Z v University Hospitals Plymouth NHS Trust & Ors

Factual and Procedural Background

This case concerns an individual, RS, subject to a transparency order restricting public discussion. On 15 December 2020, the applicant NHS Trust obtained a declaration from the Court of Protection that it was not in RS's best interests to receive life-sustaining medical treatment, including nutrition and hydration, and that such treatment could lawfully be discontinued. The declaration further provided that RS should receive palliative treatment ensuring dignity and minimal discomfort until death. The Trust's application was supported by RS's wife but opposed by RS's birth family.

Following the decision, nutrition and hydration were withdrawn on 16 December 2020 but reinstated on 18 December 2020 after RS's niece, representing the birth family, filed an application for permission to appeal. The Court of Appeal refused permission on 23 December 2020. Nutrition and hydration were withdrawn again on 24 December 2020 but reinstated on 28 December 2020 under circumstances addressed later in the judgment.

RS's birth family applied to the European Court of Human Rights (ECtHR) for interim relief after exhausting domestic remedies. The birth family, represented primarily by RS's niece, sought various orders including permission to rely on new expert evidence, declarations regarding the lawfulness and best interests of continuing nutrition and hydration, and permission to transfer RS to Poland for further treatment. The ECtHR refused interim relief applications made both by the birth family and the government of the Republic of Poland.

An urgent hearing before a duty judge resulted in a stay of the order authorising removal of life-sustaining treatment pending a hearing before the judge delivering this judgment. The hearing addressed the niece's application and the Trust’s, RS’s wife’s, and the Official Solicitor’s opposition.

Legal Issues Presented

1. Whether the court should reconsider or revise its prior reliance on medical evidence concerning RS's condition in light of subsequent events and new expert evidence.
2. Whether it is lawful and in RS's best interests to continue receiving clinically assisted nutrition and hydration (CANH).
3. Whether RS should be lawfully transferred to Poland for further treatment.

Arguments of the Parties

Appellant's Arguments (Birth Family and Niece)

• They sought to rely on a report and evidence from Dr Pullicino, an experienced neurologist and ordained priest, who opined that RS showed signs consistent with a minimally conscious state (MCS) and should not be allowed to die.
• They argued that RS’s condition had improved, warranting reconsideration of the previous decision to discontinue life-sustaining treatment.
• They requested declarations that continuing CANH was lawful and in RS’s best interests and that transfer to Poland was appropriate for further treatment.

Respondent's Arguments (NHS Trust, RS's Wife, and Official Solicitor)

• They opposed the application to rely on Dr Pullicino’s evidence, questioning its reliability and the manner in which it was obtained.
• They maintained that the original medical evidence remained accurate and that RS remained in a vegetative state (VS) with no evidence of progression to MCS.
• They opposed transfer to Poland on grounds of risk, discomfort, and lack of any superior treatment overseas.

Table of Precedents Cited

No precedents were cited in the provided opinion.

Court's Reasoning and Analysis

The court carefully examined the new evidence submitted by Dr Pullicino and found it seriously deficient and unreliable. The report was based on unstructured family-recorded video clips and one-off observations without access to medical records, prior assessments, or direct communication with the treating team. The court found the manner in which the evidence was gathered to be underhand and disrespectful to RS’s wife and the treating clinicians. The court also noted potential legal issues regarding the filming of RS without appropriate consent.

The court contrasted Dr Pullicino’s evidence with that of the treating clinicians and independent experts, including Dr W, Dr Bell, and Dr A, who conducted structured assessments and reviewed comprehensive medical information. These experts consistently concluded that RS remained in a vegetative state with no reliable evidence of progression to a minimally conscious state.

The court accepted the medical consensus that the slight increase in alertness observed was attributable to subsidence of brain swelling rather than cognitive recovery. The EEG results further confirmed the absence of cortical brain activity responsive to stimuli. The prognosis remained poor with no realistic prospect of meaningful recovery.

Regarding the proposed transfer to Poland, the court found it would pose significant risks to RS, cause unnecessary discomfort, and provide no superior treatment than what was available in the UK. The court also emphasized the importance of respecting the wishes of RS’s wife and children, who opposed the transfer.

Given the refusal of interim relief by the ECtHR and the ongoing applications there, the court extended the stay on the implementation of its earlier order for a limited period to allow the family and the Polish government to pursue their arguments before that court.

Holding and Implications

The court DISMISSED the application to rely on Dr Pullicino’s evidence and to reconsider the previous findings regarding RS’s best interests. It held that continuing life-sustaining treatment, including nutrition and hydration, was not in RS’s best interests and that withdrawal of such treatment was lawful.

The court REJECTED the application for transfer of RS to Poland due to the high risks involved, lack of superior treatment options abroad, and the opposition of RS’s immediate family.

The court continued the stay on implementation of its earlier order until 4pm on 7 January 2021 to permit the family and/or Polish government to seek further relief from the ECtHR.

This decision directly affects the parties by affirming the lawfulness of the withdrawal of life-sustaining treatment and refusal of transfer overseas. No new legal precedent was established beyond application of existing principles to the facts.