and they would not offer it because: a) It carries a high risk of bleeding (including into the brain), multi-organ failure, infection and poor healing of tissues. b) TR would be unlikely to survive the surgery because of her young age, small size and the extent of the heart defects. c) There is no obvious benefit. It will not prolong life and may reduce it. d) It will be painful and burdensome. e) It will not affect the genetic condition, or other organ issues, and will have no impact on the apnoea and seizures.[3]The application to court was for declarations that the proposed care plan (including the ceiling of care outlined above) is in the bests interests of TR. The Trust served a witness statement by a Consultant Neonatologist, Dr Z, at the hospital. Second opinions have been sought (including from Alder Hey Children’s Hospital), all of which are aligned with the Trust’s approach.[4]The application was listed before me on 16 July 2026 at 2pm for directions. All parties anticipated it would proceed in that way. On the morning of 16 July 2026, I received a position statement on behalf of the Trust seeking directions towards a final hearing in a few weeks time. I also received position statements from the parents (who were acting in person) outlining their opposition to the substantive application.[5]At 12.01, about two hours before the hearing, I received an email from the Trust saying:
“TR suffered a significant deterioration overnight, including repeated episodes of apnoea and seizure activity, requiring face mask ventilation for comfort. The clinical team's concern is that Baby TR may be actively dying, and there is a real possibility that she will not survive until the hearing this afternoon. Although this cannot be predicted with certainty.”
[6]At 14.01 I received a draft order on behalf of the Trust seeking the following:
“It is in TR’s best interests not to escalate her care to involve: i) cardiopulmonary resuscitation; ii) organ support drugs; and/or iii) invasive intubation and ventilation. It is further in TR’s best interests, whether or not her parents’ consent to the same: iv) To come off ICU observation monitoring; v) To be held; vi) To receive palliative care as clinically indicated, including such use of morphine and midazolam as is clinically indicated; vii) To insert a subcutaneous cannula, if clinically indicated, for the purposes of providing the above palliative care towards the end of life; viii) To receive oxygen so as to keep TR comfortable, either by nasal cannula or wafting via a mask away from the face, but not to receive oxygen via CPAP/positive pressure on the face.”
[7]The hearing started at 3.15pm. Counsel for the Trust submitted that a final decision had to be made immediately because of the urgency. The parents were in an invidious position in that they were in person and had not anticipated that a final order would be sought. However, in response to a question from me, they agreed that a decision should be made without delay. The Guardian was also in an invidious position. She had had no opportunity to undertake the usual inquiries, and to make a holistic welfare evaluation. Solicitor for TR indicated that he and the Guardian wished to explore the evidence to assist the court, but would not be able to make a formal recommendation. I indicated to the parties that I intended to hear the clinical evidence, and then decide whether to proceed to a final decision, or whether it would be feasible to adjourn the hearing for a short period of time, perhaps to the next day (Friday) or the start of the following week.[8]I heard from Dr Z. In the light of her evidence, I came to the conclusion that the case was so urgent that it needed immediate determination. No party indicated opposition to that approach. I gave my decision orally, and said that I would prepare a written judgment to be sent out the next day. This is my judgment, explaining why I approved the Trust’s application.[9]I was greatly assisted during the hearing by counsel for the Trust and solicitor for TR. I would like to pay tribute to the parents who, faced with unspeakably challenging circumstances, were composed and courteous throughout. They have said how grateful they are to the treating team, and recognise the compassion and treatment shown by the clinicians and nursing staff. The love and devotion of the parents to their daughter is obvious.[10]Ultimately the main issues in the case were in respect of 6(iv) and (viii) above, i.e whether TR should come off ICU monitoring, and whether CPAP ventilation should continue.

The evidence of Dr Z

[11]Dr Z provided the court with an update and an explanation for the proposed treatment plan, which essentially involves moving to palliative care. She told me that: i) TR started deteriorating rapidly at about midnight on 15-16 July 2026. Whereas before seizures and apnoea episodes occurred simultaneously (the former causing the latter), the deterioration involved apnoea episodes occurring independently. The significance of this is, to quote from a second opinion about the course of Trisomy 18:
“ The most likely cause of death is the respiratory centre in the brain stopping”
. The apnoea episodes are now not being triggered by other events. This is a clear indication that she is dying. Another indication is bradycardia as her heart rate had dropped. ii) She said the case is so urgent that it simply cannot be adjourned. It would prolong pain, and TR may die very soon in what Dr Z described as a “very unkind way”. iii) She has been on CPAP ventilation, applied manually by mask, with artificial breathing top-ups. This was at the request of the parents, but the clinical view is that it is inappropriate and unethical because of the pain and discomfort caused. The clinicians consider that breathing should be by nasal cannula, or by wafting via a mask away from the face. CPAP involves pressurised application of the mask to the face to which she responds with pain; her body stiffens, her heart rate rises and she reacts with facial grimaces. Dr Z is in no doubt that she is in distress. She considers the application of painful pressure to TR’s face to be unethical. iv) Were it not for the CPAP, she would be hours away from dying. Even with the CPAP, she is probably hours away as indicated by the apnoea and dropping heart rate. CPAP is not curative, nor is it palliative. In Dr Z’s view, it is prolonging suffering. v) The time has come for palliative care. CPAP is distressing for her, and largely prevents her family from holding her, which is a source of comfort for her. The various forms of treatment require her to remain in the ICU, whereas if she comes off the ICU observation monitoring she will be able to be in a private family room with her family. The ICU environment requires her to be flat on her back, whereas she is more comfortable being upright.[12]I accept her evidence unreservedly.

