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England and Wales High Court (Family Division) Decisions
You are here: BAILII >> Databases >> England and Wales High Court (Family Division) Decisions >> University Hospitals Plymouth NHS Trust v B (A Minor) (Urgent Medical Treatment)  EWHC 1670 (Fam) (21 June 2019)
Cite as:  EWHC 1670 (Fam)
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Strand, London, WC2A 2LL
B e f o r e :
| University Hospitals Plymouth NHS Trust
|- and -
|B (A Minor)
The Respondent did not appear and was not represented
Hearing dates: 21 June 2019
Crown Copyright ©
Mr Justice MacDonald:
i) B agreed to be admitted to the Applicant's Hospital yesterday evening after discussions with her treating paediatric diabetic consultant Dr S.
ii) At approximately 0100hours B agreed to undergo testing to determine the level of her blood sugars and ketones.
iii) At between 0900 to 0930 hours B agreed to have an intravenous cannula inserted.
i) More aggressive treatment is required in the form of intravenous fluid infusion (to reverse the current electrolyte imbalance) and intravenous insulin. Frequent blood monitoring, including two to four hourly blood test will be required;
ii) Subcutaneous insulin treatment may be required after some control of the DKA has been achieved;
iii) The treatment needed to reverse the DKA is likely to last 24- 48 hours;
iv) In the event that B develops cerebral oedema she will need a hypertonic saline bolus and, possibly, infusion, an urgent CT scan, admission to the PICU and intubation and ventilation may be required;
v) Other complications of DKA and its treatment include hypoglycaemia, cardia arrhythmias secondary to abnormal potassium levels and, in severe cases of dehydration, renal failure.
vi) Treatment for DKA is "meticulously standardised" in the United Kingdom and there is "universal consensus" in the paediatric community about the interventions that are required.
"One must start from the general premise that the protection of the child's welfare implies at least the protection of the child's life. I state this as a general and not as an invariable premise because of the possibility of cases in which a court would not authorise treatment of a distressing nature which offered only a small hope of preserving life. In general terms however, the present state of law is that an individual who has reached the age of 18 is free to do with his life what he wishes, but it is the duty of the court to ensure so far as it can that children survive to attain that age…To take it a stage further, if the child's welfare is threatened by a serious and imminent risk that the child will suffer grave and irreversible mental or physical harm, then once again the court when called upon has a duty to intervene."
i) The paramount consideration of the court is the best interests of the child. The role of the court when exercising its jurisdiction is to give or withhold consent to medical treatment 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;
iv) 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. 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 their own emotion or sentiment;
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 court has before it cogent evidence that B has developed DKA. She has already showed signs of confusion and vomiting. Testing at 0100hrs found her blood sugars and ketones to be markedly elevated with a sugar level of over 38 (versus normal of up to 10) and a ketone level of 2.5. At this point B was refusing any insulin at all. Later blood testing demonstrated a blood sugar level of 27.8 and ketone level of 5.5 and a blood pH of 7.19 (acidosis). There is no indication that those readings have improved and the medical evidence before the court is clear that her situation is now parlous. She has been admitted to the HDU.
ii) If left untreated B's DKA will be fatal to her. Her condition will worsen to the point of cerebral oedema and, ultimately death. In addition, she is at risk of hypoglycaemia, cardiac arrhythmias secondary to abnormal potassium levels and, in severe cases of dehydration, renal failure.
iii) Within this context, the window for administering treatment to B is a narrow one. As I have already noted, she has already showed signs of confusion and vomiting and her blood sugars and ketones have been markedly disordered for a significant period.
iv) There is a strong presumption in favour of taking all steps to preserve life because life has unique value and the individual human instinct to survive is strong and must be presumed to be strong in the patient. Within this context, the court must have regard to the fact that there is a strong presumption in favour of preserving B's life. In the circumstances of this case, that presumption is a very compelling factor.
v) The treatment proposed by the NHS Trust represents that favoured by a consensus of reasonable medical opinion and is, on the evidence before the court, "meticulously standardised" in the United Kingdom and there is "universal consensus" in the paediatric community about the interventions that are required. The treatment proposed will be effective in ameliorating B's DKA and thus carries with it manifest benefits.
vi) Whilst not determinative, I also bear in mind also that B's grandfather, who cares for her, is in favour of treatment being administered to address B's DKA.