JB v University Hospitals Plymouth NHS Trust & Anor

Factual and Procedural Background

The case concerns a middle-aged man ("RS") who suffered a heart attack at his home in The City, resulting in prolonged oxygen deprivation to his brain and subsequent coma. The University Hospitals Plymouth NHS Trust initiated proceedings in the Court of Protection to determine RS's best interests regarding life-sustaining treatment. On 15 December 2020, the court ruled that it was in RS's best interests to cease life-sustaining treatment, including artificial ventilation, nutrition, and fluids, leading to his expected death within weeks under palliative care.

The proceedings were complicated by a deep family rift, with disagreement among family members about RS's best interests. RS's wife and children supported the cessation of treatment, while his niece, representing other family members including his mother and sisters, opposed it and sought permission to appeal the decision. The Official Solicitor acted as litigation friend and commissioned independent medical advice. The medical prognosis was bleak, with RS in a coma and minimal chances of meaningful recovery.

The Court of Protection conducted a hearing considering RS's past expressed views, religious beliefs, and the evidence of family members and medical experts. The judge weighed these factors and concluded that RS would not have wished to be kept alive in his current condition.

Legal Issues Presented

1. Whether the Court of Protection's decision to cease life-sustaining treatment was in RS's best interests under the Mental Capacity Act 2005.
2. Whether there was a serious procedural irregularity or injustice in the lower court's handling of the evidence, particularly concerning RS's religious beliefs and the process of inquiry into his wishes.
3. Whether permission to appeal should be granted based on the appeal having a real prospect of success or a compelling reason to be heard.

Arguments of the Parties

Appellant's Arguments

• The appellant did not contend that the judge’s decision was wrong on the evidence or challenge the medical prognosis.
• The core submission was that the decision was unjust due to procedural errors, specifically that the court insufficiently inquired into how RS’s Catholic faith would influence his wishes regarding treatment.
• It was argued that the court moved too quickly to a conclusion that conflicted with religious teachings emphasizing that the end of life is a matter for God, not man.
• Reference was made to the European Court of Human Rights decision in Lambert and others v France, emphasizing the need for in-depth examination and consideration of all viewpoints, including expert medical and ethical opinions.
• Concerns were raised about the fairness of the process, including the judge’s limitation on cross-examination of RS’s wife due to distress and the acceptance of additional confidential evidence from her without disclosure to other parties.

Respondent's Arguments

• The NHS Trust and Official Solicitor contended that the proceedings were conducted fairly and with due consideration of all relevant evidence and perspectives.
• They emphasized that the judge gave full weight to RS’s religious beliefs and the sanctity of life but balanced this against medical prognosis and RS’s ascertained wishes.
• It was submitted that the pace of the proceedings was appropriate given the clinical situation and that no useful information would have been gained by delay.
• Regarding procedural fairness, it was argued that the Court of Protection operates inquisitorially, with broad powers to control evidence, and that the judge’s approach to evidence and cross-examination was proper and proportionate.
• The confidential letter from RS’s wife was a humane judicial response to her distress, did not influence the decision, and no procedural unfairness arose.

Table of Precedents Cited

Precedent	Rule or Principle Cited For	Application by the Court
Aintree University Hospitals NHS Foundation Trust v James [2013] UKSC 67	Best interests decision-making under the Mental Capacity Act 2005; starting point is that life should be preserved but not absolutely.	The court applied the principle that best interests must consider medical, social, psychological welfare, patient’s attitude, and views of others, balancing sanctity of life with individual wishes.
Lambert and others v France [2015] ECHR 545	Requirement for in-depth examination and consideration of all viewpoints in end-of-life decisions under Article 2 ECHR.	Referenced by appellant as a standard for procedural fairness and thorough inquiry, though the court found the current case met appropriate procedural standards.
NHS Trust v Y [2019] AC 978	Procedure where family disagreement exists in best interests decisions.	The court noted the Trust properly applied to the Court of Protection due to family disagreement, consistent with this precedent.
Cheshire West and Cheshire Council v P and M [2011] EWHC 1330	Court of Protection’s inquisitorial process and broad evidential control powers.	The court relied on this to justify limiting cross-examination and controlling evidence to ensure fair but proportionate process.

Court's Reasoning and Analysis

The court examined the lower court’s decision under the framework of the Mental Capacity Act 2005, focusing on the best interests of RS. It acknowledged the undisputed medical evidence of RS’s grim prognosis and the absence of any clear prior statement from RS about his wishes in these exact circumstances. The judge’s determination that RS’s wife’s account of his views was the most reliable evidence was upheld, given her longstanding close relationship with RS.

The court gave significant weight to RS’s religious beliefs but found these were not determinative, as the judge had balanced sanctity of life with RS’s ascertained wishes and the impact on his family. The court rejected the appellant’s argument that the inquiry was insufficient, finding that the process was thorough and that no additional evidence or delay would have materially changed the outcome.

Regarding procedural fairness, the court emphasized the inquisitorial nature of the Court of Protection, its broad powers to control evidence, and the appropriateness of limiting cross-examination to prevent distress. The acceptance of additional confidential evidence from RS’s wife was a compassionate judicial response and did not prejudice the parties or influence the outcome. The court noted that the appellant’s counsel did not pursue certain procedural complaints once clarified.

Overall, the court found no arguable case that the lower court’s decision was wrong or procedurally unfair, and no real prospect of success on appeal.

Holding and Implications

The court refused permission to appeal.

The direct effect is that the decision of the Court of Protection to discontinue life-sustaining treatment for RS stands. The ruling confirms the application of best interests principles under the Mental Capacity Act 2005 in complex, end-of-life cases involving religious beliefs and family disagreement. No new precedent was established, and the court expressed hope that the family could now find peace following a difficult litigation process.