The Law

[13]I bear in mind that the human rights of J and her parents are fully engaged, in particular Articles 2, 8 and 14 of the ECHR. Any interference with those rights must be necessary and proportionate.[14]In Manchester University NHS Foundation Trust v Fixsler and others [2021] EWHC 1426; [2021] 4 WLR 95 at para 56, MacDonald J said:
"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 Re B (A Minor) (Wardship: Medical Treatment) (1982) 3 FLR 117). 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 [2006] EWHC 507 (Fam)). The court has no power to require doctors to carry out a medical procedure against their own professional judgment."
[15]In Aintree University Hospital NHS Foundation Trust v James [2013] UKSC 67; [2014] AC 591 Baroness Hale said at para 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."
And at paragraph 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.”
And at para 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."
[16]At para 57 of Manchester University NHS Foundation Trust v Fixsler (supra),MacDonald J summarised the applicable principles:
"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 The General Medical Council [2005] EWCA 1003, An NHS Trust v MB [2006] 2 FLR 319, Wyatt v Portsmouth NHS Trust [2006] 1 FLR 554, Kirklees Council v RE and others [2015] 1 FLR 1316 and Yates and Gard v Great Ormond Street Hospital for Children NHS Foundation Trust [2017] EWCA Civ 410: 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 the wise words of Hedley J in Portsmouth NHS Trust v Wyatt and Wyatt, Southampton NHS Trust Intervening [2005] 1 FLR 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 must 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 Re A (A Child) [2016] EWCA 759, 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." "
The views of the child must be considered and be given appropriate weight in light of the child's age and understanding."[17]This decision was upheld by the Court of Appeal in Fixsler v Manchester University NHS Foundation Trust [2021] EWCA Civ 1018 and no part of MacDonald J’s analysis of the law was disapproved.[18]In respect of parental views, in Yates and Gard v Great Ormond Street Hospital for Children NHS Foundation Trust [2017] EWCA Civ 410, McFarlane LJobserved that:
“…the sole principle is that the best interests of the child must prevail, even to cases where parents, for the best of motives, hold on to some alternative view”
.

Conclusion

[19]I have considered the evidence in the round. I take into account the deep and abiding love of TR’s family for her and their wish to explore every option. They say, and of course they are absolutely right, that TR is a unique child with her own dignity, personality and potential. They understand that TR’s conditions are serious and life limiting. They correctly say that the court’s best interests decision goes beyond a strictly medical assessment of Trisomy 18. I have the utmost respect for their views. They point out that she has survived to one month and there are recorded examples of people with Trisomy 18 living months and, occasionally, years.[20]Weighed in the balance, however, are the following factors which in my judgment militate in favour of the Trust’s application: i) There is no cure for her condition. On the balance of evidence, TR’s life expectancy, even before recent deterioration, was measurable in, at most, months and now could be hours away; the independent apnoea episodes and the dropping heart rate point in that direction. Nothing medically can be done for her beyond making her as comfortable as possible. ii) She experiences distress, discomfort and pain. This is manifest when she has seizures, which are increasing in frequency and acuity. The additional treatment sought by the parents would be futile and, at best uncomfortable, but at worst highly painful. The CPAP, for which the parents seek continuation, causes demonstrable pain. iii) There is little by way of quality of life, although I recognise, of course, that for the parents every moment spent with her is to be cherished and is meaningful, and she derives some comfort when held by her parents. iv) For the reasons given by the clinicians (and supported by second opinions), surgical intervention to address the cardiac condition is not justifiable, and in any event is not offered. v) The deterioration has been so rapid, and her case is now so urgent, that a decision had to be made immediately. vi) In my judgment, a move to palliative care is appropriate.[21]Overall, I am satisfied that it is in the best interests of TR to grant the application in its revised form. This authorises the Trust not to give the specified additional treatment, and to proceed to implement a palliative care plan.[22]This will be devastating for the parents. I hope they understand the reasons for my decision, even if they do not agree, and that I have had TR’s interests at the forefront of my considerations.

Postscript

[23]I have been informed that approximately 3 hours after I informed the parties of my decision orally, very sadly TR passed away in the family bereavement room with her loved ones present.